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- Blomberg, Hans, 1963-
(författare)
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Influence of The Education and Training of Prehospital Medical Crews on Measures of Performance and Patient Outcomes
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Prehospital care has developed dramatically the last decades with the implementation of new devices and educational concepts. Clinical decisions and treatments have moved out from the hospitals to the prehospital setting. In Sweden this has been accompanied by an increase in the level of competence, i.e. by introducing nurses in the ambulances. With some exceptions the scientific support for these changes is poor.This thesis deals with such changes in three different subsets of prehospital care: Cardiopulmonary resuscitation (CPR), the stroke chain of survival and trauma care.We assessed the performance of ambulance crews during CPR, using a mechanical compression device, as compared to CPR using manual compressions. There was a strikingly poor quality of compressions using the mechanical device compared to CPR with manual compressions. The result calls for caution when implementing a chest compression device in clinical practice and reinforce the importance of randomised controlled trials to evaluate new interventions. Careful attention should be given to the assurance of correct application of the device. Further implementation without evaluation of the quality of mechanical compressions in a clinical setting is discouraged.Among patients with a prehospital suspicion of stroke we analysed the ambulance nurses’ ability to select the correct patient subset eligible for a CT scan as a preparation for potential thrombolysis. The results do not support an implementation of a bypass of the emergency department, using ambulance nurse competence to select patients eligible and suitable for a CT scan without a preceding assessment by a physician.The association between the Prehospital Trauma Life Support (PHTLS) course and the outcome in victims of trauma was analysed in two observational studies. A study covering one county gave some support for a protective effect from PHTLS, but the estimate had a low precision. A nationwide study, covering all of Sweden, could not confirm those results. Although there was a reduction in mortality over time coinciding with the implementation of PHTLS, it did not appear to be associated with the implementation of PHTLS. Thus, we could not detect any clear beneficial impact of the PHTLS course on the outcome of trauma patients.
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| 2. |
- Burström, Lena
(författare)
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Patient Safety in the Emergency Department : Culture, Waiting, and Outcomes of Efficiency and Quality
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this thesis was to investigate patient safety in the emergency department (ED) and to determine whether this varies according to patient safety culture, waiting, and outcomes of efficiency and quality variables.I: Patient safety culture was described in the EDs of two different hospitals before and after a quality improvement project. The questionnaire “Hospital Survey on Patient Safety Culture” was used to investigate the patient safety culture. The main finding was that the staff at both hospitals scored more positively in the dimension Team-work within hospital after implementing a new work model aimed at improving patient flow and patient safety in the ED. Otherwise, we found only modest improvements.II: Grounded theory was used to explore what happens in the ED from the staff perspective. Their main concern was reducing patients’ non-acceptable waiting time. Management of waiting was improved either by increasing the throughput of patient flow by structure pushing and by shuffling patients, or by changing the experience of waiting by calming patients and by feinting to cover up.III: Three Swedish EDs with different triage models were compared in terms of efficiency and quality. The median length of stay was 158 minutes for physician-led team triage compared with 243 and 197 minutes for nurse–emergency physician and nurse–junior physician triage, respectively. Quality indicators (i.e., patients leaving before treatment was completed, the rate of unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days) improved under the physician-led team triage.IV: Efficiency and quality variables were compared from before (2008) to after (2012) a reorganization with a shift of triage model at a single ED. Time from registration to physician decreased by 47 minutes, and the length of stay decreased by 34 minutes. Several quality measures differed between the two years, in favour of 2012. Patients leaving before treatment was completed, unscheduled return within 24 and 72 hours, and mortality rate within 7 and 30 days all improved despite the reduced admission rate.In conclusion, the studies underscore the need to improve patient safety in the ED. It is important to the patient safety culture to reduce patient waiting because it dynamically affects both patients and staff. Physician-led team triage may be a suitable model for reducing patient waiting time and increasing patient safety.
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| 3. |
- Düring, Joachim, et al.
(författare)
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Influence of circulatory shock at hospital admission on outcome after out-of-hospital cardiac arrest
- 2022
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Ingår i: Scientific Reports. - : Springer Science and Business Media LLC. - 2045-2322. ; 12:1
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Tidskriftsartikel (refereegranskat)abstract
- Hypotension after cardiac arrest could aggravate prolonged hypoxic ischemic encephalopathy. The association of circulatory shock at hospital admission with outcome after cardiac arrest has not been well studied. The objective of this study was to investigate the independent association of circulatory shock at hospital admission with neurologic outcome, and to evaluate whether cardiovascular comorbidities interact with circulatory shock. 4004 adult patients with out-of-hospital cardiac arrest enrolled in the International Cardiac Arrest Registry 2006–2017 were included in analysis. Circulatory shock was defined as a systolic blood pressure below 90 mmHg and/or medical or mechanical supportive measures to maintain adequate perfusion during hospital admission. Primary outcome was cerebral performance category (CPC) dichotomized as good, (CPC 1–2) versus poor (CPC 3–5) outcome at hospital discharge. 38% of included patients were in circulatory shock at hospital admission, 32% had good neurologic outcome at hospital discharge. The adjusted odds ratio for good neurologic outcome in patients without preexisting cardiovascular disease with circulatory shock at hospital admission was 0.60 [0.46–0.79]. No significant interaction was detected with preexisting comorbidities in the main analysis. We conclude that circulatory shock at hospital admission after out-of-hospital cardiac arrest is independently associated with poor neurologic outcome.
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| 4. |
- Ebner, Florian, et al.
(författare)
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The association of partial pressures of oxygen and carbon dioxide with neurological outcome after out-of-hospital cardiac arrest : an explorative International Cardiac Arrest Registry 2.0 study
- 2020
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Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : Springer Science and Business Media LLC. - 1757-7241. ; 28:1, s. 67-67
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Exposure to extreme arterial partial pressures of oxygen (PaO2) and carbon dioxide (PaCO2) following the return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA) is common and may affect neurological outcome but results of previous studies are conflicting.METHODS: Exploratory study of the International Cardiac Arrest Registry (INTCAR) 2.0 database, including 2162 OHCA patients with ROSC in 22 intensive care units in North America and Europe. We tested the hypothesis that exposure to extreme PaO2 or PaCO2 values within 24 h after OHCA is associated with poor neurological outcome at discharge. Our primary analyses investigated the association between extreme PaO2 and PaCO2 values, defined as hyperoxemia (PaO2 > 40 kPa), hypoxemia (PaO2 < 8.0 kPa), hypercapnemia (PaCO2 > 6.7 kPa) and hypocapnemia (PaCO2 < 4.0 kPa) and neurological outcome. The secondary analyses tested the association between the exposure combinations of PaO2 > 40 kPa with PaCO2 < 4.0 kPa and PaO2 8.0-40 kPa with PaCO2 > 6.7 kPa and neurological outcome. To define a cut point for the onset of poor neurological outcome, we tested a model with increasing and decreasing PaO2 levels and decreasing PaCO2 levels. Cerebral Performance Category (CPC), dichotomized to good (CPC 1-2) and poor (CPC 3-5) was used as outcome measure.RESULTS: Of 2135 patients eligible for analysis, 700 were exposed to hyperoxemia or hypoxemia and 1128 to hypercapnemia or hypocapnemia. Our primary analyses did not reveal significant associations between exposure to extreme PaO2 or PaCO2 values and neurological outcome (P = 0.13-0.49). Our secondary analyses showed no significant associations between combinations of PaO2 and PaCO2 and neurological outcome (P = 0.11-0.86). There was no PaO2 or PaCO2 level significantly associated with poor neurological outcome. All analyses were adjusted for relevant co-variates.CONCLUSIONS: Exposure to extreme PaO2 or PaCO2 values in the first 24 h after OHCA was common, but not independently associated with neurological outcome at discharge.
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| 5. |
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| 6. |
- Eikeland Husebö, Sissel, et al.
(författare)
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The Relationship Between Facilitators’ Questions and the Level of Reflection in Postsimulation Debriefing
- 2013
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Ingår i: Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. - 1559-2332 .- 1559-713X. ; 8:3, s. 135-42
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: Simulation-based education is a learner-active method that may en- hance teamwork skills such as leadership and communication. The importance of postsimulation debriefing to promote reflection is well accepted, but many questions concerning whether and how faculty promote reflection remain largely unanswered in the research literature. The aim of this study was therefore to explore the depth of re- flection expressed in questions by facilitators and responses from nursing students during postsimulation debriefings. Methods: Eighty-one nursing students and 4 facilitators participated. The data were collected in February and March 2008, the analysis being conducted on 24 video- recorded debriefings from simulated resuscitation teamwork involving nursing students only. Using Gibbs’ reflective cycle, we graded the facilitators’ questions and nursing students’ responses into stages of reflection and then correlated these. Results: Facilitators asked most evaluative and fewest emotional questions, whereas nursing students answered most evaluative and analytic responses and fewest emotional responses. The greatest difference between facilitators and nursing students was in the analytic stage. Only 23 (20%) of 117 questions asked by the facilitators were analytic, whereas 45 (35%) of 130 students’ responses were rated as analytic. Nevertheless, the facilitators’ descriptive questions also elicited student responses in other stages such as evaluative and analytic responses. Conclusion: We found that postsimulation debriefings provide students with the op- portunity to reflect on their simulation experience. Still, if the debriefing is going to pave the way for student reflection, it is necessary to work further on structuring the debriefing to facilitate deeper reflection. Furthermore, it is important that facilitators consider what kind of questions they ask to promote reflection. We think future research on debriefing should focus on developing an analytical framework for grading reflective questions. Such research will inform and support facilitators in devising strategies for the promotion of learning through reflection in postsimulation debriefings. (Sim Healthcare 00:00Y00, 2013) Key Words: Debriefing, Simulation, Reflection, Facilitators
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| 7. |
- Hagiwara, Magnus
(författare)
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Development and Evaluation of a Computerised Decision Support System for use in pre-hospital care
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of the thesis was to develop and evaluate a Computerised Decision Support System (CDSS) for use in pre-hospital care.The thesis was guided by a theoretical framework for developing and evaluating a complex intervention. The four studies used different designs and methods. The first study was a systematic review of randomised controlled trials. The second and the last studies had experimental and quasi-experimental designs, where the CDSS was evaluated in a simulation setting and in a clinical setting. The third study included in the thesis had a qualitative case study design.The main findings from the studies in the thesis were that there is a weak evidence base for the use of CDSS in pre-hospital care. No studies have previously evaluated the effect of CDSS in pre-hospital care. Due to the context, pre-hospital care is dependent on protocol-based care to be able to deliver safe, high-quality care. The physical format of the current paper based guidelines and protocols are the main obstacle to their use. There is a request for guidelines and protocols in an electronic format among both clinicians and leaders of the ambulance organisations. The use of CDSS in the pre-hospital setting has a positive effect on compliance with pre-hospital guidelines. The largest effect is in the primary survey and in the anamnesis of the patient. The CDSS also increases the amount of information collected in the basic pre-hospital assessment process. The evaluated CDSS had a limited effect on on-the-scene time.The developed and evaluated CDSS has the ability to increase pre-hospital patient safety by reducing the risks of cognitive bias. Standardising the assessment process, enabling explicit decision support in the form of checklists, assessment rules, differential diagnosis lists and rule out worst-case scenario strategies, reduces the risk of premature closure in the assessment of the pre-hospital patient.
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| 8. |
- Johnsson, Jesper, et al.
(författare)
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Functional outcomes associated with varying levels of targeted temperature management after out-of-hospital cardiac arrest — An INTCAR2 registry analysis
- 2020
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Ingår i: Resuscitation. - : Elsevier BV. - 0300-9572 .- 1873-1570. ; 146, s. 229-236
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: Targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) has been recommended in international guidelines since 2005. The TTM-trial published in 2013 showed no difference in survival or neurological outcome for patients randomised to 33 °C or 36 °C, and many hospitals have changed practice. The optimal utilization of TTM is still debated. This study aimed to analyse if a difference in temperature goal was associated with outcome in an unselected international registry population. Methods: This is a retrospective observational study based on a prospective registry — the International Cardiac Arrest Registry 2. Patients were categorized as receiving TTM in the lower range at 32–34 °C (TTM-low) or at 35–37 °C (TTM-high). Primary outcome was good functional status defined as cerebral performance category (CPC) of 1–2 at hospital discharge and secondary outcome was adverse events related to TTM. A logistic regression model was created to evaluate the independent effect of temperature by correcting for clinical and demographic factors associated with outcome. Results: Of 1710 patients included, 1242 (72,6%) received TTM-low and 468 (27,4%) TTM-high. In patients receiving TTM-low, 31.3% survived with good outcome compared to 28.8% in the TTM-high group. There was no significant association between temperature and outcome (p = 0.352). In analyses adjusted for baseline differences the OR for a good outcome with TTM-low was 1.27, 95% CI (0.94–1.73). Haemodynamic instability leading to discontinuation of TTM was more common in TTM-low. Conclusions: No significant difference in functional outcome at hospital discharge was found in patients receiving lower- versus higher targeted temperature management.
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| 9. |
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| 10. |
- Larsen, Robert, 1980-
(författare)
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Risk-Adjustment for Swedish In-Hospital Trauma Mortality using International Classification of disease Injury Severity Score (ICISS) : issues with description and methods
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- IntroductionDifferent methods have been used to describe the epidemiology of trauma with varying results. Crude mortality outcome data differ significantly from risk-adjusted information. A previous standard method for risk-adjustment in trauma was the Injury Severity Score (ISS), although it has several shortcomings. In this thesis I examine Swedish injury statistics from an epidemiological perspective using crude and risk-adjusted mortality, and to adjust for injury I used the International Classification of disease Injury Severity Score (ICISS). The groups of most lethal injuries (fall, traffic, and assault) were examined separately using an ICISS mortality prediction model that focused particularly on the effects on the prediction of mortality by adding coexisting conditions (comorbidity) to it. Differences in mortality between the sexes and changes over time were tested separately.Material and MethodsData from all patients with ICD-10 based diagnoses of injury (ICD-10: V01 to Y36) in the Swedish National Patient Registry and Cause of Death Registry were collected from 1999 to 2012 and used for assessment of mortality and comorbidity. A subgroup (patients in hospital) from 2001-2011 were selected as the study group. Their injuries were in the subgroups of falls, traffic, and assaults, and are the focus of this thesis. Mortality within 30 days of injury was used as the endpoint. The severity of injury was adjusted for using the ICISS, which was first described by Osler et al. The model was also adjusted for age, sex, and comorbidities.ResultsThe study group comprised 815 846 patients (of whom 17 721 died). There was a decrease over time in injuries caused by falls and traffic (coefficient -4.71, p=0.047 and coefficient -5.37, p<0.001), whereas there was no change in assault-related injuries/100 000 inhabitants. The risk-adjusted 30-day mortality showed a decrease in injuries related to traffic and assault (OR 0.95, p<0.001 and OR 0.93, p=0.022) whereas for falls it remained unchanged. There was also a risk-adjusted survival benefit for women, which increased with increasing age. Adjusting for comorbidities made the prediction of 30-day mortality by the ICISS model better (accuracy, calibration, and discrimination). However, most of this effect was found to be the result of the other characteristics of the fall related injury group (they were older, and had more coexisting conditions).ConclusionDuring a 10-year period, there has been a significant overall decrease in crude as well as risk-adjusted mortality for these three injury groups combined. Within these groups there is a clear, risk-adjusted, female survival advantage. The ICISS model for the prediction of mortality improves when comorbidities are added, but this effect is minor and seen mainly among the injuries caused by falls, where comorbidity is significant. The ICISS method was a valuable adjunct in the investigation of data on Swedish mortality after injury that has been gathered from health care registry data.
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