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Tian Y, Osgood ND, Stempien J, Onaemo V, Danyliw A, Fast G, Osman BA, Reynolds J, Basran J. The impact of alternate level of care on access block and operational strategies to reduce emergency wait times: a multi-center simulation study. CAN J EMERG MED 2023; 25:608-616. [PMID: 37261614 DOI: 10.1007/s43678-023-00514-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 04/22/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Lengthy emergency department (ED) wait times caused by hospital access block is a growing concern for the Canadian health care system. Our objective was to quantify the impact of alternate-level-of-care on hospital access block and evaluate the likely effects of multiple interventions on ED wait times. METHODS Discrete-event simulation models were developed to simulate patient flows in EDs and acute care of six Canadian hospitals. The model was populated with administrative data from multiple sources (April 2017-March 2018). We simulated and assessed six different intervention scenarios' impact on three outcome measures: (1) time waiting for physician initial assessment, (2) time waiting for inpatient bed, and (3) patients who leave without being seen. We compared each scenario's outcome measures to the baseline scenario for each ED. RESULTS Eliminating 30% of medical inpatients' alternate-level-of-care days reduced the mean time waiting for inpatient bed by 0.25 to 4.22 h. Increasing ED physician coverage reduced the mean time waiting for physician initial assessment (∆ 0.16-0.46 h). High-quality care transitions targeting medical patients lowered the mean time waiting for inpatient bed for all EDs (∆ 0.34-6.85 h). Reducing ED visits for family practice sensitive conditions or improving continuity of care resulted in clinically negligible reductions in wait times and patients who leave without being seen rates. CONCLUSIONS A moderate reduction in alternate-level-of-care hospital days for medical patients could alleviate access block and reduce ED wait times, although the magnitude of reduction varies by site. Increasing ED physician staffing and aligning physician capacity with inflow demand could also decrease wait time. Operational strategies for reducing ED wait times should prioritize resolving output and throughput factors rather than input factors.
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Affiliation(s)
- Yuan Tian
- Department of Computer Science, University of Saskatchewan, Saskatoon, SK, Canada.
| | - Nathaniel D Osgood
- Department of Computer Science, University of Saskatchewan, Saskatoon, SK, Canada
| | - James Stempien
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
- Saskatchewan Health Authority, Saskatoon, SK, Canada
| | - Vivian Onaemo
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - Graham Fast
- Saskatchewan Health Authority, Saskatoon, SK, Canada
| | | | - Janet Reynolds
- Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jenny Basran
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
- Saskatchewan Health Authority, Saskatoon, SK, Canada
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Maninchedda M, Proia AS, Bianco L, Aromatario M, Orsi GB, Napoli C. Main Features and Control Strategies to Reduce Overcrowding in Emergency Departments: A Systematic Review of the Literature. Risk Manag Healthc Policy 2023; 16:255-266. [PMID: 36852330 PMCID: PMC9961148 DOI: 10.2147/rmhp.s399045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/14/2023] [Indexed: 02/25/2023] Open
Abstract
Purpose Overcrowding is a problem that affects emergency departments (ED) all over the world; it occurs due to a disproportion between user demand and the physical, human and structural resources available. Essential prerequisites to assessing and managing the phenomenon are its accurate measurement and an understanding of its impact. The objective of this systematic review is to identify the characteristics of the problem, analyzing the proposed strategies aimed at improving patient flow, delay in services provided and overcrowding of emergency departments. Methods To achieve our objectives, a manual computerized search was performed in the bibliographic databases using as keywords "Emergency Department", "Overcrowding", "Emergency Room", "Emergency Service", "Emergency Unit"",Emergency Ward", "Emergency Outpatient Unit", "Emergency Hospital", "Crowding", "Mass Gathering", "Management" and "Comprehensive Health Care". Two independent reviewers analyzed abstracts, titles and full text articles for admissibility, according to the selected inclusion and exclusion criteria. Results The process lead to include 19 articles. It was possible to group the solutions proposed in five categories: work organization, investment in primary care, creation of new dedicated professional figures, work and structural modifications and implementation of predictive simulation models using mathematical algorithms. Conclusion The most effective measures to guarantee an improvement in the flow of patients are represented by both improving the efficiency of human resources and by developing predictive mathematical models, regardless of the type of hospital and its location. Considering the complexity of EDs and the multiple characteristics of overcrowding and that the causes of crowding are different and site-specific, a careful examination of the specifics of each ED is necessary to identify improving fields.
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Affiliation(s)
- Mario Maninchedda
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Rome, Italy
| | - Anna Silvia Proia
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Rome, Italy
| | - Lavinia Bianco
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Rome, Italy
| | | | - Giovanni Battista Orsi
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Rome, Italy,Sant’ Andrea University Hospital, Rome, Italy
| | - Christian Napoli
- Sant’ Andrea University Hospital, Rome, Italy,Department of Medical Surgical Sciences and Translational Medicine, “Sapienza” University of Rome, Rome, Italy,Correspondence: Christian Napoli, Email
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Liu Q, Yang L, Peng Q. Artificial Intelligence Technology-Based Medical Information Processing and Emergency First Aid Nursing Management. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:8677118. [PMID: 35154360 PMCID: PMC8837421 DOI: 10.1155/2022/8677118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/11/2021] [Accepted: 12/29/2021] [Indexed: 01/17/2023]
Abstract
This study was aimed at exploring the new management mode of medical information processing and emergency first aid nursing management under the new artificial intelligence technology. This study will use the artificial intelligence algorithm to optimize medical information processing and emergency first aid nursing management process, in order to improve the efficiency of emergency department and first aid efficiency. The successful rescue rates of hemorrhagic shock, coma, dyspnea, and more than three organs injury were 96.7%, 92.5%, 93.7%, and 87.2%, respectively, after the emergency first aid nursing mode was used in the hospital emergency center. The success rates of first aid within three years were compared, which were 91.8%, 93.4%, and 94.2%, respectively, showing an increasing trend year by year. 255 emergency patients in five batches in June and five batches in July were selected as the research objects by convenience sampling method. Among them, 116 cases in June were taken as the experimental group, and 139 cases in July were taken as the control group, which was used to verify the efficiency of the design model in this study. The results showed that the triage time of the two groups was 8.16 ± 2.07 min and 19.21 ± 6.36 min, respectively, and the difference was statistically significant (P < 0.01). The triage coincidence rates were 96.35% and 90.04%, respectively, and the difference was statistically significant (P < 0.05). The research proved that the design of intelligent medical information processing and emergency first aid nursing management research model can effectively improve the triage efficiency of the wounded, assist the efficiency of emergency nursing of medical staff, and improve the survival rate of emergency patients, which is worthy of clinical promotion.
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Affiliation(s)
- Qing Liu
- Department of Emergency, The First People's Hospital of Lianyungang, Lianyungang City, 222002, China
| | - Liping Yang
- Department of Emergency, The First People's Hospital of Lianyungang, Lianyungang City, 222002, China
| | - Qingrong Peng
- Department of Emergency, The First People's Hospital of Lianyungang, Lianyungang City, 222002, China
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Lee SR, Shin SD, Ro YS, Lee H, Yoon JY. Multimodal Quality Improvement Intervention With Dedicated Patient Flow Manager to Reduce Emergency Department Length of Stay and Occupancy: Interrupted Time Series Analysis. J Emerg Nurs 2022; 48:211-223.e3. [DOI: 10.1016/j.jen.2021.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 11/28/2021] [Accepted: 12/05/2021] [Indexed: 11/16/2022]
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Bouda Abdulai AS, Mukhtar F, Ehrlich M. United States' Performance on Emergency Department Throughput, 2006 to 2016. Ann Emerg Med 2021; 78:174-190. [PMID: 33865616 DOI: 10.1016/j.annemergmed.2021.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 10/30/2020] [Accepted: 01/07/2021] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE Studies of early data found that US emergency departments (EDs) were characterized by prolonged patient waiting, long visit times, frequent and prolonged boarding (ie, patients kept waiting in ED hallways or other space outside the ED on admission to the hospital), and patients leaving without receiving or completing treatment. We sought to assess recent trends in ED throughput nationally. METHODS This was a retrospective cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey from 2006 to 2016. We used survey-weighted generalized linear models to assess changes over time. The primary outcome variables were the number of visits, wait time to consult a physician, length of visit (time from arrival to leaving for home or hospital ward), boarding time, the proportion of patients leaving without being seen, the proportion treated within recommended waiting times, and the proportion dispositioned within 4, 6, and 8 hours. RESULTS Between 2006 and 2016, the number of ED visits increased from 119.2 million to 145.6 million. During this period, annual median wait time decreased from 31 minutes (interquartile range 14 to 67) to 17 minutes (interquartile range 6 to 45). The proportion of patients who left without being seen declined from 2.0% (95% confidence interval [CI] 1.7% to 2.4%) to 1.1% (95% CI 0.8% to 1.4%). The proportion treated by a qualified practitioner within recommended waiting times increased from 75.5% (95% CI 72.7% to 78.3%) to 80.8% (95% CI 77.2% to 84.4%). Overall, there was no statistically significant change in median length of visit. However, over time, decreased proportions of the sickest patients were discharged within 4, 6, and 8 hours, whereas increased proportions of low-acuity patients were discharged within 4 hours. The distribution of patient boarding time remained fairly unchanged from 2009 to 2015, with a median of approximately 75 minutes. CONCLUSION Overall, there was improvement in ED timeliness from 2006 to 2016. However, we observed a decrease in the proportion of the sickest patients discharged within 8 hours of arrival, although this may be due to increased ancillary testing or specially consultation over time.
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Affiliation(s)
- Abubakar Sadiq Bouda Abdulai
- Martin Tuchman School of Management, New Jersey Institute of Technology, Newark, NJ; New Jersey Innovation Institute Healthcare Delivery Systems iLab, Newark, NJ.
| | - Fahad Mukhtar
- Department of Behavioral Health, St. Elizabeths Hospital, Washington, DC
| | - Michael Ehrlich
- Martin Tuchman School of Management, New Jersey Institute of Technology, Newark, NJ
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McKinley KW, Chamberlain JM, Doan Q, Berkowitz D. Reducing Pediatric ED Length of Stay by Reducing Diagnostic Testing: A Discrete Event Simulation Model. Pediatr Qual Saf 2021; 6:e396. [PMID: 33718751 PMCID: PMC7952107 DOI: 10.1097/pq9.0000000000000396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 10/16/2020] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Quality improvement efforts can require significant investment before the system impact of those efforts can be evaluated. We used discrete event simulation (DES) modeling to test the theoretical impact of a proposed initiative to reduce diagnostic testing for low-acuity pediatric emergency department (ED) patients.
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Affiliation(s)
- Kenneth W McKinley
- Emergency Medicine Section of Data Analytics, Children's National, Washington, D.C
| | - James M Chamberlain
- Emergency Medicine Section of Data Analytics, Children's National, Washington, D.C
| | - Quynh Doan
- Division of Emergency Medicine, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Deena Berkowitz
- Emergency Medicine Section of Data Analytics, Children's National, Washington, D.C
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Bittencourt RJ, Stevanato ADM, Bragança CTNM, Gottems LBD, O'Dwyer G. Interventions in overcrowding of emergency departments: an overview of systematic reviews. Rev Saude Publica 2020; 54:66. [PMID: 32638885 PMCID: PMC7319499 DOI: 10.11606/s1518-8787.2020054002342] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/15/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To present an overview of systematic reviews on throughput interventions to solve the overcrowding of emergency departments. METHODS Electronic searches for reviews published between 2007 and 2018 were made on PubMed, Cochrane Library, EMBASE, Health Systems Evidence, CINAHL, SciELO, LILACS, Google Scholar and the CAPES periodicals portal. Data of the included studies was extracted into a pre-formatted sheet and their methodological quality was assessed using AMSTAR 2 tool. Eventually, 15 systematic reviews were included for the narrative synthesis. RESULTS The interventions were grouped into four categories: (1) strengthening of the triage service; (2) strengthening of the ED’s team; (3) creation of new care zones; (4) change in ED’s work processes. All studies observed positive effect on patient’s length of stay, expect for one, which had positive effect on other indicators. According to AMSTAR 2 criteria, eight revisions were considered of high or moderate methodological quality and seven, low or critically low quality. There was a clear improvement in the quality of the studies, with an improvement in focus and methodology after two decades of systematic studies on the subject. CONCLUSIONS Despite some limitations, the evidence presented on this overview can be considered the cutting edge of current scientific knowledge on the topic.
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Affiliation(s)
- Roberto José Bittencourt
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Angelo de Medeiros Stevanato
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Carolina Thomé N M Bragança
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Leila Bernarda Donato Gottems
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Gisele O'Dwyer
- Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
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Ortíz-Barrios MA, Alfaro-Saíz JJ. Methodological Approaches to Support Process Improvement in Emergency Departments: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17082664. [PMID: 32294985 PMCID: PMC7216091 DOI: 10.3390/ijerph17082664] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/22/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023]
Abstract
The most commonly used techniques for addressing each Emergency Department (ED) problem (overcrowding, prolonged waiting time, extended length of stay, excessive patient flow time, and high left-without-being-seen (LWBS) rates) were specified to provide healthcare managers and researchers with a useful framework for effectively solving these operational deficiencies. Finally, we identified the existing research tendencies and highlighted opportunities for future work. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to undertake a review including scholarly articles published between April 1993 and October 2019. The selected papers were categorized considering the leading ED problems and publication year. Two hundred and three (203) papers distributed in 120 journals were found to meet the inclusion criteria. Furthermore, computer simulation and lean manufacturing were concluded to be the most prominent approaches for addressing the leading operational problems in EDs. In future interventions, ED administrators and researchers are widely advised to combine Operations Research (OR) methods, quality-based techniques, and data-driven approaches for upgrading the performance of EDs. On a different tack, more interventions are required for tackling overcrowding and high left-without-being-seen rates.
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Affiliation(s)
- Miguel Angel Ortíz-Barrios
- Department of Industrial Management, Agroindustry and Operations, Universidad de la Costa CUC, Barranquilla 081001, Colombia
- Correspondence: ; Tel.: +57-3007239699
| | - Juan-José Alfaro-Saíz
- Research Centre on Production Management and Engineering, Universitat Politècnica de València, 46022 Valencia, Spain;
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Moskop JC, Geiderman JM, Marshall KD, McGreevy J, Derse AR, Bookman K, McGrath N, Iserson KV. Another Look at the Persistent Moral Problem of Emergency Department Crowding. Ann Emerg Med 2018; 74:357-364. [PMID: 30579619 DOI: 10.1016/j.annemergmed.2018.11.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/23/2018] [Accepted: 11/19/2018] [Indexed: 11/16/2022]
Abstract
This article revisits the persistent problem of crowding in US hospital emergency departments (EDs). It begins with a brief review of origins of this problem, terms used to refer to ED crowding, proposed definitions and measures of crowding, and causal factors. The article then summarizes recent studies that document adverse moral consequences of ED crowding, including poorer patient outcomes; increased medical errors; compromises in patient physical privacy, confidentiality, and communication; and provider moral distress. It describes several organizational strategies implemented to relieve crowding and implications of ED crowding for individual practitioners. The article concludes that ED crowding remains a morally significant problem and calls on emergency physicians, ED and hospital leaders, emergency medicine professional associations, and policymakers to collaborate on solutions.
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Affiliation(s)
- John C Moskop
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
| | - Joel M Geiderman
- Ruth and Harry Roman Emergency Department, Department of Emergency Medicine, and Center for Healthcare Ethics, Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Kenneth D Marshall
- Department of Emergency Medicine and Department of History and Philosophy of Medicine, University of Kansas Health System, Kansas City, KS
| | - Jolion McGreevy
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, and Center for Bioethics, Harvard Medical School, Boston, MA
| | - Arthur R Derse
- Center for Bioethics and Medical Humanities, Institute for Health and Society, and Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Kelly Bookman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Norine McGrath
- Department of Emergency Medicine and John J. Lynch, MD, Center for Ethics, Medstar Washington Medical Center, Washington, DC
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