OBJECTIVE: Describe the longitudinal development of crowding and patient/emergency department (ED) characteristics at a Swedish University Hospital.
METHODS: A retrospective longitudinal registry study based on all ED visits with adult patients during 2009-2016 (N = 1,063,806). Patient characteristics and measures of ED crowding (ED occupancy ratio, length-of-stay [LOS], patients/clinician's ratios) were extracted from the hospital's electronic health record. Non-parametric analyses were conducted.
RESULTS: The proportion of unstable patients (triage level 1-2) increased while the proportion of admitted patients decreased. All crowding variables were stable, except for LOS, which increased by 9 min/visit/year (95% CI: 8.8-9.1). LOS for visits by patients ≥ 80 years increased more compared to those 18-79 (248 min vs. 190 min, p < 0.001). Unstable patients increased their median LOS compared to stable patients (triage level 3-5). LOS for discharged patients increased with an average of 7.7 min/year (95% CI: 7.5-7.9) compared to 15.5 min/year (95% CI: 15.2-15.8) for those being admitted.
CONCLUSION: Fewer admissions, despite an increase of unstable patients, is likely related to lack of in-hospital beds and contributes to ED crowding. The increase in median ED LOS, especially for patients in the subgroups unstable, ≥80 years and admitted to in-hospital care reflects this problem.
OBJECTIVE: Emergency department team members frequently need to interact with each other, a circumstance causing multiple interruptions. However, information is lacking about the motives underlying these interruptions and this study aimed to explore clinicians' reasons to interrupt colleagues during emergency department work.
METHOD: Semi-structured interviews with 10 physicians and 10 registered nurses at two Swedish emergency departments. The interviews were analyzed inductively using content analysis.
RESULTS: The working conditions to some extent sustained the clinicians' need to interrupt, for example different routines. Another reason to interrupt was to improve the initiator's work process, such as when the initiators perceived that the interruption had high clinical relevance. The third reason concerns the desire to influence the work process of colleagues in order to prevent mistakes and provide information for the person being interrupted to improve patient care.
CONCLUSION: The three identified categories for why emergency department clinicians interrupt their colleagues were related to working conditions and a wish to improve/influence the work processes for both initiators and recipients. Several of the reasons given for interrupting colleagues were done in order to improve patient care. Interruptions perceived as negative to the recipient were mostly related to the working conditions.
OBJECTIVE: Emergency departments consist of multiple systems requiring interaction with one another while still being able to operate independently, creating frequent interruptions in the clinical workflow. Most research on interruptions in health care settings has focused on the relationship between interruptions and negative outcomes. However, there are indications that not all interruptions are negatively perceived by those being interrupted. Therefore, this study aimed to explore factors that influence when a clinician perceives interruptions as non-disturbing or disturbing in an emergency department context.
METHOD: Explorative design based on interviews with 10 physicians and 10 registered nurses at two Swedish emergency departments. Data were analyzed using qualitative content analysis.
RESULT: Factors influencing whether emergency department clinicians perceived interruptions as non-disturbing or disturbing were identified: clinician's constitution, external factors of influence and the nature of the interrupted task. The clinicians' perceptions were related to a complex of attributes inherent in these three factors at the time of the interruption. Thus, the same type of interruption could be perceived as either non-disturbing or disturbing contingent on the surrounding circumstances in which the event occurred.
CONCLUSION: Emergency department clinicians' perceptions of interruptions as non-disturbing or disturbing were related to the character of identified influencing factors.
Objective: The purpose of this systematic review is to describe the operationalization of interruptions measurement and to synthesize the evidence on the causes and consequences of interruptions in the emergency department (ED) work environment. Methods: This systematic review of studies explores the causes and consequences of interruptions in the ED. Of 2836 abstract/titles screened, 137 full-text articles were reviewed, and 44 articles met inclusion criteria of measuring ED interruptions. Results: All articles reported primary data collection, and most were cohort studies (n = 30, 68%). Conceptual or operational definitions of interruptions were included in 27 articles. Direct observation was the most common approach. In half of the studies, quantitative measures of interruptions in the ED were descriptive only, without measurements of interruptions’ consequences. Twenty-two studies evaluated consequences, including workload, delays, satisfaction, and errors. Overall, relationships between ED interruptions and their causes and consequences are primarily derived from direct observation within large academic hospitals using heterogeneous definitions. Collective strengths of interruptions research in the ED include structured methods of naturalistic observation and definitions of interruptions derived from concept analysis. Limitations are conflicting and complex evaluations of consequences attributed to interruptions, including the predominance of descriptive reports characterizing interruptions without direct measurements of consequences. Conclusions: The use of standardized definitions and measurements in interruptions research could contribute to measuring the impact and influence of interruptions on clinicians’ productivity and efficiency as well as patients’ outcomes, and thus provide a basis for intervention research. © 2022 Elsevier Ltd
Emergency department triage is a prerequisite for the rapid identification of critically ill patients and for allocation of the correct acuity level which is pivotal for medical safety. The patient’s first encounter with a medical professional in the emergency department is often with the triage nurse. To identify patient experience of the triage encounter. A questionnaire focusing on the patient–triage nurse relationship in terms of satisfaction with the medical and administrative information, privacy and confidentiality in the triage area as well as triage nurse competence and attitude was answered by 146 participating patients. The majority of patients perceived that while they were triaged immediately upon arrival to the emergency department, they were often given limited information about the waiting time. Although almost a quarter of the patients did not wish to have information about their medical condition from the triage nurse, 97% of the patients considered the triage nurse to be medically competent for the triage task. Patients were generally satisfied with the reception and care given by the triage nurses, but less satisfied about information about expected waiting time. We suggest therefore, that patients should be routinely informed about their estimated waiting time to be seen by the doctor in addition to their triage level.
Introduction: In emergency nursing situations, uncertainty may lead to delays, or block a decision which can have devastating consequences for a patient. The ambulance service is a complex clinical environment that often challenges the decision-making capabilities of the professionals, especially novice nurses. Novice nurses’ uncertainty may also lead to unhealthy transitions and turnover. To increase the understanding of how uncertainty affects novice nurses, this study explores novice nurses’ uncertainty during the first year of professional practice in the ambulance service.
Method: A qualitative descriptive design was applied using qualitative content analysis of thirteen individual face-to-face semi-structured deep interviews.
Result: From nine subcategories, three generic categories were derived: Reflections on contextual understanding, Strategies to create control, and Actions to take control. These were combined to form the main category Understanding what and dealing with how, while becoming a confident professional.
Conclusion: Uncertainty is exacerbated by situations that demand rapid decisions or actions. This is especially true of newcomers to a profession. Preparing novices through study programs and encouraging continuous reflection in professional practice may increase resilience and tolerance of uncertainty, as well as benefiting professional development.
Introduction: Healthcare in Sweden is moving towards a more person-centred approach in which patients are respected as capable individuals with unique needs. Partnership, the co-creation of health plans, and documentation are core components of this approach. The ambulance service is medical- and task-oriented, possibly placing it in conflict with the goals of person-centred care (PCC).
Aim: To explore how nurses in the Swedish ambulance service describe PCC.
Method: A qualitative interview study with eight nurses who served as facilitators for implementing ambulance PCC. Data was analysed using content analysis.
Findings: The analysis resulted in the main category Ambulance PCC is diffuse but applicable and in the three categories: Do good based on an ethical approach, Assemble the patient's narrative from multiple sources and Create and agree on a plan.
Conclusion: Ambulance PCC is perceived as a diffuse concept, with unclear translation into practice. The findings highlight the need to determine appropriate levels of care, manage technical equipment without disrupting communication and embody attributes such as calmness and empathy. Despite its ambiguity, ambulance PCC was seen as applicable across all care stages, although requiring adjustments based on urgency, individual circumstances and care setting.
One of several quality indicators that are relevant to study is patient’s satisfaction with health care in the ambulance services. Regular measurements of patient satisfaction in this field have not been carried out previously and a validated method of measurement is lacking.
Background In ambulance care, patients are often classified as high-risk, particularly when they are in immediate need of pain relief. It has been shown that, after ambulance nurses administer intravenous analgesic drugs, patients delivered to the emergency department tend to complain of moderate to severe pain. Aims and objectives The present study aimed to evaluate the overall patient-perceived pain during treatment with methoxyflurane (MTX) in an ambulance-care setting. We also explored potential demographic variations. Methods This prospective observational study included 50 patients in need of ambulance care that perceived acute pain, defined as a Numeric Rating Scale (NRS) value â¥4 (scale range: 1â10). We monitored the vital parameters of patients and MTX treatment characteristics, including the total number of inhaled MTX breaths and the average number of treatment sequences. Results Among the 50 patients initially assessed, we excluded 8 patients (16%), due to MTX contraindications. We excluded 10 patients (24%), due to discontinued treatment. The remaining cohort (nâ¯=â¯32) that fulfilled the pain-relieving procedure, included equal numbers of men and women. The average time spent in ambulance care was 29â¯Â±â¯15â¯min. The NRS scores for pain measured at the scene (median 8.0, interquartile range [IQR]: 7.25â10.0) were significantly higher than those measured at hospital admission (median 5.0, IQR: 4.0â¯7.0; pâ¯=â¯.001). The median NRS scores measured at the hospital were different between sexes (men: 6.0, IQR: 5â7.25; women: 4.0, IQR: 3.76â6.0; pâ¯=â¯.036). The average number of treatment sequences was 2. The overall average number of inhaled breaths was 17â¯Â±â¯9. Conclusion This study demonstrates that MTX provided clinically significant lower pain scores among patients in ambulance care without significant effects on vital parameters. However, the pharmacological characteristics of MTX appeared to affect the potential of achieving standardized treatment objectives.
The emergency department has been described as a high-risk area for errors. It is also known that working conditions such as a high workload and shortage off staff in the healthcare field are common factors that negatively affect patient safety. A limited amount of research has been conducted with regard to patient safety in Swedish emergency departments. Additionally, there is a lack of knowledge about clinicians' perceptions of patient safety risks. Therefore, the purpose of this study was to describe emergency department clinicians' experiences with regard to patient safety risks.
METHOD: Semi-structured interviews were conducted with 10 physicians and 10 registered nurses from two emergency departments. Interviews were analysed by inductive content analysis.
RESULTS: The experiences reflect the complexities involved in the daily operation of a professional practice, and the perception of risks due to a high workload, lack of control, communication and organizational failures.
CONCLUSION: The results reflect a complex system in which high workload was perceived as a risk for patient safety and that, in a combination with other risks, was thought to further jeopardize patient safety. Emergency department staff should be involved in the development of patient safety procedures in order to increase knowledge regarding risk factors as well as identify strategies which can facilitate the maintenance of patient safety during periods in which the workload is high.
Objective: The Emergency Department (ED) is a complex and dynamic environment, often resulting in a somewhat uncontrolled and unpredictable workload. Contributing factors to errors in health care and in the ED are largely related to communication breakdowns. Moreover, the ED work environment is predisposed to multitasking, overcrowding and interruptions. These factors are assumed to have a negative impact on patient safety. Reported errors from care providers are mainly related to diagnostic procedures in Swedish EDs. However, there is a lack of knowledge and national oversight regarding contributing factors. The aim of this study was therefore to describe contributing factors in regards to errors occurring in Swedish EDs.
Method: Descriptive design based on registry data from the Lex Maria database of the Swedish National Board of Health and Welfare.
Results: The results indicate that factors contributing to errors in Swedish EDs are multifactorial in nature. The most common contributing factor was human error followed by factors in the local ED environment and teamwork failure.
Conclusion: Factors contributing to ED errors were multifactorial and included both organizational and teamwork failure in which human error was implicated. To reduce errors, further research is needed to develop methods that disclose latent working conditions such as high workload and interruptions. Patient safety research needs to include understanding of human behaviour in complex organizational systems and the impact of working conditions on patient safety and quality of care.
Background: The Swedish ambulance health care services are changing and developing, with the ambulance nurse playing a central role in the development of practice. The competence required by ambulance nurses in the profession remains undefined and provides a challenge. The need for a clear and updateddescription of ambulance nurses’ competence, including the perspective of professional experiences, seems to be essential.Aim: The aim of this study was to elucidate ambulance nurses’ professional experiences and to describe aspects affecting their competence.Methods: For data collection, the study used the Critical Incident Technique, interviewing 32 ambulance nurses. A qualitative content analysis was applied.Results and conclusion: This study elucidates essential parts of the development, usage and perceptions of the competence of ambulance nurses and how, in various ways, this is affected by professional experiences.The development of competence is strongly affected by the ability and possibility to reflect on practice on a professional and personal level, particularly in cooperation with colleagues. Experiences and communication skills are regarded as decisive in challenging clinical situations. The way ambulance nurses perceive their own competence is closely linked to patient outcome. The results of this study can be used in professional and curriculum development.
Nursing is evolving into new fields of health care including ambulance care, where a branch of specialist nursing is growing. Various views exist on the desired competence for the ambulance nurse and valid guidelines are lacking in Sweden. To increase knowledge of the field, professionals were asked to describe what competences an ambulance nurse should possess. The aim of this study was therefore to elucidate the desired professional competence of the specialist ambulance nurse, according to the professionals. A modified Delphi technique was used, where a panel of professional experts expressed their views on the desired competence of the ambulance nurse. This study reports, at a high level of agreement among the panel experts, that the desired competence of the specialist ambulance nurse consist of forty-four separate competences creating ten areas of competences: execute leadership, generic abilities, interpersonal communication, institutional collaboration, pedagogic skills, possession of relevant knowledge, professional judgement, professional skills, research activities, and technical skills. The high level of agreement among the professionals as well as the large number of competences reflects the high demands placed on the ambulance nurse by the professionals themselves.
Background: Methoxyflurane (MTX) is an inhalation agent that has several potential benefits for limiting various types of pain in ambulance care.
Aim: To elucidate how ambulance nurses experience the characteristics of MTX in an ambulance care setting.
Method: This cross-sectional study applied a mixed-methods approach, using a questionnaire together with complementary interviews. The questionnaire survey was analyzed using descriptive statistics (10-point Likert scale and question index values [Q-IV], range: 0-1.0). The interviews were analyzed using directed content analysis. Study results were reported following the STROBE statement.
Results: The ambulance nurses' overall general satisfaction with the MTX concept had a median of 7.0 (IQR 5-8), corresponding to a mean Q-IV of 0.84 (very good experience). The qualitative part was divided into three categories: sense of security, patient participation, and general usefulness. The results revealed varying experiences of usefulness, including pain-relieving effect and the possibility of patient participation. The perceived strong odor of MTX seemed to concern the ambulance nurses and their patients.
Conclusion: In general, MTX was experienced as a safe and effective analgesic. However, the experiences of the overall usefulness varied, particularly since the product had a perceived strong odor. Increasing knowledge of using MTX, could likely increase the overall usefulness.
BACKGROUND: From a patient safety perspective, it is of great importance that decision support systems such as triage scales are evidence based. In the most recent national survey, the majority of Swedish Emergency Departments (EDs) apply the Swedish triage scale known as the Medical Emergency Triage Treatment Scale (METTS), subsequently renamed the Rapid Emergency Triage Treatment Scale (RETTS©). Despite national widespread implementation, there has been limited research on METTS/RETTS©.
AIM: To determine the reliability of application by registered nurses of the RETTS© triage scale in two Swedish emergency departments.
METHODS: In this prospective, cross-sectional study at two EDs, 46 written patient scenarios were triaged by 28 registered nurses (RNs). Data were analysed with descriptive statistics and Fleiss kappa (κ).
RESULTS: The RNs allocated 1281 final triage levels. There was concordance in seven (15%) of the scenarios, and dispersion over two or more triage levels in 39 (85%). Dispersion across the stable/unstable patient boundary was found in 21 (46%) scenarios. Fleiss κ was 0.562, i.e. moderate agreement.
CONCLUSION: The inability of the triage scale to distinguish between stable/unstable patients can lead to serious consequences from a patient safety perspective. No general pattern regarding concordance or dispersion was found.