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Pathways for older patients in acute situations and involved actors' experiences of decision-making in ambulatory care
Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. (Centre of Interprofessional Collaboration within Emergency Care (CICE) Linnaeus University, Sweden)ORCID iD: 0000-0002-8358-3920
2022 (English)Doctoral thesis, comprehensive summary (Other academic)
Sustainable development
SDG 3: Ensure healthy lives and promote well-being for all at all ages
Abstract [en]

Aim: The overall aim was to describe and compare pathways for older patients and the involved actors’ experiences of decision-making in acute situations in ambulatory care.

Methods: The overall three-fold design, comprising exploratory, descriptive as well as comparative ones, was conducted inductively, including a mixed method with a convergent integrated approach to empirical data. The four involved studies were analysed using either quantitative or qualitative analysis methods.

Results: Most older patients’ pathways when being assessed by ambulance personnel involved receiving care at hospitals. However, an increasing trend of non-conveyance to hospitals was identified during a five-year period (2014–2018), which means receiving care, for example, at home or primary healthcare (PHC) centres. Decision-making about the level-of-care for older patients was more or less uncertain for all involved actors, i.e. older patients, significant others and healthcare professionals such as ambulance personnel, registered nurses, specialists in general practice at PHC centres and community health nurses. To increase the level of certainty in the decision-making process, all actors was supported by both an individual and external dialogue. Individual dialogue gave support by using own experience and knowledge. For ambulance personnel and community health nurses, support was also partially gained from decision support tools but was regarded as insufficient when older patients had non-specific symptoms. External dialogue provided support through mutuality, and via collaboration, a common goal, trust and responsibility. Mutuality gave support through experience and knowledge being shared with all involved actors, which provided a common comprehensive understanding that facilitated consensus in the decision-making.

Conclusion: The increasing level of non-conveyance to hospitals and uncertainty during decision-making highlights the need to develop and extend the availability of dialogue-based collaborations as support in ambulatory care. Dialogue-based support involves all actors contributing to the decision-making. Healthcare professionals need to be aware of the prerequisites and the support that mutuality in external dialogues brings. Healthcare organisations need to develop and extend dialogue-based collaboration in ambulatory care by combining different expertise and providing conditions to increase support in decisions adapted to older patients' needs.

Place, publisher, year, edition, pages
Växjö: Linnaeus University Press, 2022. , p. 149
Series
Linnaeus University Dissertations ; 472
Keywords [en]
Acute situation, aged, ambulatory care, decision making, pathways, support
National Category
Gerontology, specialising in Medical and Health Sciences Nursing Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Health and Caring Sciences, Caring Science
Identifiers
URN: urn:nbn:se:lnu:diva-117566DOI: 10.15626/LUD.472.2022ISBN: 9789189709669 (print)ISBN: 9789189709676 (electronic)OAI: oai:DiVA.org:lnu-117566DiVA, id: diva2:1711778
Public defence
2022-12-16, Weber, Universitetsplatsen 1, Växjö, 10:00 (Swedish)
Opponent
Supervisors
Funder
The Kamprad Family Foundation, 2016-0158Available from: 2022-11-25 Created: 2022-11-18 Last updated: 2024-03-07Bibliographically approved
List of papers
1. Patients' aged ≥ 65 years dispositions during ambulance assignments, including factors associated with non-conveyance to hospital: a longitudinal and comparative study
Open this publication in new window or tab >>Patients' aged ≥ 65 years dispositions during ambulance assignments, including factors associated with non-conveyance to hospital: a longitudinal and comparative study
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2020 (English)In: BMJ Open, E-ISSN 2044-6055, Vol. 10, no 11, p. 1-7, article id e038885Article in journal (Refereed) Published
Abstract [en]

Objectives Patients >= 65 years old represent 30%-50% of all ambulance assignments (AAs), and the knowledge of which care level they are disposed to is limited and diverging. The aim of this study was therefore to describe and compare characteristics of patients' aged >= 65 years dispositions during AA, including determining changes over time and factors associated with non-conveyance to hospitals. Design A longitudinal and comparative database study. Setting Ambulance service in a Swedish region. Participants 32 085 AAs with patients >= 65 years old during the years 2014, 2016 and 2018. Exclusion criteria: AAs with interhospital patient transfers and lack of patients' dispositions data. Outcome measures Dependent factors: conveyance and non-conveyance to hospitals. Independent factors: age, sex, symptom, triage level, scene, time, day and season. Results The majority (n=29 060; 90.6%) of patients' dispositions during AA were conveyance to hospitals. In total, the most common symptoms were circulatory (n=4953; 15.5%) and respiratory (n=4529; 14.1%). A significant increase, p<0.01, of non-conveyance to hospitals was shown during 2014 and 2018, from 801 (7.8%) to 1295 (11.4%). Increasing age was associated with decreasing odds of non-conveyance, 85-89 years (OR=0.85, 95 % CI=0.72 to 0.99) and 90 years or older (OR=0.80, 95 % CI=0.68 to 0.93). Several factors were associated with non-conveyance, for example, symptoms of diabetes (OR=8.57, 95 % CI=5.99 to 12.26) and mental disorders (OR=5.71, 95 % CI=3.85 to 8.48) in comparison with infections. Conclusions The study demonstrates several patient characteristics, and factors associated with non-conveyance to hospitals, such as age, symptom, triage level, scene, time, day and season. The increasing non-conveyance trend highlights the importance of further studies on optimal care levels for patients >= 65 years old.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2020
Keywords
accident & emergency medicine, geriatric medicine, organisation of health services
National Category
Nursing
Research subject
Health and Caring Sciences
Identifiers
urn:nbn:se:lnu:diva-99995 (URN)10.1136/bmjopen-2020-038885 (DOI)000596216900001 ()33243795 (PubMedID)2-s2.0-85096947341 (Scopus ID)
Available from: 2021-01-15 Created: 2021-01-15 Last updated: 2023-08-28Bibliographically approved
2. The dialogue as decision support; lived experiences of extended collaboration when an ambulance is called
Open this publication in new window or tab >>The dialogue as decision support; lived experiences of extended collaboration when an ambulance is called
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2021 (English)In: International Journal of Qualitative Studies on Health and Well-being, ISSN 1748-2623, E-ISSN 1748-2631, Vol. 16, no 8, article id 1970095Article in journal (Refereed) Published
Abstract [en]

Purpose This study aimed to describe extended collaboration in situations when an ambulance was called, as experienced by older patients, a significant other, and ambulance- and primary healthcare (PHC) centre personnel. Methods The study used a phenomenological reflective lifeworld research (RLR) approach. Participants included in three specific situations with extended collaboration were interviewed: three older patients, one significant other, three ambulance personnel and four personnel at the PHC centre. The transcribed interviews were analysed for meanings of the phenomenon. Results The extended collaboration means that decisions were supported through dialogue by bridging knowledge spaces between person, within-team and across-team levels. Through dialogue experience and knowledge were shared and certainty in decisions was increased. The extended collaboration was built on trust, responsibility taken, shared and entrusted, and the common goal of adapted care for the unique patient. A need for further improvement and transparency was elucidated. Conclusions The difficulty of making care decisions stresses the importance of available extended collaboration based on the dialogue between patients, significant others, and ambulance- and PHC centre personnel to increase certainty in decisions. Collaboration further requires respectful encounters, trust, responsibility and a common goal of adapting the care for the unique patient.

Place, publisher, year, edition, pages
Taylor & Francis Group, 2021
Keywords
Aged, emergency medical services, experiences of care, intersectoral collaboration, patients, prehospital emergency care, primary health care, reflective lifeworld research
National Category
Nursing
Research subject
Health and Caring Sciences, Nursing
Identifiers
urn:nbn:se:lnu:diva-106778 (URN)10.1080/17482631.2021.1970095 (DOI)000688087900001 ()34427535 (PubMedID)2-s2.0-85113555042 (Scopus ID)2021 (Local ID)2021 (Archive number)2021 (OAI)
Funder
The Kamprad Family Foundation
Available from: 2021-09-03 Created: 2021-09-03 Last updated: 2022-11-18Bibliographically approved

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Forsgärde, Elin-Sofie

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