Anaesthesia and Pain Management for Use in Orthopaedic Day Surgery

Day surgery has gained a large popularity during the last decades. In Finland, 57% of the elective procedures, and 50% at Turku University Hospital, were already conducted on day basis during 2012. The steady growth of day surgery is mostly due to an increased safety in perioperative care and cost-effectiveness. The development of surgical techniques and anaesthetic methods has advanced the modern day surgery and extended the repertory of the procedures for use in day surgery operations. Day surgery also offers certain benefits like reduced risk for hospital-related infections, stress and confusion. Patient satisfaction, regarding several issues, is high. Most concerns and complaints are related to postoperative pain, nausea and vomiting pain and nausea. Pain can hamper recovery and pain management is a crucial factor for hospital discharge. Appropriate pain treatment is effective, safe, easy and economical. A procedure-specific approach and an individually planned, multimodal analgesia should be the basis of modern pain management. The main aim of this thesis was to evaluate the effectiveness and safety of anaesthetic technique and methods in pain treatment of orthopaedic day case surgery, and following conclusions were made. Unilateral spinal block was achieved using hyperbaric bupivacaine with a small dose of clonidine but clonidine prolonged the block. Continuous subacromial bupivacaine was found to be safe but conferring only moderate efficacy in pain care after shoulder arthroscopy. Transdermal fentanyl, 12 g/h, as part of multimodal analgesia, offered a safe and easy option to pain management in this patient group. However, after forefoot surgery, it did not reduce pain any further. In general, pain scores in all patient groups were low and the need for rescue opioid moderate.

Hoitoketjun kustannukset perusterveydenhuollosta erikoissairaanhoitoon: Case Lappeenranta ja Imatra

Työn tavoitteena oli selvittää perusterveydenhuollon ja erikoissairaanhoidon välillä kulkevien lappeenrantalaisten (34 potilasta) ja imatralaisten (20 potilasta) hoitoketjun kustannukset ja hoitoajat, sekä analysoida niitä. Kustannusten ja hoitoketjun läpimenoaikojen esittämisessä käytettiin kustannuskertymäajattelua. Tutkimuksessa tutkittiin prosessien ohjauksen ja toiminnanohjauksen teoriaa sekä terveydenhuollossa että teollisuudessa, ja kustannuslaskennan perusteita. Huomattiin, että erityisesti lean -ajattelua voidaan käyttää myös terveydenhuollossa ja hoitoketjuja tarkasteltaessa. Empiirisessä osuudessa tarkasteltiin Lappeenrannan ja Imatran tutkittavien kolmen potilasryhmän kustannuksia ja hoitoaikoja kustannuskertymäkäyrien avulla. Tarkastelussa olivat kaupunkien ja potilasryhmien maksimi-, minimi- ja mediaanikustannuspotilaan hoitoketjun kustannukset ja läpimenoajat. Keskeisenä tuloksena havaittiin, että perusterveydenhuollon osuus kustannuksista oli suuri etenkin potilailla, joilla oli pitkä läpimenoaika hoitoketjussa, sillä hoitoaika painottui tällöin terveyskeskussairaalaan. Hyvin lyhyen läpimenoajan potilailla taas erikoissairaanhoidon osuus kustannuksista oli suurempi, mutta tällaiset potilaat olivat lähinnä minimi-, tai korkeintaan mediaanikustannuspotilaita. Päiväkohtainen kustannus havaittiin erikoissairaanhoidossa korkeammaksi, mutta perusterveydenhuollon terveyskeskussairaalahoito nousi maksimikustannuspotilailla aina selvästi suurimmaksi kustannuksen aiheuttajaksi. Havaittiin myös, että potilaiden lyhyt keskussairaalahoito ei takaa alentuneita hoitoketjun kokonaiskustannuksia. Työssä havaittiin, että perusterveydenhuollon toimivuus on koko terveydenhuollon toimivuuden ja tuottavuuden selkäranka. Erityisesti keskeisiä osia, mihin tulee kiinnittää huomiota hoitoketjussa, ovat potilaan sijoittaminen oikeinkeskussairaalahoitoon tultaessa ja sieltä lähdettäessä. Muun muassa näillä tavoilla voidaan karsia potilaiden ylipitkiä hoitojaksoja perusterveydenhuollossa tai potilaan jäämistä kiertämään hoitoketjuun.

Tietojohtaminen toiminnanohjausjärjestelmän tukena; Case: Kespro Oy

Tutkielman tarkoituksena on tutkia oppimisprosessin muodostumista ja toteutumista sekä prosessijohtamisen ja prosessien roolia SAP:in käyttöönottoprojektissa. Tutkielman case-organisaationa toimii Kespro Oy ja tutkimuskohteena on SAP:in käyttöönottoprojekti Kespron tukuissa. Tutkimus- ja tiedonkeruumenetelmänä käytetään kvantitatiivista kyselylomaketta. Tutkimuksessa saatiin selkeä kuva prosessijohtamisen ja prosessien roolista muutostilanteessa sekä oppimisprosessin muodostumisesta jatoteutumisesta. Johdon ja esimiesten tuen korostuminen sekä onnistunut strategisten linjausten tiedottaminen tulivat esille käytännön työssä prosessien toimivuuden ja oman työn merkityksen kautta. Tärkeänä haasteena osaamisen varmistamiseksi käyttöönoton yhteydessä oli varmistaa koulutuksen ja käyttäjäohjeiden riittävä taso ja sisältö. Käyttöönoton aikana ja sen jälkeen korostuivat tiedon jakamisessa pääkäyttäjien ja henkilöstön keskinäinen yhteistyö ja avunanto. Tehokas tiedon jakaminen mahdollisti käyttöönoton onnistumisen. Käyttöönottoon vaikutti oleellisesti myös tietotekninen näkökulma: käyttäjien kyky erottaa toisistaan oma osaaminen ja tietotekniset ongelmat. Näiden tekijöiden huomioiminen mahdollisti SAP-toiminnanohjausjärjestelmän sujuvan liikkeellelähdön Kespron tukuissa mahdollisimman vähillä operatiivisilla ongelmilla.

Evaluation of an eLearning pilot course based on user experiences: corporate case study

Diplomityön tavoitteena oli arvioida sähköisen oppimisen soveltuvuutta kohdeyrityksessä ja selvittää, voidaanko luokkahuonekoulutusta korvata sähköisen oppimisen kursseilla. Tietojärjestelmän raportoinnista tehtiin sähköisen oppimisen kurssi, joka oli koekäytössä. Koekäytön jälkeen tehtiin käyttäjäkysely, kerättiin käyttötietoja kurssista ja tehtiin haastatteluja. Koekäyttäjien kokemuksista tehdyn arvioinnin perusteella sähköinen oppiminen soveltuu käytettäväksi selkeiden asioiden koulutukseen kohdeyrityksessä, mutta se ei voi kokonaan korvata luokkahuonekoulutusta. Luokkahuonekoulutuksessa tulisi keskittyä monimutkaisempiin asioihin ja ongelmanratkaisuun. Positiivisten tulosten perusteella sähköisen oppimisen kehittämistä päätettiin jatkaa yrityksessä. Sähköisen oppimisen kurssin avulla saadaan kustannussäästöjä kohdeyrityksessä, kun käyttäjämäärä on suurempi kuin 66. Jos koko koekäytössä olleen kurssin kohdeyleisö suorittaa kurssin sähköisesti, ovat kustannukset vain noin 15% vastaavista kustannuksista luokkahuoneessa järjestettynä. Lisäksi sähköisen oppimisen tehokkuutta tutkittiin ja koekäytössä olleen kurssin arvioitiin olevan positiivinen työssä kehitetyn Consensus-mallin mukaan.

Osakeanti-ilmoitusten informaatiovaikutus: case Helsingin Arvopaperipörssi 1993 – 2002

Tutkielman päätavoitteena on selvittää, miten osakkeenomistajien merkintäetuoikeuteen perustuva uusmerkintäilmoitus ja suunnattu osakeanti-ilmoitus vaikuttavat osakekursseihin julkistamispäivän ympäristössä. Tutkimusmetodiikka on lähinnä nomoteettinen, vaikkakin tutkimus sisältää myös komparatiivisen tutkimuksen tunnusmerkkejä. Tutkielman empiriaosuudessa tutkitaan merkintäoikeusantien ja suunnattujen osakeantien informaatiovaikutuksia Helsingin Arvopaperipörssissä vuosina 1993 – 2002. Epänormaalit tuotot laskettiin ajanjaksolta t=-15 ja t=15 käyttämällä keskiarvokorjattua mallia ja markkinakorjattua mallia. Merkintäoikeusantien osalta havaittiin positiivisia kumulatiivisia epänormaaleja tuottoja, kun laskentamenetelmänä käytettiin markkinakorjattua mallia. Nämä positiiviset kumulatiiviset epänormaalit tuotot eivät kuitenkaan olleet tilastollisesti merkitseviä. Tutkimuksessa todettiin myös se, että osakemarkkinat eivät reagoi tilastollisesti merkittävästi merkintäoikeusanti-ilmoituspäivänä. Suunnattujen osakeantien osalta havaittiin tilastollisesti merkitseviä (10 % merkitsevyystasolla) negatiivisia kumulatiivisia epänormaaleja tuottoja. Lisäksi todettiin, että osakemarkkinat eivät reagoi tilastollisesti merkittävästi suunnattuna osakeanti-ilmoituspäivänä. Suunnattujen osakeantien osalta havaittiin myös informaation vuotamista markkinoille 11 päivää ennen suunnattua osakeanti-ilmoitusta.

Unitizing in Supply Chain – Case SECU Container

The aim of this thesis is to analyze how increasing the level of unitizing affects to the costs in the transport system of a Finnish paper and board company. The parts of the supply chain where costs are analyzed are limited to domestic inland transport and port operations. Supply Chain management is important aspect of modern day companies’ strategies. Intermodal transport and different transport systems are the key items which are studied in the theory part of this thesis. In the case study the payload simulations for SECU container (Stora Enso Cargo Unit) stuffed in mills sites are base of the cost analyze of this thesis. Thesis also makes a glance for the restrictions and development trends in Finnish railroads. In analyze SECU containers are moved up to the mill site for stuffing. This increases the level of unitizing in supply chain. Analyze is made for three variation of current traffic lines. Analyze shows that when idea of intermodalism is well used there is considerable cost savings to gather in pre-transportation and port operations. But also effects to mill sites and destination ports needs to be take under considering. In analyze the effects of increased axle weight for SECU container transportation in Finnish railroads is studied. When transport unit is stuffed in earliest possible point supply chain and unloaded the last possible point the savings made in chain can be considerable. In case study of this thesis almost 40% savings in total costs could be reached in pre transportation and port operations when unitizing level is increased in supply chain.

Satamatoimijoiden riskienhallinta alusrajapinnassa, case HaminaKotkan kaasu- ja nestesatama

This study examined the risk management of port operators in the surface of vessel and terminal. This study was specially focused on the safety aspects as well as operational risks in surface of port of HaminaKotka liquid bulk terminal. Operational risks are examined during loading and unloading only. The theory of this study is based on strategy and competence of organizations and introducing different kind of methods of risk analysis. In addition, safety and directives of liquid bulk terminal is examined. Process scenario is represented concerning risks and risk management occurring in the surface of vessel and terminal. Finally the affect of human errors for the occurred accidents are examined. The method of explore was survey method. Survey was implemented via e-mail and enquiry was formatted as multiple choice enquiries. The main outcome of this study was that security level among enterprises operating in the liquid bulk terminal is high. Each enterprise has chosen the best risk analysis methods, which are suitable for their purposes. There is not one risk analysis available only used by every enterprise in the liquid bulk terminal. Using coherent risk analysis would clear out the everyday activities on that area. Greater presence of port master would also be desirable during every day activities in liquid bulk terminal.

Price spike forecasting in a competitive day-ahead energy market

Electricity price forecasting has become an important area of research in the aftermath of the worldwide deregulation of the power industry that launched competitive electricity markets now embracing all market participants including generation and retail companies, transmission network providers, and market managers. Based on the needs of the market, a variety of approaches forecasting day-ahead electricity prices have been proposed over the last decades. However, most of the existing approaches are reasonably effective for normal range prices but disregard price spike events, which are caused by a number of complex factors and occur during periods of market stress. In the early research, price spikes were truncated before application of the forecasting model to reduce the influence of such observations on the estimation of the model parameters; otherwise, a very large forecast error would be generated on price spike occasions. Electricity price spikes, however, are significant for energy market participants to stay competitive in a market. Accurate price spike forecasting is important for generation companies to strategically bid into the market and to optimally manage their assets; for retailer companies, since they cannot pass the spikes onto final customers, and finally, for market managers to provide better management and planning for the energy market. This doctoral thesis aims at deriving a methodology able to accurately predict not only the day-ahead electricity prices within the normal range but also the price spikes. The Finnish day-ahead energy market of Nord Pool Spot is selected as the case market, and its structure is studied in detail. It is almost universally agreed in the forecasting literature that no single method is best in every situation. Since the real-world problems are often complex in nature, no single model is able to capture different patterns equally well. Therefore, a hybrid methodology that enhances the modeling capabilities appears to be a possibly productive strategy for practical use when electricity prices are predicted. The price forecasting methodology is proposed through a hybrid model applied to the price forecasting in the Finnish day-ahead energy market. The iterative search procedure employed within the methodology is developed to tune the model parameters and select the optimal input set of the explanatory variables. The numerical studies show that the proposed methodology has more accurate behavior than all other examined methods most recently applied to case studies of energy markets in different countries. The obtained results can be considered as providing extensive and useful information for participants of the day-ahead energy market, who have limited and uncertain information for price prediction to set up an optimal short-term operation portfolio. Although the focus of this work is primarily on the Finnish price area of Nord Pool Spot, given the result of this work, it is very likely that the same methodology will give good results when forecasting the prices on energy markets of other countries.

In search of information systems value : a case study of the EHR benefits realisation efforts of three Swedish hospitals.

The Swedish public health care organisation could very well be undergoing its most significant change since its specialisation during the late 19th and early 20th century. At the heart of this change is a move from using manual patient journals to electronic health records (EHR). EHR are complex integrated organisational wide information systems (IS) that promise great benefits and value as well as presenting great challenges to the organisation. The Swedish public health care is not the first organisation to implement integrated IS, and by no means alone in their quest for realising the potential benefits and value that it has to offer. As organisations invest in IS they embark on a journey of value-creation and capture. A journey where a costbased approach towards their IS-investments is replaced with a value-centric focus, and where the main challenges lie in the practical day-to-day task of finding ways to intertwine technology, people and business processes. This has however proven to be a problematic task. The problematic situation arises from a shift of perspective regarding how to manage IS in order to gain value. This is a shift from technology delivery to benefits delivery; from an ISimplementation plan to a change management plan. The shift gives rise to challenges related to the inability of IS and the elusiveness of value. As a response to these challenges the field of IS-benefits management has emerged offering a framework and a process in order to better understand and formalise benefits realisation activities. In this thesis the benefits realisation efforts of three Swedish hospitals within the same county council are studied. The thesis focuses on the participants of benefits analysis projects; their perceptions, judgments, negotiations and descriptions of potential benefits. The purpose is to address the process where organisations seek to identify which potential IS-benefits to pursue and realise, this in order to better understand what affects the process, so that realisation actions of potential IS-benefits could be supported. A qualitative case study research design is adopted and provides a framework for sample selection, data collection, and data analysis. It also provides a framework for discussions of validity, reliability and generalizability. Findings displayed a benefits fluctuation, which showed that participants’ perception of what constituted potential benefits and value changed throughout the formal benefits management process. Issues like structure, knowledge, expectation and experience affected perception differently, and this in the end changed the amount and composition of potential benefits and value. Five dimensions of benefits judgment were identified and used by participants when finding accommodations of potential benefits and value to pursue. Identified dimensions affected participants’ perceptions, which in turn affected the amount and composition of potential benefits. During the formal benefits management process participants shifted between judgment dimensions. These movements emerged through debates and interactions between participants. Judgments based on what was perceived as expected due to one’s role and perceived best for the organisation as a whole were the two dominant benefits judgment dimensions. A benefits negotiation was identified. Negotiations were divided into two main categories, rational and irrational, depending on participants’ drive when initiating and participating in negotiations. In each category three different types of negotiations were identified having different characteristics and generating different outcomes. There was also a benefits negotiation process identified that displayed management challenges corresponding to its five phases. A discrepancy was also found between how IS-benefits are spoken of and how actions of IS benefits realisation are understood. This was a discrepancy between an evaluation and a realisation focus towards IS value creation. An evaluation focus described IS-benefits as well-defined and measurable effects and a realisation focus spoke of establishing and managing an on-going place of value creation. The notion of valuescape was introduced in order to describe and support the understanding of IS value creation. Valuescape corresponded to a realisation focus and outlined a value configuration consisting of activities, logic, structure, drivers and role of IS.

Characteristics of urban heat island (UHI) in a high latitude coastal city - a case study of Turku, SW Finland

The term urban heat island (UHI) refers to the common situation in which the city is warmer than its rural surroundings. In this dissertation, the local climate, and especially the UHI, of the coastal city of Turku (182,000 inh.), SW Finland, was studied in different spatial and temporal scales. The crucial aim was to sort out the urban, topographical and water body impact on temperatures at different seasons and times of the day. In addition, the impact of weather on spatiotemporal temperature differences was studied. The relative importance of environmental factors was estimated with different modelling approaches and a large number of explanatory variables with various spatial scales. The city centre is the warmest place in the Turku area. Temperature excess relative to the coldest sites, i.e. rural areas about 10 kilometers to the NE from the centre, is on average 2 °C. Occasionally, the UHI intensity can be even 10 °C. The UHI does not prevail continuously in the Turku area, but occasionally the city centre can be colder than its surroundings. Then the term urban cool island or urban cold island (UCI) is used. The UCI is most common in daytime in spring and in summer, whereas during winter the UHI prevails throughout the day. On average, the spatial temperature differences are largest in summer, whereas the single extreme values are often observed in winter. The seasonally varying sea temperature causes the shift of relatively warm areas towards the coast in autumn and inland in spring. In the long term, urban land use was concluded to be the most important factor causing spatial temperature differences in the Turku area. The impact was mainly a warming one. The impact of water bodies was emphasised in spring and autumn, when the water temperature was relatively cold and warm, respectively. The impact of topography was on average the weakest, and was seen mainly in proneness of relatively low-lying places for cold air drainage during night-time. During inversions, however, the impact of topography was emphasised, occasionally outperforming those of urban land use and water bodies.

Continuity of patient care in day surgery

Continuity is a part of high-quality patient care. The purpose of this study was to analyse what factors are important in the continuity of patients’ care, and how well continuity is achieved in different stages of the care of day surgical patients. Day surgery has become significantly more prevalent in the past few decades, and in order for it to be carried out successfully, continuity in care is particularly essential. The study was carried out in two stages. In the first stage (2001–2005) of the study, continuity was examined through a review of literature from the perspective of critical pathways, naming the continuity categories of time flow, coordination flow, caring relationship flow, and information flow. The first stage also entailed an analysis of matters important to the patient and problems concerning the achievement of care continuity, carried out by interviewing 25 day surgical patients. In the second stage (2006–2015), the degree to which the continuity of day surgical patient care was achieved was analysed from the perspective of patients (n=203, 58%) and nurses working in day surgery units (n=83, 69%), and suggestions for developing the continuity of day surgery patient care were made. In this study continuity of care was examined through a review of literature from the perspective of critical pathways, naming the continuity categories of time flow, coordination flow, caring relationship flow, and information flow. Within these categories, several important factors for the patient were found. According to both patients and nurses, continuity of care is generally achieved to a high degree. Continuity of care is improved by patients being acquainted with and meeting the staff attending to them (nurse and surgeon) before and after the operation. From patients’ perspective, there is room for improvement especially in terms of being admitted to care and in the carer-patient relationship. From nurses’ perspective, there is room for improvement in terms of the smoothness of care. Nurses evaluated the continuity of care to be the least successful before and after the operation. An extensive social and health care reform is planned in Finland in the coming years, aiming to enhance social and health care services and to create smoothly functioning service and care. As a topic of further study supporting the development of the service system, it is important to follow the patient’s progress throughout the entire chain of care, e.g. as a case study. On the other hand, there is also a need to study the views of nurses and other health care professionals in health care, e.g. in primary health care.