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Dissertations / Theses on the topic 'Emergency care'
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Hodkinson, Peter William. "Developing a patient-centred care pathway for paediatric critical care in the Western Cape." Doctoral thesis, University of Cape Town, 2015. http://hdl.handle.net/11427/17259.
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Includes bibliographical referencesBackground: Emergency care of critically ill or injured children requires prompt identification, high quality treatment and rapid referral. This study examines the critical care pathways in a health system to identify preventable care failures by evaluating the entire pathway to care, the quality of care at each step along the referral pathway, and the impact on patient outcomes. Methods: A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation until paediatric intensive care unit admission or emergency centre death, using a modified confidential enquiry process of expert panel review and caregiver interview. Outcomes were expert panel assessment of quality of care, avoidability of death or PICU admission and severity at PICU admission, identification of modifiable factors, adherence to consensus standards of care, as well as time delays and objective measures of severity and outcome. Results: The study enrolled 282 children: 85% medical and 15% trauma cases (252 emergency admissions, and 30 children who died at referring health facilities). Global quality of care was graded poor in 57(20%) of all cases and 141(50%) had at least one major impact modifiable factor. Key modifiable factors related to access and identification of the critically ill, assessment of severity, inadequate resuscitation, delays in decision making and referral, and access to paediatric intensive care. Standards compliance increased with increasing level of healthcare facility, as did caregiver satisfaction. Children presented primarily to primary health care (54%), largely after hours (65%), and were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 74% of children, indicating room for improvement. Conclusions and Relevance: The study presents a novel methodology, examining the quality of paediatric critical care across a health system in a middle income country. The findings highlight the complexity of the care pathway and focus attention on specific issues, many amenable to suggested interventions that could reduce mortality and morbidity, and optimize scarce critical care resources; as well as demonstrating the importance of continuity and quality of care throughout the referral pathway.
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Abd, Hamid Harris Shah. "Situation awareness amongst emergency care practitioners." Thesis, Loughborough University, 2011. https://dspace.lboro.ac.uk/2134/9114.
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The increase and changes in the demand for emergency care require pro-active responses from the designers and implementers of the emergency care system. The role of Emergency Care Practitioner (ECP) was introduced in England to improve the delivery of emergency care in the community. The role was evaluated using cost-benefit approach and compared with other existing emergency care roles. An analysis of the cognitive elements (situation awareness (SA) and naturalistic decision making (NDM)) of the ECP job was proposed considering the mental efforts involved. While the cost-benefit approach can justify further spending on developing the role, a cognitive approach can provide the evidence in ensuring the role is developed to fulfil its purpose. A series of studies were carried out to describe SA and NDM amongst ECPs in an ambulance service in England. A study examined decision-making process using Critical Decision Method interviews which revealed the main processes in making decision and how information was used to develop SA. Based on the findings, the subsequent studies focus on the non-clinical factors that influence SA and decision making. Data from a scoping study were used to develop a socio-technical systems framework based on existing models and frameworks. The framework was then used to guide further exploration of SA and NDM. Emergency calls that were assigned to ECPs over a period of 8 months were analysed. The analysis revealed system-related influences on the deployment of ECPs. Interviews with the ECPs enabled the identification of influences on their decision-making with respect to patient care. Goal-directed task analysis was used to identify the decision points and information requirements of the ECPs. The findings and the framework were then evaluated via a set of studies based on an ethnographic approach. Participant observations with 13 ECPs were carried out. Field notes provided further insight into the characteristics of jobs assigned to the ECPs. It was possible to map the actual information used by the ECP to their information needs. The sources of the information were classified according to system levels. A questionnaire based on factors influencing decision-making was tested with actual cases. It was found that the items in the questionnaire could reliably measure factors that influence decision-making. Overall, the studies identify factors that have direct and indirect influences on the ECP job. A coherent model for the whole emergency care systems can be developed to build safety into the care delivery process. Further development of the ECP role need to consider the support for cognitive tasks in light of the findings reported in this thesis.
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Powell, Cindy M. "Parental perception of pediatric emergency care /." Staten Island, N.Y. : [s.n.], 1997. http://library.wagner.edu/theses/nursing/1997/thesis_nur_1997_powel_paren.pdf.
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Kihlgren, Annica. "Older patients in transition : from home care towards emergency care /." Stockholm, 2005. http://diss.kib.ki.se/2005/91-7140-271-3/.
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Maurin, Söderholm Hanna. "Emergency visualized : exploring visual technology for paramedic-physician collaboration in emergency care." Doctoral thesis, Högskolan i Borås, Institutionen Biblioteks- och informationsvetenskap / Bibliotekshögskolan, 2013. http://urn.kb.se/resolve?urn=urn:nbn:se:hb:diva-3658.
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This thesis explores the potential of visual information and communication technologies (ICTs) for collaboration in emergency care. The thesis consists of four studies exploring future technology, 3D telepresence technology for medical consultation (3DMC), from several different methodological and analytical perspectives. Together the studies provide a broad view of the potential benefits, risks and implications of using visual technologies for collaboration in emergency care. The results show that paramedic-physician collaboration via 3DMC might have some benefits for patient care, both in the immediate patient care situation and beyond, for example, when coordinating transport and resources; improving understanding between different actors; and in developing paramedic competence and confidence in their skills. However, collaboration is heavily impacted by physicians’ and paramedics’ respective work practices which are situated in very different physical, professional and organizational contexts. Adding a visual dimension to this collaboration presents unique challenges for the overall design, development, implementation, and appropriation process. Thus, the thesis emphasizes the importance of understanding both the individual users as well as the complex overall image which, although often neglected or ignored, is crucial to understand when developing and introducing new technology that is successful and justified in the overall context while also being useful and meaningful for the individual users.Academic dissertation for the Degree of Doctor of Philosophy in Library and Information Science at the University of Gothenburg and the University of Borås to be publicly defended on Thursday 19 September 2013 at 13:15 in the auditorium at Simonsland, University of Borås, Skaraborgsvägen 3, Borås.
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Stander, Charnelle. "Prehospital emergency care provider’s understanding of their responsibilities towards a mental health care user, during a behavioural emergency." Master's thesis, Faculty of Health Sciences, 2019. http://hdl.handle.net/11427/31266.
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Background: Prehospital emergency care providers in South Africa are regularly called to assist with the management of mental healthcare users. The Mental Health Care Act no 17 of 2002 regulates mental healthcare in South Africa but makes no reference to the roles and responsibilities of prehospital emergency care providers in the provision of mental healthcare, rather giving the South African Police Services authority over the wellbeing of a mental healthcare user outside the hospital setting. Aims: To investigate what prehospital emergency care providers understand their responsibilities are towards a mental healthcare user and the community during the management of a behavioural emergency. Setting: Prehospital emergency care providers from the three main levels of care, currently operational within the boundaries of Pretoria. Methods: A grounded theory qualitative study design was chosen using semi-structured focus groups for each level of prehospital emergency care; Basic Life Support, Intermediate Life Support and Advanced Life Support. Data from each focus group was collected through audio recordings, transcribed and analysed using a framework approach. Results: A total of 19 prehospital emergency care providers from all three main levels of care participated in the focus group discussions (4 BLS, 6 ILS and 9 ALS). Four main themes were identified: Perceptions of behavioural emergencies, responsibilities, understanding of legislation and barriers experienced. Conclusion: Participants placed high value on their moral and medical responsibilities towards a mental healthcare user and would like to have the backing of legislation to fulfil their role. There is a desire for better education, skill development and awareness of mental healthcare in the prehospital emergency care setting.
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Symons, Nicholas. "Quality of care in emergency general surgery." Thesis, Imperial College London, 2014. http://hdl.handle.net/10044/1/18617.
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There are more than 600,000 emergency general surgery admissions per year in England. These patients comprise about 50 percent of general surgical workload but make up 80-90 percent of all general surgical deaths. In recent years surgical colleges and societies in the UK have warned of significant variability in the quality of care between hospitals but, to date, little formal evaluation of the quality of care in emergency general surgery exists. This thesis uses the Structure/Process/Outcome quality assessment framework, devised by Avedis Donabedian, to examine quality of care in emergency general surgery across all three of these domains. A study of high risk emergency general surgical admissions using the administrative Hospital Episode Statistics dataset demonstrated significant variability in 30-day in-hospital mortality between NHS Trusts. Investigation of NHS Trust structure was performed using data from the Department of Health. There were significant differences in the provision of intensive care beds and in the utilization of computed tomography and ultrasound scanning between low mortality and high mortality NHS Trusts. The process of care was assessed using an explicit checklist for the admission phase of care and using ethnographic field notes for patients’ subsequent hospital stay. Across 5 London hospitals, process reliability during admissions to hospital was poor, with nearly 20% of recommended processes omitted. Failures in the process of care were also common in subsequent ward based care. Failures were considered to be highly preventable and frequently caused harm to patients or delayed their discharge. Overall, this thesis has identified significant variability in the quality of care for emergency general surgical patients in structure, process and outcomes. While the thesis does not evaluate every single aspect of patient care it demonstrates the degree of improvement required in emergency surgical care and provides some recommendations for future quality improvement.
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Bae, Crystal. "Emergency care assessment tool for health facilities." Master's thesis, University of Cape Town, 2016. http://hdl.handle.net/11427/20990.
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Includes bibliographical referencesTo date, health facilities in Africa have not had an objective measurement tool for evaluating essential emergency service provision. One major obstacle is the lack of consensus on a standardized evaluation framework, applicable across a variety of resource settings. The African Federation for Emergency Medicine has developed an assessment tool, specifically for low- and middle-income countries, via consensus process that assesses provision of key medical interventions. These interventions are referred to as essential emergency signal functions. A signal function represents the culmination of knowledge of interventions, supplies, and infrastructure capable for the management of an emergent condition. These are evaluated for the six specific clinical syndromes, regardless of aetiology, that occur prior to death: respiratory failure, shock, altered mental status, severe pain, trauma, and maternal health. These clinical syndromes are referred to as sentinel conditions. This study used the items deemed "essential", developed by consensus of 130 experts at the African Federation for Emergency Medicine Consensus Conference 2013, to develop a tool, the Emergency Care Assessment Tool (ECAT), incorporating these using signal functions for the specific emergency sentinel conditions. The tool was administered in a variety of settings to allow for the necessary refinement and context modifications before and after administering in each country. Four countries were chosen: Cameroon, Uganda, Egypt, and Botswana, to represent West/Central, East, North, and Southern Africa respectively. To enhance effectiveness, ECAT was used in varying facility levels with different health care providers in each country. This pilot precedes validation studies and future expansive roll out throughout the region.
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Lin, Junwei, and 林俊伟. "Overcrowding in emergency departments in Hong Kong and interventions to improve emergency care." Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2013. http://hdl.handle.net/10722/193798.
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Background Emergency department (ED) overcrowding has become a worldwide problem over the past few years, which has been reported in USA, Canada, New Zealand and Australia. For the past two decades, ED overcrowding has also become a controversial issue in Hong Kong, due to high demand for emergency service and misuse of emergency services. In 2002, although there was a charge for emergency department visit which led to a markedly decrease (19.1%) of total attendance, but now the rising trend of ED overcrowding seems to resurface during past few years. This paper aims to review and synthesis causes of ED overcrowding and possible interventions so as to provide possible recommendations for emergency care in Hong Kong.
Methods Literatures on ED overcrowding and potential interventions were searched from PubMed, Google Scholar and Google to locate all relevant articles in English up to May 2013. Through PubMed, ED was described using “Emergency Medicine [MeSH]” OR “emergency department” OR “emergency”, and overcrowding was described using “Crowding [MeSH]” OR “crowded” OR “overcrowding” OR “overcrowded” OR “congestion”, and interventions was described using “interventions” OR “solutions”. Besides, relevant emergency medicine literatures published from the Hong Kong Journal of Emergency Medicine were also reviewed.
Results
I identified and reviewed relevant articles and found that ED attendance has been steadily rising during the past decades in Hong Kong. Although the causes may be somewhat different between different countries, causes of ED overcrowding could be related to easy access to emergency services, barriers to primary care as well as specialist care, and the rising aging population which might be an important underlying cause. As the problem of ED overcrowding will have significant negative impact on patient outcomes, such as unnecessary death, two common interventions to the problem are increasing the resources and demand management. Apart from increasing resources within emergency departments to cater for the increasing demand, it is of highly significance to improve community and primary care for the needs of older people who will contribute a great proportion to ED overcrowding in the future.
Conclusion Semi-urgent and non-urgent visits do account for a great proportion among the total attendance, so it is important triage these patients to alleviate the overcrowding. What’s more, pressure on EDs can be related to a significant increase in the number of elderly patients who may require more investigation or admissions, and need much longer time to manage. As a result, future health policies should focus more on the aging population to improve emergency care.published_or_final_version
Public Health
Master
Master of Public Health
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Broccoli, Morgan Carol. "Community-based perceptions of emergency care in communities lacking formalised emergency medicine systems." Master's thesis, University of Cape Town, 2015. http://hdl.handle.net/11427/15459.
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Kenya and Zambia face an increasing burden of emergent disease, with a high incidence of communicable diseases, increasing prevalence of non-communicable diseases and traumatic injuries. However, neither country has an integrated emergency care system that provides community access to high-quality emergency services. There has been recent interest in strengthening the emergency care systems in these countries, but before any interventions are implemented, an assessment of the current need for emergency care must be conducted, as the burden of acute disease and barriers to accessing emergency care in Zambia and Kenya remain largely undocumented. Aims and Objectives: The aim of this project was to ascertain community-based perceptions of the critical interventions necessary to improve access to emergency care in Zambia and Kenya, with the following objectives: 1. Determine the current pattern of out-of-hospital emergency care delivery at the community level. 2. Identify the communities’ experiences with emergency conditions and the barriers they face when trying to access care. 3. Discover community-generated solutions to the paucity of emergency care in urban and rural settings. Methods: Semi-structured focus groups were piloted in Zambia with 200 participants. Results were analysed with subsequent tool refinement for Kenya. Data were collected via focus groups with 600 urban and rural community members in cities and rural villages in the 8 Kenyan provinces. Thematic analysis of community member focus groups identified frequency of emergencies, perceptions of emergency care, perceived barriers to emergency care, and ideas for potential interventions. Results: Analysis of the focus group data identified several common themes. Community members in Zambia and Kenya experience a wide range of medical emergencies, and they rely on family members, neighbours, and Good Samaritans for assistance. These community members frequently provide assistance with transportation to medical facilities, and also attempt some basic first aid. These communities are already assisting one another during emergencies, and are willing to help in the future. Participants in this study also identified several barriers to emergency care : a lack of community education, absent or non-functional communication systems, insufficient transportation, no triage system, a lack of healthcare providers trained in emergency care, and inadequate equipment and supplies. Conclusions: Community members in Zambia and Kenya experience a wide range of medical emergencies. There is substantial reliance on family members and neighbours for assistance, commonly with transportation. Creating community education initiatives, identifying novel transportation solutions, implementing triage in healthcare facilities, and improving receiving facility care were community-identified solutions to barriers to emergency care.
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Shaffer, Claire. "EMERGENCY DEPARTMENT CROWDING: EXPLORING BIAS AND BARRIERS TO EQUITABLE ACCESS OF EMERGENCY CARE." Master's thesis, Temple University Libraries, 2018. http://cdm16002.contentdm.oclc.org/cdm/ref/collection/p245801coll10/id/487771.
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Urban BioethicsM.A.
The emergency department (ED) has often been considered the safety net of the American healthcare system. It earned this distinction because every person in the United States has access to a medical screening exam and stabilization at an ED regardless of their ability to pay. Unfortunately, over the past several decades, decreasing numbers of EDs and inpatient beds, coupled with increasing rates of ED usage, has led to crowding of EDs across the country. Crowding leads to unsafe conditions that may increase morbidity and mortality for patients, or cause patients to leave the ED without being evaluated by a physician. Essentially, crowding causes a barrier for patients to access their right to emergency evaluation. The problem of crowding is most pronounced in large urban communities, and these already frequently underserved patients suffer the most from the crowding burden. The main cause of crowding seems to be the boarding of admitted patients in the ED, however many often cite high rates of non-urgent patients presenting to the ED as a cause of crowding. Some have even suggested diverting non-urgent patients to help solve the problem of crowding. I became interested in this topic due to crowding concerns and initiatives to decrease the number of patients who left without being seen at my own institution. As I reviewed relevant research, I became aware of my own misconceptions and noted a trend of literature suggesting non-urgent patients are not the cause of crowding. Drawing on research from many different sources, paired with evaluation based on principles in bioethics, I have come to several conclusions. I believe the systematic diversion of non-urgent patients is unsafe, and that the unequal burden of ED crowding on urban communities represents an unjust barrier in access to care. We must continue to carefully research the demographics of patients frequently presenting to EDs to avoid perpetuating stereotypes about which types of patients are responsible for crowding. We should also look for ways to ease the crowding burden in urban communities. Additionally, we should take a qualitative assessment of our individual communities to determine if there are any particular reasons in our community that people choose to use the ED rather than other healthcare options. I believe these suggestions can be an important addition to the efforts already in motion to help reduce ED crowding and provide equitable access to emergency medical evaluation.
Temple University--Theses
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Babst, Terrill Anne. "Trauma nursing care :a workload model." Thesis, Cape Technikon, 2000. http://hdl.handle.net/20.500.11838/1015.
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Thesis (MTech (Business Administration))--Cape Technikon, Cape Town, 2000The current rationalisation of health care in the Western Cape may result in a decrease in the number of patients attending the Trauma Unit at Groote Schuur Hospital (GSH), one of the two large tertiary care hospitals in the Western Cape. This in turn may result in cuts in staff allocations to this unit. The nursing staff need to be proactive in preventing potential cuts which may compromise the services that they offer. Current statistics collected by nursing managers in the trauma unit at GSH provide an indication of the volume of work handled, but do not necessarily capture the intensity of that work. The purpose of this research project will determine the extent to which nursing care required by patients attending the trauma unit at GSH has increased and to establish appropriate staff workload scheduling. The existing classification systems available for assessing patient acuity levels are no longer suitable as they use patient numbers to describe workload. By using a classification system specifically developed for the use by nurse managers in high care units (trauma units), the appropriate staffing norms based on the acuity level of patients can be determined. Finally, this research project will determine a suitable model for measuring the intensity of workload specific to a trauma unit environment for the effective and efficient allocation of staff.
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Thomas, Brian. "Emergency room nurse burnout." Thesis, Pepperdine University, 2016. http://pqdtopen.proquest.com/#viewpdf?dispub=10139345.
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This study explores the pervasiveness of job fatigue in Emergency Room nurses. It identifies factors that contribute to nurse burnout, including job dissatisfaction and workplace bullying, and explores strategies for assessing and reducing fatigue syndrome. As the literature suggests, there is a link between nurse burnout and patient safety. These findings are expected to help organizations develop strategies to reduce stress in the workplace and develop wellness programs. Upon using an interviewing process, the study found several themes that pointed to the key factors of increased ER nurse burnout, and provided several implications as to the changes that need to be made to improve the ER department environment. Some of the key findings included the need to hire more staff, make supervisors and management more approachable and available, and increasing support to ER nurses. Doing so will clearly help mitigate the problem of high stress levels among ER nurses and help to prevent the likelihood of burnout.
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Conradie, Nathan John. "A comparison of critical care transportation modules taught in bachelor's degrees in emergency medical care in South Africa." Master's thesis, Faculty of Health Sciences, 2020. http://hdl.handle.net/11427/32212.
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The aim of this literature review was to collect and appraise literature related to curricula in critical care transportation and retrieval, pre-hospital care, and aeromedical transportation. The search strategy was twofold. Firstly peer-reviewed published literature was sourced from established platforms. Secondly, grey literature was sourced from internet sources. An assessment of reliability and validity was performed on peer-reviewed literature in the appraisal process. The results of the literature review show that there is a paucity of literature describing critical care modules of pre-hospital educational programmes in South Africa. This lack of literature has led the authors of this review to conclude that there is a potential for insufficient benchmarking and standardisation of the critical care module between universities. The results of this study could allow stakeholders to begin the process of academic standardisation. To provide a comprehensive background on the field of critical care transportation and retrieval and specifically education and training, this literature review starts by describing the field locally. It then attempts to outline the risks associated with critical care retrieval and thereby demonstrating the importance of quality education and regulation that can guide practitioners who perform retrievals. It then seeks to understand the importance of standardsetting within education broadly and the role of curricula in standard-setting. Finally, it provides an overview of methods for comparing curricula. After the background sections, the gathered literature was grouped into themes according to the types of curricula included in the literature. All these types of curricula form part of the critical care transportation and retrieval field, as graduates from these programmes are usually involved in the transportation of critically ill patients between facilities.
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Evans, Katya. "Prehospital care providers' decision to transport the patient with a suicide attempt refusing care in the Cape Town Metropole, Western Cape: A survey based on the Mental Healthcare Act of 2002." Master's thesis, University of Cape Town, 2015. http://hdl.handle.net/11427/16478.
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Includes bibliographical referencesAnecdotally incidents of inappropriate refusal of treatment or transportation by patients referred to hospital under the Mental Healthcare Act of 2002 have been noted. There is little documented about the knowledge and understanding of prehospital providers of the mental healthcare act, their responsibilities and the issues around patient competence and refusal of care. The transportation of patients presenting with a suicide attempt who have not yet been formally assessed for involuntary admission poses a particular problem. Aim: To determine the knowledge of prehospital providers with respect to the transport of patients presenting with suicide attempts and the mental health act and to describe their management of cases where these patients may refuse treatment. Methods: A cross-sectional survey and including open ended questions of 100 prehospital providers in the Western Cape both public and private. The questionnaire will include knowledge testing, vignettes describing patient management and open-ended questions regarding their opinions on suicidal patients. Simple descriptive statistics will be used for the knowledge test. Qualitative data will be coded using a grounded theory approach. Discussion: The findings of the study will be used to determine provider knowledge and attitudes regarding the prehospital management of patients presenting with suicide attempts. Recommendations will be made for provincial EMS guidelines and the results will be disseminated in an article for publication.
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Stickney, Remington Bigelow, and Remington Bigelow Stickney. "Transitional Care of Elderly Frequent Emergency Department Users." Diss., The University of Arizona, 2017. http://hdl.handle.net/10150/626348.
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Background: Frequent ED users are generally over the age of 65 years, Medicare beneficiaries, sicker and have more health issues than non-frequent users. Elderly patients suffer a 20% mortality rate upon admission and a 30% decrease in activities of daily living (ADL) after discharge. Transitional care programs (TCP) decrease ED visits and readmission rates, improves ADLs, and increases event-free survival.
Purpose: To evaluate the need of an ED TCP in the ED. Aims are to assess ED providers’, nurses’ and managers’ perceptions of elderly frequent ED users’ discharge needs, resources, and potential role of a TCP.
Methods: Conducted within one community based ED in Tucson, Arizona. Survey content determined by a review of the literature focused upon elderly transitional care. Recruitment of nurses, providers, and managers following verbal consent. Inclusion criteria: willingness to participate in a 10-minute survey and work two shifts a month minimum within the ED. The survey is comprised of 19 questions focused on patient needs, current resources and the role of a TCP. Surveys were followed by a 5-minute post-survey session to review questions regarding content. Questions structured using a Likert scale format and categorical answers. Data analyzed using descriptive statistics. A needs assessment (NA) executive summary was presented to the ED staff and management.
Results: One hundred providers, nurses, and managers completed the survey of which 79% were female, 73% registered nurses, 14% physicians, and 10% advanced practice providers. The majority of respondents believed elderly patients are discharged unsafely, additional resources were needed, more time was spend caring for elderly patients, and TCPs were a viable supportive option. “What is a transitional care team (TCT)?” was the most asked question during question and answer session.
Implications: This NA revealed providers’, nurses’, and managers’ perceptions of elderly frequent ED user needs and the role of a TCP. Concerns identified are consistent with the literature. This NA provided information about ED staff perceptions of elderly frequent users and addressed transitional care while laying the groundwork for the potential future implementation of a TCP initiated in the ED.
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Silva, Andreia Luísa Reis da. "Emergency and critical care of the avian patient." Master's thesis, Universidade Técnica de Lisboa. Faculdade de Medicina Veterinária, 2012. http://hdl.handle.net/10400.5/3988.
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Dissertação de Mestrado Integrado em Medicina VeterináriaIncreasing numbers of exotic animals are being kept as pets and owners want to receive the same high quality veterinary medical care as given to other animals. The field of emergency and critical care is rapidly developing so this dissertation focus on clinically relevant information, some new advances and their application to therapy. In the first part of this work, the data gathered regarding all medical and surgical procedures performed during a four-month externship at Great Western Referrals Hospital, United Kingdom, under the scientific supervision of Dr. Neil Forbes is presented. The second part is a description of the most common emergency presentations, effective diagnostic and therapeutic protocols, including the pathophysiology of shock and fluid therapy. In the third part of this work, 12 clinical cases observed during the externship are presented. These cases were chosed due to their being representative of what the clinician may have to deal with in terms of avian emergency and critical care. For each case, clinical signs, diagnostic testing and treatment are described and discussed. The clinical presentation for each case is extremely diverse with inter- and intra- specific variations which is further complicated by the fact that most avian species mask signs of disease so owners are rarely aware of health problems that may occur. One of the limitations of emergency avian procedures is the challenge to reach an adequate diagnosis and establish adequate treatment protocols for critical patients, for which time is crucial. Stabilization on initial presentation is more urgent than making a definitive diagnosis and supportive care can save more exotic animals than any other treatment.
RESUMO - EMERGÊNCIA E CUIDADOS INTENSIVOS EM AVES - Cada vez mais animais exóticos são mantidos como animais de estimação e os seus donos desejam receber o mesmo nível de qualidade em termos de cuidados médico-veterinários que o prestado a outros animais. O ramo das emergências e cuidados intensivos está a desenvolver-se rapidamente sendo esta dissertação baseada em informação clinicamente relevante, avanços recentes na área e suas aplicações terapêuticas. Na primeira parte deste trabalho é apresentada informação relativa a todos os procedimentos médicos e cirúrgicos realizados durante um estágio de quatro meses no hospital Great Western Referrals, Reino Unido, sob a supervisão científica do Dr. Neil Forbes. A segunda parte contém uma descrição das apresentações clínicas de emergência mais comuns, protocolos de diagnóstico e terapia, incluindo patofisiologia do choque e fluidoterapia. Na terceira parte deste trabalho são apresentados 12 casos clínicos observados durante o estágio. Estes casos foram escolhidos como sendo representativos do que o clínico poderá encontrar em termos de emergência e cuidados intensivos de aves. Para cada caso, sinais clínicos, exames complementares e tratamento são descritos e discutidos. A apresentação clínica de cada caso é extremamente variada, com variações inter- e intra- específicas, sendo isto complicado pelo facto de que a maioria das espécies de aves escondem sinais de doença estando os seus donos raramente conscientes de problemas de saúde que possam ocorrer. Uma das limitações dos procedimentos de emergência em aves é a dificuldade em estabelecer um diagnóstico adequado com o devido protocolo terapêutico em pacientes críticos para os quais o tempo é crucial. A estabilização inicial é mais urgente do que a elaboração de um diagnóstico definitivo e um tratamento de suporte adequado pode salvar mais animais exóticos do que qualquer outro tratamento.
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Ayati, S. B. "A portable EIT system for emergency medical care." Thesis, Loughborough University, 2016. https://dspace.lboro.ac.uk/2134/20770.
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Electrical Impedance Tomography (EIT) is a medical imaging technique in which images of tissue conductivity within a body can be inferred from surface electrode measurements. The main goal of this study is to develop a portable EIT system incorporating an optimized electrode layout to detect intracranial haematomas for use in emergency care. A growing haematoma can cause severe and even permanent damage to the delicate tissue of the brain, morbidity, and eventual death of the patient. No capability is at present available for the diagnosis of haematomas pre-hospitalisation or by first-responders. The lack of this crucial information can lead to bad decisions on patient management, and in particular, where to send the patient. Blood has a high electrical conductivity contrast relative to other cranial tissue and can be detected and monitored using electrical impedance methods. EIT is a non-invasive, low-cost monitoring alternative to other imaging modalities, and has the potential to detect bleeding and to localize the approximate bleeding site. A device of this nature would reduce treatment delays, save on costs and waste, and most significantly, positively impact patient outcomes. The first step was a numerical simulation study on FE models. The full array and the hemi-array electrode layouts were modelled and the anomalies were simulated in different positions with different sizes. The results were obtained using TSVD and WMNM reconstruction methods by COMSOL linked with MATLAB. The simulated anomalies were detected for all the positions using both layouts; however those from the full array were in general superior to the hemi-array. In order to perform realistic experiments, a prototype EIT system was constructed in the laboratory. The constructed EIT has 16 channels and operates in the frequency range of 10 kHz to 100 kHz with a temporal resolution of 100 frames per second and high level of accuracy of 93.5 %. The minimum number of 8 electrodes was chosen in this study for emergency care. Minimizing the number of electrodes speeds up the electrode setup process and avoids the need to move the patient s head in emergency care. In the second part of this study, phantom experiments were performed to find an optimised electrode layout for emergency care. The full array and the hemi-array were investigated using phantom experiments. As expected, the full array layout had the best performance in general; however, the performance of the hemi-array layout was very poor. Thus a novel optimised electrode layout (semi-array) for emergency care was proposed and evaluated in phantom experiments. For the hemi-array and the semi-array layouts, measurement sensitivity depends strongly on the anomaly location since the electrodes are not placed all over the head. The HA layout performed very badly, with the best radial localization error of 0.8100 mm, compared to the SA layout with the worst error of 0.2486 mm. Some reconstructed anomalies located far from the electrodes in the posterior region were almost invisible or erroneous for the hemi-array layout; however, it is enhanced by using the semi-array layout. Finally, in vitro experiments were conducted on ovine models. In most of the experiments carried out by other researchers, since the location of the simulated anomalies was not known and the simulated blood was normally injected into the body or the head, localization of the anomalies was not considered and the quantity of the injected blood was investigated solely. In our new method of experiment, the position of the anomalies was known a priori and thus could be compared accurately to the EIT results. The full array and the semi-array layouts were compared in terms of detection, localisation and size estimation of haematomas. As expected, the full array layout was found to be more robust than the semi-array layout with the best mean value of the localization error of 0.0564 mm and the worst QI error of around 30%. Using a minimum number of electrodes in an optimised layout is always desirable in clinical applications. The semi-array 8-electrode layout prevents unnecessary movements and the electrode connections to the head would be very quick in emergency care. Although the semi-array 8-electrode layout reduced the sensitivity of the measurements, the findings from the experiments indicated its potential to detect and monitor haematomas and probably extend its application for emergency applications where the required accuracy is not critical.
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Rogers, Ruthie Waters. "Implementing Relationship Based Care in an Emergency Department." ScholarWorks, 2015. https://scholarworks.waldenu.edu/dissertations/363.
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When patients and families come to the emergency department seeking medical attention, they come in with many mixed emotions and thoughts. The fast paced, rapid turnover of patients and the chaotic atmosphere may leave patients who visit the emergency department with the perception that staff is uncaring. The purpose of this project was to implement a patient care delivery model, relationship-based care, in the emergency department. The model is comprised of several caring theories including Jean Watson's model of human care and Kristen Swanson's middle range theory of caring. The main goals of the project were to help staff enhance the patient and caregiver interaction, strengthen co-worker relationships, and gain appreciation of the importance of self-care. The intervention was an educational workshop about the relationship-based care model. Eight participants were consented, given a preassessment survey, educated about the model, and then given a postassessment survey. Prior to education, 83% of participants believed strongly that patients and families need to feel cared for during an emergency department visit; this increased to 100% posteducation. Perception about the importance of coworkers' relationships being trusting went from 38% to 50% and the importance of caring for one's self increased from 63% to 100%. It was recommended that the model be implemented in all emergency departments and all staff educated in its use as a way to promote social change through intentional focus on caring in every patient interaction.
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Wood, Robert D. "Emergency Department Nurses' Suggestions for Improving End-of-Life Care." BYU ScholarsArchive, 2012. https://scholarsarchive.byu.edu/etd/3259.
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Introduction: Death is not an uncommon outcome for patients who seek immediate care in an emergency department. Although death is common in the emergency department there is little literature regarding end-of-life care in the emergency department. The purpose of this research study is to determine what changes emergency nurses would suggest to improve end-of-life care for dying patients and their families in emergency departments.
Background: A national, geographically dispersed, random sample of 1000 emergency nurses were sent a questionnaire entitled, "Emergency Nurses' Perceptions of End-of-Life Care." Inclusion criteria included nurses who were members of the Emergency Nurses Association, could read English, worked in an emergency department, and had cared for at least one emergency patient at the end-of-life.
Results: There was an overwhelming consistency in recommended changes to improve care of the dying emergency department patient by the nurses participating in the study. Five major themes were identified: 1) increasing the amount of time emergency nurses have to care for dying patients and their families; 2) consistently allowing family presence during resuscitation; 3) providing a comfortable patient room; 4) providing for more privacy at the end-of-life; and 5) providing a family grief room.
Conclusion: The emergency department will continue to be the primary access point for dying patients to receive medical and nursing care. Implementing changes based on emergency nurse recommendations may dramatically improve the experience for the dying patient as well as their family members.
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Alibhai, Alyshah Zulfikar. "The availability of acute care resources to treat major trauma in different income settings: a self-reported survey of acute care providers." Master's thesis, Faculty of Health Sciences, 2019. http://hdl.handle.net/11427/31405.
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Introduction: Injury and violence is a neglected global health problem, despite being largely predictable and therefor preventable. This study aimed to indirectly describe and compare the availability of resources to manage major trauma between high income, and low- to middle-income countries, as self-reported by delegates at the 2016 International Conference on Emergency Medicine held in Cape Town, South Africa. Materials and methods: A survey was distributed to delegates at the International Conference on Emergency Medicine 2016, Cape Town to achieve the study aim. The survey instrument was based on the 2016 NICE guidelines for the management of patients with major trauma. It captured responses from participants working in both pre- and in hospital settings. Responses were grouped according to income group (either high income, or low- to middle-income) based on the responding delegate’s nationality (using the World Bank definition for income group). A Fisher’s Exact test was conducted to compare delegate responses Results: The survey was distributed and opened by 980 delegates, of whom 392 (40%) responded. A total of 206 (53%) respondents were from high-income countries and 186 (47%) were from low- to middle-income countries. Responders of this self-reported survey described a significant discrepancy between the resources and services available to high income countries s and low- to middle-income countries to adequately care for major trauma patients both pre- and in-hospital. Shortages ranged from consumables to analgesia, imaging to specialist services, pre-hospital to in-hospital. Discussion: Resource restriction is a major concern in the care for major trauma patients in low- to middle-income countries. Current accepted reference standards does not take the resource restrictions that apply to the vast majority of the world’s injured patients into account. More research is required to describe the problem of resource restrictions in low to middle-income countries, and then working out how to overcome it.
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Sobuwa, Simpiwe. "A critical realist study into the emergence and absence of academic success among Bachelor of Emergency Medical Care students." Doctoral thesis, University of Cape Town, 2018. http://hdl.handle.net/11427/29475.
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This critical realist thesis explores academic success in the four-year Bachelor of Emergency Medical Care degree in South Africa. The Bachelor of Emergency Medical Care degree is a relatively new degree that is offered at four universities in South Africa. In view of the existing shortage of paramedics both in South Africa and on the African continent, an understanding of the factors that play a role in academic success may lead to an increase in the number of emergency care providers. Accordingly, this study was conceptualised to explore the reasons why academic success is either evident or absent among Bachelor of Emergency Medical Care students. The study utilised a sequential, explanatory, mixed methods research design. The quantitative phase consisted of an online survey that was disseminated to Bachelor of Emergency Medical Care students in South Africa with the aim of gaining an insight into their socio-cultural history. Continuous and categorical variables were described using basic descriptive statistics. The Pearson’s chi-square and Fisher’s exact test were used to test associations between the various survey variables and repeating a year. A p-value of less than 0.05 was considered to be statistically significant. During the qualitative phase focus groups were held with students while semi-structured interviews were conducted with lecturing staff members. The aim of the qualitative approach was to explore the causal powers and generative mechanisms that give rise to or enable the emergence or absence of academic success among Bachelor of Emergency Medical Care students. Thematic analysis was used to analyse results from the focus groups and semistructured interviews. A critical realist concept of the laminated system was also used to explore the themes that emerged. A total of 176 participants from an available sample of 408 students responded to the survey. Not repeating a year was significantly associated with two important variables, namely, the possession of a pre-existing emergency care qualification and not being a white student. The results revealed that the following interactive generative mechanisms played a role in the lack of academic success, namely, biological, socioeconomic, socio-cultural, normative, psychosocial and psychological factors while the following interactive generative mechanisms facilitated the emergence of academic success – psychological, psycho-social, normative and socioeconomic factors.
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Krook, Maura. "Advanced nurse practitioners in emergency and primary care settings." Thesis, Sophiahemmet Högskola, 2013. http://urn.kb.se/resolve?urn=urn:nbn:se:shh:diva-1395.
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Scott, Patricia. "Sudden death processing : an ethnographic study of emergency care." Thesis, Durham University, 2003. http://etheses.dur.ac.uk/3731/.
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The following doctoral thesis provides an ethnographic account of sudden deathwork performed by emergency personnel. The study centres on three accident and emergency departments in the North East of England. Sudden death practices and perceptions are revealed using thick description from focus groups, narratives and informant accounts. Three emergency disciplines: accident and emergency nurses, police traffic officers and paramedics provide the backdrop to describing three sudden death trajectories, which take the dead body from a state of collapse to a mortuary. Particular attention is paid to the significance of status passage as a temporal dimension of deathwork with due consideration being given to the concept of body handling as 'dirty work'. A feminist concept of embodiment challenges the dominant discourse of the death processing industry in relation to beneficence and non- maleficence for those who are left behind to grieve. The theatrical representation of the body to relatives is discussed within a dramaturgical frame, questioning what is appropriate and achievable within the boundaries of an emergency care environment. An exploration of the roles of emergency personnel illuminates problems of dealing with a phenomenon, which annihilates the possibility of a sense of order and emotionally incapacitates emergency personnel. The procedural base to sudden death is presented through accounts of emergency personnel contact with human suffering and emotional pain with the intention to build a substantive theory of a sudden death milieu. Finally, Schutzian relevances highlight key concepts of significance within the data demonstrating how, despite an evidence-base to practice, some myths are highly influential in shaping the behaviours of emergency personnel throughout the sudden death event. It is hoped that insight gained may provide a catalyst to inform change where needed, in service provision and enhance interprofessional working relationships.
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Fontaine, Nancy Victoria Clair. "An exploration of humour amongst nurses in emergency care." Thesis, University of Essex, 2011. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.537959.
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Buechner-wiegand, Dana K. "Contraception Management at Point of Care for Emergency Contraception." Otterbein University / OhioLINK, 2013. http://rave.ohiolink.edu/etdc/view?acc_num=otbn1367841736.
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Pitchforth, Emma. "Emergency obstetric care : needs of poor women in Bangladesh." Thesis, University of Aberdeen, 2004. http://digitool.abdn.ac.uk/R?func=search-advanced-go&find_code1=WSN&request1=AAIU178610.
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Background: Ensuring that all women have access to emergency obstetric care (EmOC) in the event of a complication is vital. One well-accepted conceptual model suggests that the three main areas of delay facing women in accessing EmOC are: (1) deciding to seek care; (2) reaching an appropriate health facility; and (3) receiving treatment once at a health facility. This study explores whether poorer women are disadvantaged in receiving treatment once at a health facility. Methods: The mixed-method study is based in a large teaching hospital in Bangladesh. The poverty status of obstetrics patients is assessed and a case note review is conducted for women staying in the hospital longer than 24 hours. Treatment and time waited are then analysed by poverty status. A sub-group of women are followed-up for more indepth interviews after discharge. These interviews explore the experience of women and relatives in using EmOC. Observation and staff interviews are also conducted within the hospital. Findings: Compared to the wider population, the poorest women are not utilising EmOC. Women face considerable costs in receiving treatment but there did not appear to be differences in treatment received by different poverty groups. The main costs were for drugs, blood and other medical supplies. Most families had to sell assets or borrow money to meet these costs. The doctors operated a 'poor fund', which could provide help for the poorest women in immediately life threatening situations. The government funded welfare organization did not operate well in emergency cases. Conclusions: As the provision of EmOC increases, efforts must ensure equitable uptake among women of all socioeconomic status. Sustainable support mechanisms are needed within hospitals as well as community-based programmes promoting uptake of care. Better maternity services and strengthening the role of trained midwives may be important in improving the uptake of EmOC.
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Stupples, Caroline Elizabeth. "Enhancing recovery in non-critical care emergency bowel resection." Thesis, University of Northampton, 2016. http://nectar.northampton.ac.uk/8829/.
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Ameh, Charles. "The effectiveness of emergency obstetric care training in Kenya." Thesis, University of Liverpool, 2014. http://livrepository.liverpool.ac.uk/2008539/.
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Background and introduction: Maternal deaths are highest in low resource countries. Skilled attendance at birth (SBA) and the availability of emergency obstetric care (EmOC) are key strategies to improve maternal health and achieve the millennium development goal number 5. In-service emergency obstetric and newborn care (EmONC) training has been used for many years to improve the quality of skilled attendance at birth and availability of EmOC, however few packages have been properly described and evaluated. There is no published comprehensive evaluation of EmONC in-service training packages in low resourced countries. An evaluation of the effectiveness of an EmONC training intervention in 10 comprehensive EmOC Kenya hospitals was carried out from 2010-2011. Methods: A systematic review was performed based on grading of recommendations assessments development and evaluation (GRADE) guidelines to identify the various EmONC training packages in low and middle income countries, identify literature on the effectiveness of these packages or effectiveness of various components of EmONC training globally. The components of the intervention were training in EmONC, provision of EmOC equipment and supportive supervision. The objective of the intervention was to improve the recognition and treatment of emergency obstetric and newborn complications at all study sites by trained maternity care providers (MCP). A before/after study design and an adapted four level Kirkpatrick framework (level 1: reaction to training, level 2: learning, level 3: behaviour/practice, level 4: EmOC availability, health outcomes and ‘up-skilling’) was used to evaluate the effectiveness of the training package. Mixed research methods (quantitative and qualitative approaches) were used to collect data 3 months before the intervention and at 3 monthly intervals after up to 12 months after the intervention. Quantitative data were analysed using SPSS version 20 and qualitative data was analysed using Nvivo 9. Descriptive statistics and analysis using t-tests were performed for quantitative data (significance in mean difference at 95% confidence) while framework analysis was used for qualitative data. Results: 20 EmONC in-service training programmes implemented in low and middle-income countries were identified. The content of 85% (17) of the programmes identified included EmOC signal functions and 7 programmes were 7 days or more in duration. 50% (10) of the EmONC training packages identified had training reports of which only two studies were evaluated at Kirkpatrick level 3 (behaviour) and there was no evaluation at level 4 (health outcomes) identified. Over 70% of all identified maternity care providers from all 10 hospitals were trained. 83% (328) of the 400 health care workers trained were midwives, 6% (26) were medical doctors, 2% (8) were clinical officers and 3% (11) were obstetricians. At 12 months post training the proportion of MCP trained in each hospital was at least 83% except for Nakuru PGH (23%) and Mbagathi GH (50%). Kirkpatrick level 1: About 95% (380) participants responded to level 1 assessment questionnaire. Trainees reacted positively to all lectures (n=11, mean score was 9.38/100, SD: 0.12) and breakout sessions (n=25, mean score was 9.33/10, SD: 0.14). Kirkpatrick level 2: There was a statistically significant difference between the pre and post training knowledge scores in all modules except preventing obstructed labour 0.10 CI (0.06-0.26) p=0.201. The mean difference between pre and post-test skill scores was statistically significant 3.5 CI (3.3-3.8) P<0.001, n=284. Kirkpatrick level 3: 153 data sources (FGDs, paired interviews, KIIs) were collected over 12 months and analysed. 49% (184) and 129 (34.5%) of health care workers and managers participated. They reported a positive impact of the intervention on communication and teamwork, pre-service midwifery education, reduced treatment time, improved knowledge, skills, improved confidence to perform EmOC, organisation of care and supportive supervision. Availability of EmOC equipment post training and supportive supervisors were factors that facilitated change in practice post training. Barriers to availability of EmOC identified were poor staff deployment and retention policy post training, lack of equipment to perform EmONC, lack of support from obstetricians, senior midwives and nurse/midwifery administrators, lack of training for all MCP (including medical interns, medical officers and staff from lower level health care facilities) and lack of clarity on the scope of practice for nurses/midwives. Kirkpatrick level 4: 16, 764 and 17, 404 deliveries were conducted at baseline and at 12 months post intervention respectively. There was 66.8% increase in obstetric complications recorded and managed at 12 months post training compared to baseline. Health outcome indicators: There was an expected increasing trend for number of complications recorded and treated, availability of SBA and EmOC. There was also an expected decreasing trend in the proportion of newborns admitted to NBU for birth asphyxia, direct obstetric case fatality rate (DOCFR) and stillbirth rate (SBR). There was no change in caesarean section (C/S) rate or Fresh stillbirth rate (FSBR). For the health outcome indicators (DOCFR, SBR, FSBR), when PGH Nakuru was excluded from the analysis, a non-statistically significant reduction but greater effect at 12 months compared to baseline was observed for complications recorded and treated (87.9% vs. 66.8%), DOCFR (47% vs. 35%), SBR (66% vs. 34%) and FSBR (14 vs. 10%). There was 34%, 48%, and 35% mean reduction in the SBR, proportion of newborns admitted to newborn care unit and DOCFR at 12 months post intervention compared to baseline respectively. “Up-skilling” indicators: There was a 53.8%, 80%, 100% mean increase in the proportion of all breech vaginal deliveries, proportion of all vacuum extractions performed and proportion of vacuum extractions performed by non-physician clinicians, at 12 months post intervention compared to baseline. Assisted vaginal delivery by vacuum extraction was the least available EmOC signal function (SF) and medical doctors only performed this SF at baseline. At 12 months post intervention, non-physician clinicians performed this as well, in all study sites. Overall the EmONC training intervention resulted in improved ‘up-skilling’ of maternity care providers, a trend towards improved availability of SBA and EmOC and improved health outcomes. Implications for policy and practice The results of this study are important for designing and implementing evidence based EmONC programmes in resource poor countries. None medical doctors can be ‘up-skilled’, the recognition and management of obstetric and newborn emergencies and the availability of quality EmOC can be improved using similar packages and implementation methods in other resource poor settings. Future research: Evaluation designs that include control groups are needed. Studies to assess the relative importance of supportive supervision for behaviour change after training, the knowledge and skills retention with time post training in resource limited settings should be undertaken.
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Kereri, Dovison. "Relationship between Affordable Care Act and Emergency Department Visits." Diss., NSUWorks, 2018. https://nsuworks.nova.edu/hpd_hs_stuetd/11.
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Affordable Care Act (ACA) was passed and implemented to expand insurance coverage, reduce health care cost, and improve the quality of care. The purpose of this dissertation study was to investigate whether the ACA insurance expansion correlates with the number of visits made to emergency departments (EDs). The quasi-experimental design interrupted time series was utilized in the analysis. The ED visits were compared using MANOVA to determine the relationship between ED visits and ACA and canonical correlation analysis to assess the strength of the relationship and the extent to which independent variables could predict the dependent variable. The hypothesis was that the ACA will reduce the uninsured, increase the insured, and reduce the ED visits. The relationship between number of ED visits and the ACA will present whether the uninsured patients contributed significantly to the ED overcrowding. Analysis of secondary data from four EDs (H1, H2, H3, and H4) in the Chicago area showed that 484,742 visits were made, and 2,801 were excluded due to unknown payer type. Medicaid patients recorded the largest number of visits (181,226) while the uninsured patients recorded the least number of visits (56,572). The ED visits decreased by 6% from 2012 to 2013 (pre-ACA) and increased by 4% from 2013 to 2105 (post-ACA). The ACA implementation increased the people with insurance who visited the EDs by 11%. The results demonstrated a strong relationship between ACA and ED visits. The correlation of the variables (hospital and year) and ED visits demonstrated that the hospital could explain 97% of the Medicaid visits and 87% of uninsured while the year could predict 82.6% of the uninsured visits and 52.5% of Medicaid visits.
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Gihwala, Raina Tara. "Out-of-hospital assessment and management of rape survivors by pre-hospital emergency care providers in the Western Cape." Master's thesis, University of Cape Town, 2016. http://hdl.handle.net/11427/21186.
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South African incidence of rape ranks amongst the highest worldwide. No direct policy exists for the emergency care provider management of rape victims in the pre-hospital setting. The pre-hospital exposure to rape cases is unknown as its health information system is not gender-based violence sensitive. In the absence of a clearly defined protocol, indiscretion in the emergency care treatment of rape victims remains undocumented. As a particularly vulnerable group globally, victims of rape are deserving of focused intervention. A qualitative, descriptive approach guided the research in which nine semi-structured voluntary interviews were held with emergency care providers, forensic medical practitioners and emergency consultants. Through a critical theory lens thematic content analysis was employed. University of Cape Town ethics approval was attained. The study found that pre-hospital providers lack knowledge and skills of rape victim identification and management but are desirous of evidence-informed guidelines for treatment and referral in a multidisciplinary approach. Educational and policy deficiencies are documented. The recommendations support a community of practice that is mutually inclusive of specialist rape-care centres, emergency department and pre-hospital providers in the interest of forensic emergency medicine. Due regard must be had for needs of practitioners at risk of vicarious traumatization from sexual assault management. Transformative curricula and responsive clinical guidelines are likely to redress any complicity of the health sector non-response to rape/sexual assault. This study is likely to benefit emergency care regulators, educators and researchers whose professional interest is to promote responsivity of the health system to rape.
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Diango, Ken Ngoy. "Teleconsultation for diagnosis and care of burn injuries in the Western Cape: Evaluation of healthcare providers intention to use mHealth technology." Master's thesis, Faculty of Health Sciences, 2021. http://hdl.handle.net/11427/32649.
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Background: Burn care in resource-constrained settings represents a significant challenge. Mobile health (mHealth) could have useful advantages by providing timely expert advice. As part of a larger study on teleconsultation in burn care, a mobile application – the Vula App – was developed and tested in the Western Cape. This study gauges healthcare providers' intention to use this mHealth technology and factors influencing its adoption. Methods: 48 healthcare providers working in Emergency Centres of three health facilities answered a questionnaire immediately after being trained in the use of the app. The survey was based on the Technology Acceptance Model of Davis and included the constructs of ease of use, usefulness, design quality, impact on care, compatibility, and behavioural intention to adopt. Descriptive statistics were used for data analysis. Results: The mean age of participants was 29.5 years old and the male-to-female ratio was 1:2. 73.9% of respondents were doctors and the remainder nurses. 93.4% of them already owned and used smartphones, with 76% using them in medical practice. 93% of respondents thought the app was easy to use and 91.3% found it useful. 17.8% found it incompatible with their routine work. 84.8% of participants expressed their intention to adopt and use the system. 4.3% of participants rejected it and 10.9%remained undecided. Conclusion: The majority of participants already used smartphones and found the Vula app useful, easy to use, well designed, beneficial in burn care and compatible with their routine work. These factors led them to express the intention to use the app. This significantly predicts actual future use and is essential to the successful implementation of mHealth.
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Muange, Dennis. "A descriptive analysis of emergency care provided in Northern Somalia." Master's thesis, Faculty of Health Sciences, 2019. http://hdl.handle.net/11427/30893.
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Emergency care is an integral part of an effective healthcare system. However, emergency care systems remain largely underdeveloped in low- and middle-income countries, particularly in Sub-Saharan Africa. Somalia is in the horn of Africa. Decades of civil war, political instability, and terrorism insurgency have greatly hampered healthcare in the country, and the country does not have a formal emergency care system. The aim of the study was to assess the current provision of emergency care in healthcare facilities in northern Somalia, namely Somaliland and Puntland. This was a cross-sectional descriptive study carried out in all emergency units in Hargeisa and Garowe, the capital cities of Somaliland and Puntland respectively. A standardised WHO emergency care assessment tool was used to assess the performance of emergency care procedures in the emergency units. Simple descriptive statistics were used to analyse the data. Six facilities - two in Puntland, and four in Somaliland - participated in the study. Two of these were regional referral public facilities, while the rest were private. The performance of sixty emergency care procedures was assessed. Absent equipment was the main reason (47%, n=60 for the non-performance of these emergency care procedures. Lack of training (29%), stock out of supplies (13%), and lack of skilled personnel (10%) were the other reasons for the non-performance of these emergency care procedures. The findings of this study underscore the need for more resource allocation with a focus on equipping emergency units and having adequate supplies. The study also highlights the need for training of healthcare providers who routinely provide care in emergency units.
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Ruthven, David Benjamin. "The interactive medical emergency department [iMED] architectural integration of digital systems into the emergency care environment /." Connect to this title online, 2007. http://etd.lib.clemson.edu/documents/1181669333/.
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Bester, Beatrix Hendrina. "A descriptive study of patients presenting with a chief complaint of seizures to the prehospital emergency care practitioner of the Western Cape." Master's thesis, Faculty of Health Sciences, 2019. http://hdl.handle.net/11427/31572.
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Background
Seizures are considered one of the most common time-sensitive and potentially life-threatening medical emergencies presenting to emergency centres and attended to by prehospital emergency care practitioners. These require a rapid response, prompt identification and appropriate management. There is a paucity of information describing the demographics and prehospital management of patients presenting with seizures in South Africa.
Objectives
The aim of this study was to describe the demographics and prehospital management of patients presenting with a chief complaint of seizures and/or convulsions to prehospital emergency care practitioners within the Western Cape Government Emergency Medical Services.
Methods
This retrospective study included all Western Cape Government Emergency Medical Services calls indicating a chief complaint of seizures and/or convulsions between August 2017 and July 2018. Descriptive statistics were performed to describe basic demographics in this population. A sample of emergency calls originating within the City of Cape Town was selected for a clinical chart review to describe on-scene clinical presentation and vitals, response times, and prehospital treatment provided.
Results
A total of 24 746 seizure and/or convulsion cases were recorded during the study period. The highest frequency of patients was in the 21 - 40 year age group (31%), and 57% of patients were male. The subsample (n=3 075) yielded 1 571 cases with completed electronic patient care records. The mean dispatch and response times were 20 (±36) and 14 (±10) minutes respectively with a mean on-scene time of 25 (±13) minutes. No on-scene vital signs were recorded in 11.3% of patients. Recorded on-scene vitals indicated that 36% of patients presented with a tachycardia, 14% had an oxygen saturation of < 95%. Airway manoeuvres were performed in 30% of cases, and 50% of patients presenting with a SpO2 < 95% received supplemental oxygen. The benzodiazepine Diazepam was the most common medication administered, and 83% of medications were administer through the intravenous route.
Conclusions
Seizures are a recognised time-sensitive emergency, however in this sample of patients we observed a longer than expected dispatch time. Although the importance of recording baseline vital signs is recognised, there was a large proportion of undocumented vital signs 35 within the sample. Despite consensus recommendations that intramuscular midazolam are the preferred medication and route, IV diazepam was the most frequently administered. Seizures are an under-recognised burden on Emergency Medical Services within the Western Cape. This study provides an initial description of the epidemiology within this population, allowing for optimization of recognition and management in these patients.
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Mahomed, Zeyn. "Emergency department patients' perception of care: do doctors understand their patients?" Master's thesis, University of Cape Town, 2011. http://hdl.handle.net/11427/11526.
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Includes abstract.Includes bibliographical references (leaves 42-55).
The aim of my study is to directly compare the patient’s perceptions of care received in the emergency department to that of the attending physician’s. The aim is to give us better insight into how the patient experiences their care, with a view to improving the level of care offered. The study elucidates the emphasis a patient places on aspects of their care such as empathy, communication, waiting times, etc. The study was conducted at GF Jooste Emergency Department over a period of eight weeks. Patients voluntarily, and with full anonymity, filled in a short questionnaire. The attending physician did the same. Questionnaires were collected and data fed into a database, analyzed and the results interpreted.
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Shah, Jalpa. "Factors associated with higher emergency department utilization." Thesis, California State University, Long Beach, 2015. http://pqdtopen.proquest.com/#viewpdf?dispub=1586168.
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The purpose of this study was to analyze the factors associated with higher Emergency Department (ED) visits in the United States. Higher ED utilization contributes in a major way to costs in the healthcare industry. Unnecessary utilization of emergency department causes medication errors, poor patient satisfaction, lower quality and higher cost. This study analyzed the data from National Hospital Ambulatory Medical Care Survey (NHAMCS) collected in 2010, which involved a sample size of 34,936 ED visits nationwide. The variables in this study included age, ethnicity, type of coverage and gender differences. The result showed that Medicaid population has a higher number of ED visits than other types of insurance coverage; white population shows maximum ED visits than other race types; males visits ED more than females and infants has higher ED rate than other age groups. More research is needed to develop health policies to limit the non-urgent ED visits.
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Charrier, Ronald J. "Mass care (ESF-6) preparedness for catastrophic disasters." Thesis, Monterey, California : Naval Postgraduate School, 2009. http://edocs.nps.edu/npspubs/scholarly/theses/2009/Sep/09Sep_Charrier.pdf.
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Thesis (M.A. in Security Studies (Homeland Security and Defense))--Naval Postgraduate School, September 2009.Thesis Advisor(s): Gordon, Ellen M. "September 2009." Description based on title screen as viewed on November 5, 2009. Author(s) subject terms: mass care, ESF-6, American Red Cross (ARC), Salvation Army (TSA), Southern Baptist Convention, Convoy of Hope, sheltering, disaster shelter, mass feeding, bulk distribution, catastrophic disaster response, New Madrid earthquake, long-term recovery process, National Shelter System (NSS), multi-agency coordination, voluntary agency, post-congregate sheltering policies, Missouri State Emergency Management Agency. Includes bibliographical references (p. 87-91). Also available in print.
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Nagula, Prasad. "Redesigning the patient care delivery processes at an emergency department." Diss., Online access via UMI:, 2006.
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Corbett, Elise Megan. "Emergency Nurses' Department Design Recommendations for Improved End-of-Life Care." BYU ScholarsArchive, 2018. https://scholarsarchive.byu.edu/etd/7243.
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Introduction: Death occurs frequently in emergency departments (EDs). Obstacles present in EDs can make providing end-of-life (EOL) care stressful and challenging for emergency nurses. Although death is common in EDs, there is a paucity of research regarding ED design as an obstacle to EOL care. The purpose of this study was to identify emergency nurses<'> experiences and recommendations regarding ways ED designs negatively or positively impacted EOL care for dying patients and their families. Methods: At 25-item questionnaire regarding ED design and EOL care was sent to a geographically dispersed, national random sample of 500 emergency nurses. Inclusion criteria were nurses who could read English, worked in an emergency department, and had cared for at least one patient at the EOL. Responses were individually reviewed and coded by the research team.Results: Major obstacles relating to ED design identified by emergency nurses included (1) many issues related to limited space, (2) poor department layout and design features, and (3) the lack of privacy. Despite EDs being a challenging place to provide EOL care, positive ED design characteristics impacted EOL care for dying patients and families.Discussion: Emergency nurses understand the need for family presence during resuscitation, for secure body stowage areas, and for more resuscitation rooms so that families have time to grieve before being removed due to the immediate need for a second trauma patient and family. Nurses can evaluate existing facilities and identify areas where potential change and remodeling would improve patient care, increase patient privacy, or further utilize space. Conclusion: Understanding ED design<'>s impact on EOL care is crucial. Modifications to ED layout and design may be challenging; however, improvements to space, layout, and privacy need to be considered when planning new EDs or remodeling existing departments. Further research is required to determine the impact of ED design on EOL care.
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Forslund, Kerstin. "Challenges in prehospital emergency care : Patient, spouse and personnel perspectives." Doctoral thesis, Örebro : Örebro universitetsbibliotek Örebro University Library, 2007. http://urn.kb.se/resolve?urn=urn:nbn:se:oru:diva-1525.
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Morrish, Sherri. "Streaming in the emergency department : an innovative care delivery design." Thesis, University of British Columbia, 2012. http://hdl.handle.net/2429/43213.
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Emergency departments (EDs) in urban settings are experiencing extreme challenges such as overcrowding, long wait times, and patient dissatisfaction (Kelley, Bryant, Cox, & Jolley, 2007). Streaming in the Emergency Department is an innovative care delivery design that is designed to reduce ED overcrowding and improve access to care. Streaming enables moderately acute ambulatory Triage Level 3 patients, who often wait the longest, to be cared for in a separate area embedded within the main ED. These patients receive care to the same standards but sit in a chair for most of their stay, only lying in a bed for examinations, treatments, and tests. This care approach often closely matches the way fast track or minor treatment clinics are run for lower acuity Triage Levels 4 and 5 patients in many urban EDs. This study aims to create a deeper understanding of “streaming.” The research examined what factors influenced the successful streaming of moderately acute ambulatory patients within the streaming unit of Hospital X (British Columbia, Canada). A qualitative descriptive design using a single site case study was employed. The data analysis involved reducing data into meaning units, then reducing them to sub-themes which were finally grouped into four major themes (Graneheim & Lundman, 2003; Yin, 2004). These themes were: “facing health care realities,” “doing it right,” “maintaining flow,” and "what matters?” From this research, it is clear that streaming is improving care, patient outcomes, and staff satisfaction in Hospital X’s emergency department. This innovative care delivery design for moderately acute ambulatory patients is challenging the traditional paradigm of ED care, bringing positive changes in a complex health care environment. Timely care for ED patients, through such innovative models as a streaming unit, can save lives (Devkaran, Parsons, Van Dyke, Drennan, & Rajah, 2009).
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Kvederienė, Rūta. "The impact of emergency care on severe pediatric trauma outcomes." Doctoral thesis, Lithuanian Academic Libraries Network (LABT), 2012. http://vddb.laba.lt/obj/LT-eLABa-0001:E.02~2012~D_20121227_085948-00813.
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Trauma is the main cause of death in paediatric population worldwide. Lithuania has the highest trauma-related mortality in the European Union (EU). Lithuanian standardised injury death rate is 150.9 per 100000 inhabitants while in comparison the mean standardised injury death rate in the EU is 41.4, and the lowest one is in the Netherlands (26.4 injury death rate per 100000 inhabitants). The aim of this study was to analyze the impact of pre-hospital and in-hospital emergent trauma care on severe pediatric trauma outcomes, performing a prospective observational clinical trial in the Vilnius University Children’s Hospital and Vilnius Pre-hospital Emergency Service Center. Trauma registry fields were defined in details and validated during this study. The recommended quality indicators were defined and used for pre-hospital pediatric trauma care and in-hospital emergent management evaluation. The study results showed that the level of pre-hospital care is associated statistically significantly with trauma outcomes: higher pre-hospital care level caused better trauma outcome assessed according to the Glasgow Outcome Scale. The longer time until the first key emergency intervention in hospital was associated statistically significantly with the worse trauma outcomes. Calculation of the Probability of survival (Ps) according to Trauma Score Injury Severity Score model (TRISS) revealed unexpected death (Ps > 50 %) rate 74%. The reasons for fatal outcome in the patient group with... [to full text]Traumos yra pagrindinė vaikų, paauglių ir jaunų suaugusiųjų mirties priežastis. Stebimas didžiulis skirtumas Europos Sąjungos (ES) šalyse lyginant mirštamumą nuo traumų. Lietuvoje didžiausias ES standartizuotas traumų mirčių dažnis (150.9 mirtys dėl traumų 100.000 gyventojų). Palyginimui: ES šalių vidurkis yra 41.4 mirtys dėl traumos 100.000 gyventojų, mažiausias standartizuotas traumų mirčių dažnis yra Olandijoje – 26.4 mirtys 100.000 gyventojų. Toks skirtumas nurodo potencialią galimybę sumažinti mirčių dėl traumų skaičių, naudojant visas priemones: tiek traumų prevenciją, tiek skubios pagalbos prieinamumą ir kokybę. Darbo tikslas – išanalizuoti vaikų, patyrusių sunkias traumas, ikihospitalinės pagalbos ir skubiosios pagalbos ligoninėje laiko bei apimties įtaką traumų išeitims, atliekant perspektyvinį tyrimą Vilniaus Universiteto Santariškių klinikų Vaikų ligoninėje bei Vilniaus Greitosios medicinos pagalbos stotyje. Rezultatai parodė, kad pagalbos lygis ikihospitaliniu laikotarpiu susijęs su išeitimi: pacientams, gavusiems aukštesnio lygio pagalbą traumos išeitys pagal Glazgo išeičių skalę buvo geresnės. Ilgesnis laikas nuo paciento atvežimo į ligoninę iki pirmos skubiosios intervencijos statistiškai patikimai koreliavo su blogesne traumos išeitimi. Apskaičiavus išgyvenamumo tikimybę (Ps) pagal traumos skalės pažeidimų sunkumo modelį (TRISS), 74 proc. mirčių dėl traumų pateko į netikėtų mirčių (Ps > 50 proc.) kategoriją. Kiekviena netikėta mirtis, identifikuota naudojant... [toliau žr. visą tekstą]
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Jones, Simon Andrew. "Prediction of demand for emergency care in an acute hospital." Thesis, Kingston University, 2005. http://eprints.kingston.ac.uk/20739/.
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This thesis describes some models that attempt to forecast the number of occupied beds due to emergency admissions each day in an acute general hospital. Hospital bed managers have two conflicting demands: they must not only ensure that at all times they have sufficient empty beds to cope with possible emergency admissions but they must fill as many empty beds as possible with people on the waiting list. This model is important as it could help balance these two conflicting demands. The research is based on data from a district general and a postgraduate teaching hospital in South East London. Several tests indicate that emergency bed occupancy may have a nonlinear underlying data generating process. Therefore, both linear models and nonlinear models have been fitted to the data. At horizons up to 14 days, it was found that there was no statistically significant difference in the errors from the linear and nonlinear models. However at the 35 day forecast horizon the linear model gives the best forecast and tests indicate errors from this model are within 4% of mean occupancy. It is noted that a Markov Switching model gave very good forecasts of up to 4 days into the future. A search of the literature found no previous research that tested emergency bed occupancy for nonlinearities. The thesis ends with a gravity model to predict the change in number of Accident and Emergency (A&E) attendances following the relocation of an A&E Department in South East London.
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Cobbs, Brian W., and Brian W. Cobbs. "Improving Hand-Off Communication from Primary Care to Emergency Department." Diss., The University of Arizona, 2017. http://hdl.handle.net/10150/624310.
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A hand-off represents the transfer of patient information and care responsibility between a sending and receiving provider. Hand-offs occur in single locations such as inpatient wards and across care settings like from primary care offices to emergency departments. This care transition quality improvement (QI) project was created to improve patient hand-off communication from a primary care office to a hospital based emergency department within the greater Phoenix, AZ metropolitan area. No uniform hand-off process existed before the QI project. The purpose of the QI project was to demonstrate process necessary to achieve desired outcomes, in this case, a superior patient hand-off. The QI project goal was to develop a standardized hand-off protocol and tool. The aim of this QI project was to replace existing hand-off methods with a formalized new hand-off process and tool used during care transition from a primary care office to an emergency department. QI project methods followed two (2) plan-do-study-act (PDSA) cycles involving QI team meetings and end-user feedback that iteratively led to the adoption of a standardized hand-off process and tool. PDSA cycle one identified the best handoff tool. PDSA cycle two established an efficient process for conducting hand-offs. The new hand-off tool consistently demonstrated superior information transfer. Program participant satisfaction increased and was reflected by positive feedback as most nurses and doctors embraced the new process.
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Singh, S. "Referral systems and transport for emergency obstetric care in India." Thesis, London School of Hygiene and Tropical Medicine (University of London), 2018. http://researchonline.lshtm.ac.uk/4647889/.
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Background: Institutional delivery rates in India have improved in the past decade, but maternal mortality remains high. The aim of this study was to describe current referral pathways and transport services for pregnant women in the Indian public health sector to identify strategies for strengthening the referral system for emergency obstetric care. Methods: I conducted three literature reviews; a health provider’s KAP survey of staff in primary level public health facilities from two states; analyses of ‘108’ ambulance service data from six states; and telephone interviews of women who called this service in two states. Results: The reviews found no standard protocols or guidelines for referral of women with obstetric high-risk or complications in India, and over half of pregnant women attending primary level health facilities were referred. There was poor quality institution referral care and no studies on the effectiveness of transport interventions. The KAP study found staff had sub-optimal knowledge and practice for screening common high-risk conditions and complications, and low confidence and resources to manage emergency situations. Less than a quarter of pregnancies and institutional deliveries in the study populations used ‘108’ ambulances. Most women called the service for normal labour: only 4.3% had an obstetric emergency and 5.8% were inter-facility transfers. Of pregnant callers to the ‘108’ service, one third reported a high-risk condition or early complication in pregnancy. Women transported using other means were more likely to use private facilities than those transported by ‘108’. Conclusion: The quality of obstetric care at peripheral health centres is suboptimal and the high proportion of referrals could be avoided. The ‘108’ ambulance service is underused, especially in emergency situations. India’s health systems should improve the provision of obstetric care by standardising services at each level of health care. Strategies are required to increase the use of ‘108’ services for obstetric emergencies.
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Rouse, Eno J. "Care Intervention in Reducing Emergency Department Utilization in Medicaid Populations." Thesis, Walden University, 2019. http://pqdtopen.proquest.com/#viewpdf?dispub=13425519.
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Expansion of Medicaid and private health insurance coverage through passage of the Affordable Care Act of 2010 was expected to increase primary care access and reduce emergency department (ED) use by reducing financial burden and improving affordability of care. The aim of this study was to examine the differences in utilization patterns that exist among the Medicaid population that participated in an optimal level of care (OLC) intervention inclusive of appointments scheduled to primary care providers. Using the integrated behavior model as a theoretical framework, the key research question focused on determining if there was a difference in ED use among Medicaid individuals who scheduled follow-up appointments compared to those that did not schedule follow-up appointments. The sample population consisted of 176 Medicaid enrollees who presented to the ED for treatment of nonurgent conditions and participated in an OLC intervention from June 2016 to July 2017. The results showed that there were no differences in ED utilization between the population that had scheduled appointments compared to the population that did not have scheduled appointments. A bivariate analysis on demographic variables also showed no differences in ED utilization among the variables. The social change implications of this study are that the practice of scheduling appointments with primary care providers does not reduce or affect ED utilization in the Medicaid population. This study contributes to positive social change through the findings that reducing ED utilization requires more than follow-up appointment scheduling with primary care providers. Further studies are warranted to understand the potential barriers and factors that affect ED utilization.
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Scherr, Tanya Marie. "Perceived Effects of the Affordable Care Act on Emergency Preparedness." ScholarWorks, 2016. https://scholarworks.waldenu.edu/dissertations/3070.
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National healthcare as executed through the Patient Protection and Affordable Care Act (ACA) was introduced in 2010, but was discussed for several decades prior to its enactment. Section 5210 of the ACA established funding for a Regular and Ready Reserve Corps (RRRC) to provide support to local healthcare entities with emergency preparedness. It is unknown what impact Section 5210 of the ACA has had on local emergency preparedness, as well as what obstacles are encountered with implementing this piece of legislation at the local level. The purpose of this case study was to understand the obstacles encountered at a local level by healthcare entities by combining rational choice theory and complex adaptive systems through Ostrom's institutional analysis and development theory. Data for this case study were obtained through interviews with 6 hospital emergency coordinators of hospitals in the Tennessee Highland Rim Region. These data were coded and analyzed following Moustakas' modified Van Kaam procedure. Findings from this study concluded that participants perceived that Section 5210 of the ACA did not impact hospital operations at the local level. However, other obstacles including employee turnover, communication, and process standardization and education are perceived to exist in terms of planning and emergency preparedness. The results of this study may impact social change by enhancing state and local policy makers' ability to identify and create a future roadmap for health care policy implementation at local and regional levels.
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Porth, Leslie. "A Comparison of Regional Health Care Structures for Emergency Preparedness." ScholarWorks, 2015. https://scholarworks.waldenu.edu/dissertations/330.
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Since 2001, increased policy attention and federal funding mechanisms have required more effective disaster response by government actors and private sector organizations, including the health care system. However, there is limited scholarly evidence documenting which structural elements have been associated with efficacious regional coalitions. This study addressed the gap by examining whether the number of different participating disciplines (a proxy for coalition roles), community setting, and prior weather-related disaster declaration influenced the number of activities (a proxy for coalition responsibilities) conducted by the health care coalition. Social network theory was the theoretical lens with which the study results were used to examine the relational structures within coalitions. The quantitative study was based on archival data from a survey in 2011 of 375 acute care hospitals in the United States. A general linear model analysis was conducted, and results suggest a statistically significant relationship between the number of disciplines and the number of conducted activities. As the number of different disciplines increases in a coalition, so do the different types of conducted activities. Based on the analysis, community setting--urban versus nonurban--and the occurrence of a federally declared, weather-related disaster did not influence the number of coalition activities. This study provides evidence that establishing network structures for health care coalitions will advance the field of health care emergency preparedness and disaster response. The findings from this research may promote social change by guiding future policy development and research necessary to develop resilient and efficacious disaster response systems, resulting in reduced loss of life and injury.
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Presuma, Dumi. "THE USE OF EMERGENCY SERVICES IN THE URBAN SETTING." Master's thesis, Temple University Libraries, 2017. http://cdm16002.contentdm.oclc.org/cdm/ref/collection/p245801coll10/id/465326.
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Urban BioethicsM.A.
Emergency rooms often are used for extremely ill patients, but they also are used and overused for non-urgent acute-care needs, especially in the urban setting where patients might not have access to primary care services. While U.S. legislation has aimed to reduce emergency-room usage for non-emergency needs, the emergency room continues to be an essential support in low-income and urban neighborhoods. Specifically, North Philadelphia residents rely on and use the emergency room for reliable care. The central premise of this thesis is that we should shift from working to curtail emergency room usage, and therefore costs, to fundamentally re-redefining the nature and identity of emergency rooms.
Temple University--Theses