Patient throughput times and inflow patterns in Swedish emergency departments. A basis for ANSWER, A National SWedish Emergency Registry

Objective: Quality improvement initiatives in emergency medicine (EM) often suffer from a lack of benchmarking data on the quality of care. The objectives of this study were twofold: 1. To assess the feasibility of collecting benchmarking data from different Swedish emergency departments (EDs) and 2. To evaluate patient throughput times and inflow patterns. Method: We compared patient inflow patterns, total lengths of patient stay (LOS) and times to first physician at six Swedish university hospital EDs in 2009. Study data were retrieved from the hospitals' computerized information systems during single on-site visits to each participating hospital. Results: All EDs provided throughput times and patient presentation data without significant problems. In all EDs, Monday was the busiest day and the fewest patients presented on Saturday. All EDs had a large increase in patient inflow before noon with a slow decline over the rest of the 24 h, and this peak and decline was especially pronounced in elderly patients. The average LOS was 4 h of which 2 h was spent waiting for the first physician. These throughput times showed a considerable diurnal variation in all EDs, with the longest times occurring 6-7 am and in the late afternoon. Conclusion: These results demonstrate the feasibility of collecting benchmarking data on quality of care targets within Swedish EM, and form the basis for ANSWER, A National SWedish Emergency Registry

Risk attitude and Patients experience with treatment of abdominal aortic aneurysm and severe claudication

The overall aim of this thesis was to investigate the effect of information on well-being after open surgical repair (OR) of abdominal aortic aneurysm (AAA) and to explore the experience of the care pathway of OR from the patients perspective as well as to describe risk attitude and preference for treatment of AAA and severe intermittent claudication (IC). The effect of information was assessed during the first week after returning to the surgical ward using a study-specific questionnaire in patients with AAA randomized to receive either additional written information (EG) or best practice (CG). The experience of the care pathway was investigated in patients with AAA three months after going through OR using in-depth interview. Risk attitude and preference for treatment was evaluated in a general population sample stratified in four age groups facing a hypothetical scenario of going through OR, in patients scheduled for AAA treatment as well as in patients with severe IC before and six months after treatment using time trade off (TTO), standard gamble (SG) questions and a derived TTO value. Health related quality of life as well as cost-effectiveness was also evaluated in patients with severe IC. Preoperative written information did not have beneficial effects on postoperative recovery in patients with AAA. The EG reported a significantly worse psychological well-being during the first three days after returning from ICU. Otherwise there were no significant differences between the EG and CG in physical or psychological well being. The experience of the care pathway of OR describe patients awareness of having a deadly disease, feeling no option to decline surgery and the physical and emotional impact of OR which is difficult to cope with. During the care pathway there was a need for information and dialogue not fully met by the health care staff. Not understanding the risk and implications with surgery resulted in being unprepared for the long recovery period. A hypothetical situation of having AAA and facing OR was tested in otherwise healthy persons showing that the oldest age group was not prepared to take a deadly risk with treatment or trade off years to live their remaining life without the risk of rupture, to the same extent as reported by the three younger age groups. A decreased HRQL and functional ability in patients with severe IC influences risk attitude and preference for treatment, showing that the patients were prepared to accept a considerable treatment risk and shorten their remaining life to be free from their symptoms. Clinical parameters, HRQL and walking ability improved considerably after revascularization. Revascularization could also be considered cost-effective. In conclusion, patients with AAA seem to need better structured information and a possibility for a dialogue with the health care staff during the care pathway. The physical and emotional impact of OR has to be assessed to meet patients need. Preference for treatment should be considered individually, with special attention to the reluctance of taking a risk with OR seen in the very elderly and to patients with severe IC willing to take considerable risks with treatment

Perceptions of managers regarding prerequisites for the development of professional competence of newly graduated nurses : A qualitative study

Aim and objectives: To describe perceptions of managers regarding prerequisites for professional competence development of newly graduated nurses following a 1-year residency programme. Background: In general, managers are unsatisfied with the professional competence of newly graduated nurses. Therefore, they have been involved in residency programmes to support the nurses' transition from being nursing students to professional nurses. However, perceptions of managers regarding the professional competence development of nurses have been sparingly studied. Design/Methods: Qualitative, descriptive study with a data-driven inductive approach with content analysis to obtain an understanding of the perceptions of nine managers through interviews. EQUATOR checklist COREQ is used (see FileS1). Results: Three themes emerged: (a) the nurses' relationships with their teams and patients, (b) expectations regarding the development of practical skills and leadership skills and (c) prerequisites for continuing learning by supportive structures and a mutual responsibility between the manager and the nurse. Reflection was perceived by the managers as a cornerstone in the learning and development of professional competence. Learning theory was important, but learning practical clinical skills was essential for the nurses to develop competence and be able to perform their work, including being a leader of the team. Some structures discouraged continued learning in the development of professional competence, indicating a gap between the healthcare settings and the basic nursing programme. Conclusions: There is a gap between the university and the healthcare settings in maintaining a structure for continued learning, which requires cooperation. This gap and tension can be a driving force for the learning process of competence development. Relationships with team members and patients are considered fundamental for developing professional competence. Relevance to clinical practice To overcome the gap between the university and the healthcare settings, the managers can facilitate nurses' continued learning by creating structures for reflection

The patient safety culture as perceived by staff at two different emergency departments before and after introducing a flow-oriented working model with team triage and lean principles: a repeated cross-sectional study

Abstract Background: Patient safety is of the utmost importance in health care. The patient safety culture in an institution has great impact on patient safety. To enhance patient safety and to design strategies to reduce medical injuries, there is a current focus on measuring the patient safety culture. The aim of the present study was to describe the patient safety culture in an ED at two different hospitals before and after a Quality improvement (QI) project that was aimed to enhance patient safety

Patient throughput times and inflow patterns in Swedish emergency departments. A basis for ANSWER, A National SWedish Emergency Registry

Abstract Objective Quality improvement initiatives in emergency medicine (EM) often suffer from a lack of benchmarking data on the quality of care. The objectives of this study were twofold: 1. To assess the feasibility of collecting benchmarking data from different Swedish emergency departments (EDs) and 2. To evaluate patient throughput times and inflow patterns. Method We compared patient inflow patterns, total lengths of patient stay (LOS) and times to first physician at six Swedish university hospital EDs in 2009. Study data were retrieved from the hospitals' computerized information systems during single on-site visits to each participating hospital. Results All EDs provided throughput times and patient presentation data without significant problems. In all EDs, Monday was the busiest day and the fewest patients presented on Saturday. All EDs had a large increase in patient inflow before noon with a slow decline over the rest of the 24 h, and this peak and decline was especially pronounced in elderly patients. The average LOS was 4 h of which 2 h was spent waiting for the first physician. These throughput times showed a considerable diurnal variation in all EDs, with the longest times occurring 6-7 am and in the late afternoon. Conclusion These results demonstrate the feasibility of collecting benchmarking data on quality of care targets within Swedish EM, and form the basis for ANSWER, A National SWedish Emergency Registry.</p