1
|
Monahan AC, Feldman SS, Fitzgerald TP. Reducing Crowding in Emergency Departments With Early Prediction of Hospital Admission of Adult Patients Using Biomarkers Collected at Triage: Retrospective Cohort Study. JMIR BIOINFORMATICS AND BIOTECHNOLOGY 2022; 3:e38845. [PMID: 38935936 PMCID: PMC11135233 DOI: 10.2196/38845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/05/2022] [Accepted: 07/17/2022] [Indexed: 06/29/2024]
Abstract
BACKGROUND Emergency department crowding continues to threaten patient safety and cause poor patient outcomes. Prior models designed to predict hospital admission have had biases. Predictive models that successfully estimate the probability of patient hospital admission would be useful in reducing or preventing emergency department "boarding" and hospital "exit block" and would reduce emergency department crowding by initiating earlier hospital admission and avoiding protracted bed procurement processes. OBJECTIVE To develop a model to predict imminent adult patient hospital admission from the emergency department early in the patient visit by utilizing existing clinical descriptors (ie, patient biomarkers) that are routinely collected at triage and captured in the hospital's electronic medical records. Biomarkers are advantageous for modeling due to their early and routine collection at triage; instantaneous availability; standardized definition, measurement, and interpretation; and their freedom from the confines of patient histories (ie, they are not affected by inaccurate patient reports on medical history, unavailable reports, or delayed report retrieval). METHODS This retrospective cohort study evaluated 1 year of consecutive data events among adult patients admitted to the emergency department and developed an algorithm that predicted which patients would require imminent hospital admission. Eight predictor variables were evaluated for their roles in the outcome of the patient emergency department visit. Logistic regression was used to model the study data. RESULTS The 8-predictor model included the following biomarkers: age, systolic blood pressure, diastolic blood pressure, heart rate, respiration rate, temperature, gender, and acuity level. The model used these biomarkers to identify emergency department patients who required hospital admission. Our model performed well, with good agreement between observed and predicted admissions, indicating a well-fitting and well-calibrated model that showed good ability to discriminate between patients who would and would not be admitted. CONCLUSIONS This prediction model based on primary data identified emergency department patients with an increased risk of hospital admission. This actionable information can be used to improve patient care and hospital operations, especially by reducing emergency department crowding by looking ahead to predict which patients are likely to be admitted following triage, thereby providing needed information to initiate the complex admission and bed assignment processes much earlier in the care continuum.
Collapse
Affiliation(s)
| | - Sue S Feldman
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Tony P Fitzgerald
- School of Mathematical Sciences, University College Cork, Cork, Ireland
- School of Public Health, University College Cork, Cork, Ireland
| |
Collapse
|
2
|
France DJ, Levin S, Ding R, Hemphill R, Han J, Russ S, Aronsky D, Weinger M. Factors Influencing Time-Dependent Quality Indicators for Patients With Suspected Acute Coronary Syndrome. J Patient Saf 2020; 16:e1-e10. [PMID: 26756723 PMCID: PMC4940339 DOI: 10.1097/pts.0000000000000242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Rapid risk stratification and timely treatment are critical to favorable outcomes for patients with acute coronary syndrome (ACS). Our objective was to identify patient and system factors that influence time-dependent quality indicators (QIs) for patients with unstable angina/non-ST elevation myocardial infarction (NSTEMI) in the emergency department (ED). METHODS A retrospective, cohort study was conducted during a 42-month period of all patients 24 years or older suspected of having ACS as defined by receiving an electrocardiogram and at least 1 cardiac biomarker test. Cox regression was used to model the effects of patient characteristics, ancillary service use, staffing provisions, equipment availability, and ED and hospital crowding on ACS QIs. RESULTS Emergency department adherence rates to national standards for electrocardiogram readout time and biomarker turnaround time were 42% and 37%, respectively. Cox regression models revealed that chief complaints without chest pain and the timing of stress testing and medication administration were associated with the most significant delays. CONCLUSIONS Patient and system factors both significantly influenced QI times in this cohort with unstable angina/NSTEMI. These results illustrate both the complexity of diagnosing patients with NSTEMI and the competing effects of clinical and system factors on patient flow through the ED.
Collapse
Affiliation(s)
- Daniel J France
- From the Department of Anesthesiology, Vanderbilt Medical Center, Nashville, Tennessee
| | - Scott Levin
- Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ru Ding
- Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Robin Hemphill
- National Center for Patient Safety, Veterans Affairs, Ann Arbor, Michigan
| | - Jin Han
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Stephan Russ
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Dominik Aronsky
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Matt Weinger
- From the Department of Anesthesiology, Vanderbilt Medical Center, Nashville, Tennessee
| |
Collapse
|
3
|
Mishra V, Tu SP, Heim J, Masters H, Hall L, Clark RR, Dow AW. Predicting the Future: Using Simulation Modeling to Forecast Patient Flow on General Medicine Units. J Hosp Med 2019; 14:9-15. [PMID: 30534642 DOI: 10.12788/jhm.3081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hospitals are complex adaptive systems within which multiple components such as patients, practitioners, facilities, and technology interact. A careful approach to optimization of this complex system is needed because any change can result in unexpected deleterious effects. One such approach is discrete event simulation, in which what-if scenarios allow researchers to predict the impact of a proposed change on the system. However, studies illustrating the application of simulation in optimization of general internal medicine (GIM) team inpatient operations are lacking. METHODS Administrative data about admissions and discharges, data from a time-motion study, and expert opinion on workflow were used to construct the simulation model. Then, the impact of four changes: aligning medical teams with nursing units, adding a hospitalist team, adding a nursing unit, and adding both a nursing unit and hospitalist team with higher admission volume were modeled on key hospital operational metrics. RESULTS Aligning medical teams with nursing units improved team metrics for aligned teams but shifted patients to unaligned teams. Adding a hospitalist team had little benefit, but adding a nursing unit improved system metrics. Both adding a hospitalist team and a nursing unit would be required to maintain operational metrics with increased patient volume. CONCLUSION Using simulation modeling, we provided data on the implications of four possible strategic changes on GIM inpatient units, providers, and patient throughput. Such analyses may be a worthwhile investment to study strategic decisions and make better choices with fewer unintended consequences.
Collapse
Affiliation(s)
- Vimal Mishra
- Division of Hospital Medicine, Medical Director of Telemedicine, Physician Informaticist, Virginia Commonwealth University Health System; Richmond, Virginia, USA.
| | - Shin-Ping Tu
- Division of General Internal Medicine, Geriatrics and Bioethics, University of California Davis, Davis, California, USA
| | - Joseph Heim
- Department of Industrial and Systems Engineering, Department of Health Services, University of Washington, Seattle, Washington, USA
| | - Heather Masters
- Associate Chief Medical Officer for Clinical Operations, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Lindsey Hall
- Office of Health Innovation, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Ralph R Clark
- Chief Medical Officer and Vice President for Clinical Activities, Virginia Commonwealth University Health System; Richmond, Virginia, USA
| | - Alan W Dow
- Assistant Vice President of Health Sciences for Interprofessional Education and Collaborative Care, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| |
Collapse
|
4
|
Ordu M, Demir E, Tofallis C. A decision support system for demand and capacity modelling of an accident and emergency department. Health Syst (Basingstoke) 2019; 9:31-56. [PMID: 32284850 DOI: 10.1080/20476965.2018.1561161] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 12/15/2018] [Indexed: 10/27/2022] Open
Abstract
Accident and emergency (A&E) departments in England have been struggling against severe capacity constraints. In addition, A&E demands have been increasing year on year. In this study, our aim was to develop a decision support system combining discrete event simulation and comparative forecasting techniques for the better management of the Princess Alexandra Hospital in England. We used the national hospital episodes statistics data-set including period April, 2009 - January, 2013. Two demand conditions are considered: the expected demand condition is based on A&E demands estimated by comparing forecasting methods, and the unexpected demand is based on the closure of a nearby A&E department due to budgeting constraints. We developed a discrete event simulation model to measure a number of key performance metrics. This paper presents a crucial study which will enable service managers and directors of hospitals to foresee their activities in future and form a strategic plan well in advance.
Collapse
Affiliation(s)
- Muhammed Ordu
- Hertfordshire Business School, University of Hertfordshire, Hatfield, UK
| | - Eren Demir
- Hertfordshire Business School, University of Hertfordshire, Hatfield, UK
| | - Chris Tofallis
- Hertfordshire Business School, University of Hertfordshire, Hatfield, UK
| |
Collapse
|
5
|
Abstract
Purpose
In hospitals, several patient flows compete for access to shared resources. Failure to manage these flows result in one or more disruptions within a hospital system. To ensure continuous care delivery, solving flow problems must not be limited to one unit, but should be extended to other departments – a prerequisite for solving flow problems in the entire hospital. Since most current studies focus solely on overcrowding in emergency units, additional insights are needed on system-wide patient flow management. The purpose of this paper is to look at the information available in system-wide patient flow management studies, which were also systematically evaluated to demonstrate which interventions improve inpatient flow.
Design/methodology/approach
The authors searched PubMed and Web of Science (Core Collection) literature databases and collected full-text articles using two selection and classification stages. Stage 1 was used to screen articles relating to patient flow management for inpatient settings with typical characteristics. Stage 2 was used to classify the articles selected in Stage 1 according to the interventions and their impact on patient flow within a hospital system.
Findings
In Stage 1, 107 studies were selected. Although a growing trend was observed, there were fewer studies on patient flow management in inpatient than studies in emergency settings. In Stage 2, 61 intervention studies were classified. The authors found that most interventions were about creating and adding supply resources. Since many hospital managers these days cannot easily add capacity owing to cost and resource constraints, using existing capacity efficiently is important – unfortunately not addressed in many studies. Furthermore, arrival variability was the factor most frequently mentioned as affecting flow. Of all interventions addressed in this review, the most prominent for advancing patient access to inpatient units was employing a specialized individual or team to maintain patient flow and bed placement across hospital units.
Originality/value
This study provides the first patient flow management systematic overview within an inpatient setting context.
Collapse
|
6
|
Hayden EM, Wong AH, Ackerman J, Sande MK, Lei C, Kobayashi L, Cassara M, Cooper DD, Perry K, Lewandowski WE, Scerbo MW. Human Factors and Simulation in Emergency Medicine. Acad Emerg Med 2018; 25:221-229. [PMID: 28925571 DOI: 10.1111/acem.13315] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 09/04/2017] [Accepted: 09/12/2017] [Indexed: 01/21/2023]
Abstract
This consensus group from the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes" held in Orlando, Florida, on May 16, 2017, focused on the use of human factors (HF) and simulation in the field of emergency medicine (EM). The HF discipline is often underutilized within EM but has significant potential in improving the interface between technologies and individuals in the field. The discussion explored the domain of HF, its benefits in medicine, how simulation can be a catalyst for HF work in EM, and how EM can collaborate with HF professionals to effect change. Implementing HF in EM through health care simulation will require a demonstration of clinical and safety outcomes, advocacy to stakeholders and administrators, and establishment of structured collaborations between HF professionals and EM, such as in this breakout group.
Collapse
Affiliation(s)
- Emily M. Hayden
- Department of Emergency Medicine; Massachusetts General Hospital; Boston MA
| | - Ambrose H. Wong
- Department of Emergency Medicine; Yale-New Haven Hospital; New Haven CT
| | - Jeremy Ackerman
- Department of Emergency Medicine; Emory University School of Medicine; Atlanta GA
- Department of Biomedical Engineering; Emory University/Georgia Institute of Technology; Atlanta GA
| | - Margaret K. Sande
- Centra Health; Fairfax VA
- Department of Emergency Medicine; University of Colorado School of Medicine; Denver CO
| | - Charles Lei
- Department of Emergency Medicine; Vanderbilt University Medical Center; Nashville TN
| | - Leo Kobayashi
- Department of Emergency Medicine; Alpert Medical School of Brown University; Providence RI
| | - Michael Cassara
- Department of Emergency Medicine; Northwell Health; Manhassat NY
| | - Dylan D. Cooper
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - Kimberly Perry
- Department of Psychology; Old Dominion University; Norfolk VA
| | | | - Mark W. Scerbo
- Department of Psychology; Old Dominion University; Norfolk VA
| |
Collapse
|
7
|
Laker LF, Torabi E, France DJ, Froehle CM, Goldlust EJ, Hoot NR, Kasaie P, Lyons MS, Barg-Walkow LH, Ward MJ, Wears RL. Understanding Emergency Care Delivery Through Computer Simulation Modeling. Acad Emerg Med 2018; 25:116-127. [PMID: 28796433 PMCID: PMC5805575 DOI: 10.1111/acem.13272] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 07/21/2017] [Accepted: 08/04/2017] [Indexed: 01/02/2023]
Abstract
In 2017, Academic Emergency Medicine convened a consensus conference entitled, "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes." This article, a product of the breakout session on "understanding complex interactions through systems modeling," explores the role that computer simulation modeling can and should play in research and development of emergency care delivery systems. This article discusses areas central to the use of computer simulation modeling in emergency care research. The four central approaches to computer simulation modeling are described (Monte Carlo simulation, system dynamics modeling, discrete-event simulation, and agent-based simulation), along with problems amenable to their use and relevant examples to emergency care. Also discussed is an introduction to available software modeling platforms and how to explore their use for research, along with a research agenda for computer simulation modeling. Through this article, our goal is to enhance adoption of computer simulation, a set of methods that hold great promise in addressing emergency care organization and design challenges.
Collapse
Affiliation(s)
| | | | - Daniel J. France
- Vanderbilt University Medical Center, Department of Anesthesiology
| | - Craig M. Froehle
- University of Cincinnati, Lindner College of Business
- University of Cincinnati, Department of Emergency Medicine
| | | | - Nathan R. Hoot
- The University of Texas, Department of Emergency Medicine
| | - Parastu Kasaie
- John Hopkins University, Bloomberg School of Public Health
| | | | | | - Michael J. Ward
- Vanderbilt University Medical Center, Department of Emergency Medicine
| | | |
Collapse
|
8
|
Uncovering effective process improvement strategies in an emergency department using discrete event simulation. Health Syst (Basingstoke) 2017. [DOI: 10.1057/hs.2014.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
9
|
Validation of the RETRIEVE (REverse TRIage EVEnts) Criteria for Same Day Return of Non-ST Elevation Acute Coronary Syndrome Patients to Referring Non-PCI Centres. Heart Lung Circ 2017; 27:792-797. [PMID: 28919071 DOI: 10.1016/j.hlc.2017.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 07/29/2017] [Accepted: 08/04/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND There are continuing bed constraints in percutaneous coronary intervention centres (PCI) so efficient patient triage from referral hospitals is pivotal. To evaluate a strategy of PCI centre (PCIC) bed-sparing we examined return of patients to referral hospitals screened by the RETRIEVE (REverse TRIage EVEnts) criteria and validated its use as a tool for screening suitability for same day transfer of non-ST-elevation acute coronary syndrome (NSTEACS) patients post PCI to their referring non-PCI centre (NPCIC). METHODS From May 2008 to May 2011, 433 NSTEACS patients were prospectively screened for suitability for same day transfer back to the referring hospital at the completion of PCI. Of these patients, 212 were excluded from same day transfer using the RETRIEVE criteria and 221 patients met the RETRIEVE criteria and were transferred back to their NPCIC. RESULTS Over the study period, 218 patients (98.6%) had no major adverse events. The primary endpoint (death, arrhythmia, myocardial infarction, major bleeding event, cerebrovascular accident, major vascular site complication, or requirement for return to the PCIC) was seen in only three transferred patients (1.4%). CONCLUSIONS The RETRIEVE criteria can be used successfully to identify NSTEACS patients suitable for transfer back to NPCIC following PCI. Same day transfer to a NPCIC using the RETRIEVE criteria was associated with very low rates of major complications or repeat transfer and appears to be as safe as routine overnight observation in a PCIC.
Collapse
|
10
|
Dvorak MF, Cheng CL, Fallah N, Santos A, Atkins D, Humphreys S, Rivers CS, White BA, Ho C, Ahn H, Kwon BK, Christie S, Noonan VK. Spinal Cord Injury Clinical Registries: Improving Care across the SCI Care Continuum by Identifying Knowledge Gaps. J Neurotrauma 2017; 34:2924-2933. [PMID: 28745934 PMCID: PMC5653140 DOI: 10.1089/neu.2016.4937] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Timely access and ongoing delivery of care and therapeutic interventions is needed to maximize recovery and function after traumatic spinal cord injury (tSCI). To ensure these decisions are evidence-based, access to consistent, reliable, and valid sources of clinical data is required. The Access to Care and Timing Model used data from the Rick Hansen SCI Registry (RHSCIR) to generate a simulation of healthcare delivery for persons after tSCI and to test scenarios aimed at improving outcomes and reducing the economic burden of SCI. Through model development, we identified knowledge gaps and challenges in the literature and current health outcomes data collection throughout the continuum of SCI care. The objectives of this article were to describe these gaps and to provide recommendations for bridging them. Accurate information on injury severity after tSCI was hindered by difficulties in conducting neurological assessments and classifications of SCI (e.g., timing), variations in reporting, and the lack of a validated SCI-specific measure of associated injuries. There was also limited availability of reliable data on patient factors such as multi-morbidity and patient-reported measures. Knowledge gaps related to structures (e.g., protocols) and processes (e.g., costs) at each phase of care have prevented comprehensive evaluation of system performance. Addressing these knowledge gaps will enhance comparative and cost-effectiveness evaluations to inform decision-making and standards of care. Recommendations to do so were: standardize data element collection and facilitate database linkages, validate and adopt more outcome measures for SCI, and increase opportunities for collaborations with stakeholders from diverse backgrounds.
Collapse
Affiliation(s)
- Marcel F. Dvorak
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Nader Fallah
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Argelio Santos
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Derek Atkins
- Operations and Logistics Division, Sauder School of Business, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Chester Ho
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Henry Ahn
- University of Toronto Spine Program, Toronto, Ontario, Canada
| | - Brian K. Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean Christie
- Research Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | | |
Collapse
|
11
|
lin D, Vasilakos AV, Tang Y, Yao Y. Neural networks for computer-aided diagnosis in medicine: A review. Neurocomputing 2016. [DOI: 10.1016/j.neucom.2016.08.039] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
12
|
Toerper MF, Flanagan E, Siddiqui S, Appelbaum J, Kasper EK, Levin S. Cardiac catheterization laboratory inpatient forecast tool: a prospective evaluation. J Am Med Inform Assoc 2015; 23:e49-57. [PMID: 26342217 DOI: 10.1093/jamia/ocv124] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 07/11/2015] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To develop and prospectively evaluate a web-based tool that forecasts the daily bed need for admissions from the cardiac catheterization laboratory using routinely available clinical data within electronic medical records (EMRs). METHODS The forecast model was derived using a 13-month retrospective cohort of 6384 catheterization patients. Predictor variables such as demographics, scheduled procedures, and clinical indicators mined from free-text notes were input to a multivariable logistic regression model that predicted the probability of inpatient admission. The model was embedded into a web-based application connected to the local EMR system and used to support bed management decisions. After implementation, the tool was prospectively evaluated for accuracy on a 13-month test cohort of 7029 catheterization patients. RESULTS The forecast model predicted admission with an area under the receiver operating characteristic curve of 0.722. Daily aggregate forecasts were accurate to within one bed for 70.3% of days and within three beds for 97.5% of days during the prospective evaluation period. The web-based application housing the forecast model was used by cardiology providers in practice to estimate daily admissions from the catheterization laboratory. DISCUSSION The forecast model identified older age, male gender, invasive procedures, coronary artery bypass grafts, and a history of congestive heart failure as qualities indicating a patient was at increased risk for admission. Diagnostic procedures and less acute clinical indicators decreased patients' risk of admission. Despite the site-specific limitations of the model, these findings were supported by the literature. CONCLUSION Data-driven predictive analytics may be used to accurately forecast daily demand for inpatient beds for cardiac catheterization patients. Connecting these analytics to EMR data sources has the potential to provide advanced operational decision support.
Collapse
Affiliation(s)
- Matthew F Toerper
- Johns Hopkins Department of Emergency Medicine, 1830 East Monument Street, Suite 6-100, Baltimore, MD 21287, USA Johns Hopkins Health System Operations Integration, 600 N. Wolfe Street, Administration Bldg. Suite 420, Baltimore, MD 21287, USA
| | - Eleni Flanagan
- Johns Hopkins Heart and Vascular Institute, 600 N. Wolfe Street, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Sauleh Siddiqui
- Department of Civil Engineering, Johns Hopkins Systems Institute, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA Department of Applied Mathematics and Statistics, Johns Hopkins Systems Institute, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA
| | - Jeff Appelbaum
- Johns Hopkins Health System Operations Integration, 600 N. Wolfe Street, Administration Bldg. Suite 420, Baltimore, MD 21287, USA
| | - Edward K Kasper
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Scott Levin
- Johns Hopkins Department of Emergency Medicine, 1830 East Monument Street, Suite 6-100, Baltimore, MD 21287, USA Johns Hopkins Health System Operations Integration, 600 N. Wolfe Street, Administration Bldg. Suite 420, Baltimore, MD 21287, USA
| |
Collapse
|
13
|
Best AM, Dixon CA, Kelton WD, Lindsell CJ, Ward MJ. Using discrete event computer simulation to improve patient flow in a Ghanaian acute care hospital. Am J Emerg Med 2014; 32:917-22. [PMID: 24953788 PMCID: PMC4119494 DOI: 10.1016/j.ajem.2014.05.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 05/09/2014] [Accepted: 05/11/2014] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Crowding and limited resources have increased the strain on acute care facilities and emergency departments worldwide. These problems are particularly prevalent in developing countries. Discrete event simulation is a computer-based tool that can be used to estimate how changes to complex health care delivery systems such as emergency departments will affect operational performance. Using this modality, our objective was to identify operational interventions that could potentially improve patient throughput of one acute care setting in a developing country. METHODS We developed a simulation model of acute care at a district level hospital in Ghana to test the effects of resource-neutral (eg, modified staff start times and roles) and resource-additional (eg, increased staff) operational interventions on patient throughput. Previously captured deidentified time-and-motion data from 487 acute care patients were used to develop and test the model. The primary outcome was the modeled effect of interventions on patient length of stay (LOS). RESULTS The base-case (no change) scenario had a mean LOS of 292 minutes (95% confidence interval [CI], 291-293). In isolation, adding staffing, changing staff roles, and varying shift times did not affect overall patient LOS. Specifically, adding 2 registration workers, history takers, and physicians resulted in a 23.8-minute (95% CI, 22.3-25.3) LOS decrease. However, when shift start times were coordinated with patient arrival patterns, potential mean LOS was decreased by 96 minutes (95% CI, 94-98), and with the simultaneous combination of staff roles (registration and history taking), there was an overall mean LOS reduction of 152 minutes (95% CI, 150-154). CONCLUSIONS Resource-neutral interventions identified through discrete event simulation modeling have the potential to improve acute care throughput in this Ghanaian municipal hospital. Discrete event simulation offers another approach to identifying potentially effective interventions to improve patient flow in emergency and acute care in resource-limited settings.
Collapse
Affiliation(s)
- Allyson M Best
- University of Cincinnati, College of Medicine, Cincinnati, OH 45229
| | - Cinnamon A Dixon
- Division of Emergency Medicine, Center for Global Health, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH 45229
| | - W David Kelton
- Department of Operations, Business Analytics and Information Systems, University of Cincinnati, Cincinnati, OH 45221
| | | | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN 37232.
| |
Collapse
|
14
|
Kang H, Nembhard HB, Rafferty C, DeFlitch CJ. Patient flow in the emergency department: a classification and analysis of admission process policies. Ann Emerg Med 2014; 64:335-342.e8. [PMID: 24875896 DOI: 10.1016/j.annemergmed.2014.04.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 04/02/2014] [Accepted: 04/07/2014] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE We investigate the effect of admission process policies on patient flow in the emergency department (ED). METHODS We surveyed an advisory panel group to determine approaches to admission process policies and classified them as admission decision is made by the team of providers (attending physicians, residents, physician extenders) (type 1) or attending physicians (type 2) on the admitting service, team of providers (type 3), or attending physicians (type 4) in the ED. We developed discrete-event simulation models of patient flow to evaluate the potential effect of the 4 basic policy types and 2 hybrid types, referred to as triage attending physician consultation and remote collaborative consultation on key performance measures. RESULTS Compared with the current admission process policy (type 1), the alternatives were all effective in reducing the length of stay of admitted patients by 14% to 26%. In other words, patients may spend 1.4 to 2.5 hours fewer on average in the ED before being admitted to internal medicine under a new admission process policy. The improved flow of admitted patients decreased both the ED length of stay of discharged patients and the overall length of stay by up to 5% and 6.4%, respectively. These results are framed in context of teaching mission and physician experience. CONCLUSION An efficient admission process can reduce waiting times for both admitted and discharged ED patients. This study contributed to demonstrating the potential value of leveraging admission process policies and developing a framework for pursuing these policies.
Collapse
Affiliation(s)
- Hyojung Kang
- Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA; Penn State Hershey Medical Center, and the Penn State University Center for Integrated Healthcare Delivery Systems, Pennsylvania State University, University Park, PA
| | - Harriet Black Nembhard
- Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park, PA; Penn State Hershey Medical Center, and the Penn State University Center for Integrated Healthcare Delivery Systems, Pennsylvania State University, University Park, PA.
| | - Colleen Rafferty
- Department of Internal Medicine, Pennsylvania State University, University Park, PA; Penn State Hershey Medical Center, and the Penn State University Center for Integrated Healthcare Delivery Systems, Pennsylvania State University, University Park, PA
| | - Christopher J DeFlitch
- Department of Emergency Medicine, Pennsylvania State University, University Park, PA; Penn State Hershey Medical Center, and the Penn State University Center for Integrated Healthcare Delivery Systems, Pennsylvania State University, University Park, PA
| |
Collapse
|
15
|
Noonan VK, Soril L, Atkins D, Lewis R, Santos A, Fehlings MG, Burns AS, Singh A, Dvorak MF. The application of operations research methodologies to the delivery of care model for traumatic spinal cord injury: the access to care and timing project. J Neurotrauma 2013; 29:2272-82. [PMID: 22800432 DOI: 10.1089/neu.2012.2317] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The long-term impact of spinal cord injury (SCI) on the health care system imposes a need for greater efficiency in the use of resources and the management of care. The Access to Care and Timing (ACT) project was developed to model the health care delivery system in Canada for patients with traumatic SCI. Techniques from Operations Research, such as simulation modeling, were used to predict the impact of best practices and policy initiatives on outcomes related to both the system and patients. These methods have been used to solve similar problems in business and engineering and may offer a unique solution to the complexities encountered in SCI care delivery. Findings from various simulated scenarios, from the patients' point of injury to community re-integration, can be used to inform decisions on optimizing practice across the care continuum. This article describes specifically the methodology and implications of producing such simulations for the care of traumatic SCI in Canada. Future publications will report on specific practices pertaining to the access to specialized services and the timing of interventions evaluated using the ACT model. Results from this type of research will provide the evidence required to support clinical decision making, inform standards of care, and provide an opportunity to engage policymakers.
Collapse
|
16
|
Freund Y. Saturation des urgences : parallèle et paradoxe. ANNALES FRANCAISES DE MEDECINE D URGENCE 2013. [DOI: 10.1007/s13341-013-0295-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
17
|
|
18
|
Levin SR, Harley ET, Fackler JC, Lehmann CU, Custer JW, France D, Zeger SL. Real-time forecasting of pediatric intensive care unit length of stay using computerized provider orders. Crit Care Med 2013; 40:3058-64. [PMID: 22824935 DOI: 10.1097/ccm.0b013e31825bc399] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop a model to produce real-time, updated forecasts of patients' intensive care unit length of stay using naturally generated provider orders. The model was designed to be integrated within a computerized decision support system to improve patient flow management. DESIGN Retrospective cohort study. SETTING Twenty-six bed pediatric intensive care unit within an urban, academic children's hospital using a computerized order entry system. PATIENTS A total of 2,178 consecutive pediatric intensive care unit admissions during a 16-month time period. MEASUREMENTS AND MAIN RESULTS We obtained unit length of stay measurements, time-stamped provider orders, age, admission source, and readmission status. A joint discrete-time logistic regression model was developed to produce probabilistic length of stay forecasts from continuously updated provider orders. Accuracy was assessed by comparing forecasted expected discharge time with observed discharge time, rank probability scoring, and calibration curves. Cross-validation procedures were conducted. The distribution of length of stay was heavily right-skewed with a mean of 3.5 days (95% confidence interval 0.3-19.1). Provider orders were predictive of length of stay in real-time accurately forecasting discharge within a 12-hr window: 46% for patients within 1 day of discharge, 34% for patients within 2 days of discharge, and 27% for patients within 3 days of discharge. The forecast model incorporating predictive orders demonstrated significant improvements in accuracy compared with forecasts based solely on empirical and temporal information. Seventeen predictive orders were found, grouped by medication, ventilation, laboratory, diet, activity, foreign body, and extracorporeal membrane oxygenation. CONCLUSIONS Provider orders reflect dynamic changes in patients' conditions, making them useful for real-time length of stay prediction and patient flow management. Patients' length of stay represent a major source of variability in intensive care unit resource utilization and if accurately predicted and communicated, may lead to proactive bed management with more efficient patient flow.
Collapse
Affiliation(s)
- Scott R Levin
- Departments of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | | | | | | | | | | |
Collapse
|
19
|
Forero R, Hillman KM, McCarthy S, Fatovich DM, Joseph AP, Richardson DB. Access block and ED overcrowding. Emerg Med Australas 2012; 22:119-35. [PMID: 20534047 DOI: 10.1111/j.1742-6723.2010.01270.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Prospective and retrospective access block hospital intervention studies from 1998 to 2008 were reviewed to assess the evidence for interventions around access block and ED overcrowding, including over 220 documents reported in Medline and data extracted from The State of our Public Hospitals Reports. There is an estimated 20-30% increased mortality rate due to access block and ED overcrowding. The main causes are major increases in hospital admissions and ED presentations, with almost no increase in the capacity of hospitals to meet this demand. The rate of available beds in Australia reduced from 2.6 beds per 1000 (1998-1999) to 2.4 beds per 1000 (2002-2007) in 2002, and has remained steady at between 2.5-2.6 beds per 1000. In the same period, the number of ED visits increased over 77% from 3.8 million to 6.74 million. Similarly, the number of public hospital admissions increased at an average rate of 3.4% per year from 3.7 to 4.7 million. Compared with 1998-1999 rates, the number of available beds in 2006-2007 is thus similar (2.65 vs 2.6 beds per 1000), but the number of ED presentations has almost doubled. All patient groups are affected by access block. Access block interventions may temporarily reduce some of the symptoms of access block, but many measures are not sustainable. The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.
Collapse
Affiliation(s)
- Roberto Forero
- Simpson Centre for Health Services Research Affiliated with The Australian Institute of Health Innovation, University of New South Wales, Kensington, New South Wales, Australia.
| | | | | | | | | | | |
Collapse
|
20
|
MATHEMATICAL MODELING: THE CASE OF EMERGENCY DEPARTMENT WAITING TIMES. Int J Technol Assess Health Care 2012; 28:93-109. [DOI: 10.1017/s0266462312000013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A decision analytic model often comprises a significant part of a health technology assessment. As health technology assessment in the hospital setting evolves, there is an increased need for modeling methods that account for patient care pathways and interactions between patients and their environment. For example, an evaluation of a computed tomography (CT) scanner for a new indication would need to consider the current and increased demand of the machine and how that may affect service in other areas of the hospital. This problem solving approach views “problems” through a systems perspective.
Collapse
|
21
|
Day TE, Al-Roubaie AR, Goldlust EJ. Decreased length of stay after addition of healthcare provider in emergency department triage: a comparison between computer-simulated and real-world interventions. Emerg Med J 2012; 30:134-8. [PMID: 22398851 PMCID: PMC3582047 DOI: 10.1136/emermed-2012-201113] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE (1) To determine the effects of adding a provider in triage on average length of stay (LOS) and proportion of patients with >6 h LOS. (2) To assess the accuracy of computer simulation in predicting the magnitude of such effects on these metrics. METHODS A group-level quasi-experimental trial comparing the St. Louis Veterans Affairs Medical Center emergency department (1) before intervention, (2) after institution of provider in triage, and discrete event simulation (DES) models of similar (3) 'before' and (4) 'after' conditions. The outcome measures were daily mean LOS and percentage of patients with LOS >6 h. RESULTS The DES-modelled intervention predicted a decrease in the %6-hour LOS from 19.0% to 13.1%, and a drop in the daily mean LOS from 249 to 200 min (p<0.0001). Following (actual) intervention, the number of patients with LOS >6 h decreased from 19.9% to 14.3% (p<0.0001), with the daily mean LOS decreasing from 247 to 210 min (p<0.0001). CONCLUSION Physician and mid-level provider coverage at triage significantly reduced emergency department LOS in this setting. DES accurately predicted the magnitude of this effect. These results suggest further work in the generalisability of triage providers and in the utility of DES for predicting quantitative effects of process changes.
Collapse
|
22
|
Faust O, Acharya UR, Tamura T. Formal Design Methods for Reliable Computer-Aided Diagnosis: A Review. IEEE Rev Biomed Eng 2012; 5:15-28. [DOI: 10.1109/rbme.2012.2184750] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
23
|
Wiler JL, Griffey RT, Olsen T. Review of modeling approaches for emergency department patient flow and crowding research. Acad Emerg Med 2011; 18:1371-9. [PMID: 22168201 DOI: 10.1111/j.1553-2712.2011.01135.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Emergency department (ED) crowding is an international phenomenon that continues to challenge operational efficiency. Many statistical modeling approaches have been offered to describe, and at times predict, ED patient load and crowding. A number of formula-based equations, regression models, time-series analyses, queuing theory-based models, and discrete-event (or process) simulation (DES) models have been proposed. In this review, we compare and contrast these modeling methodologies, describe the fundamental assumptions each makes, and outline the potential applications and limitations for each with regard to usability in ED operations and in ED operations and crowding research.
Collapse
Affiliation(s)
- Jennifer L Wiler
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, MO, USA.
| | | | | |
Collapse
|
24
|
Forero R, McCarthy S, Hillman K. Access block and emergency department overcrowding. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:216. [PMID: 21457507 PMCID: PMC3219412 DOI: 10.1186/cc9998] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Roberto Forero
- The Simpson Center for Health Systems Research, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.
| | | | | |
Collapse
|
25
|
Utilization of resource leveling to optimize ERCP efficiency. Ir J Med Sci 2010; 180:143-8. [DOI: 10.1007/s11845-010-0570-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Accepted: 08/26/2010] [Indexed: 10/19/2022]
|