Impact of the COVID-19 pandemic on the workflow of an ambulatory endoscopy center: an assessment by discrete event simulation

The recovery of endoscopic activity and cancer detection after the COVID-19 pandemic

Background

The COVID-19 pandemic had a substantial impact on cancer services. The aim of our study was to evaluate the recovery of endoscopic activity and cancer detection after the COVID-19 pandemic.

Methods

Endoscopic data from January 2019 to December 2020 were retrospectively collected to assess the endoscopic activity and cancer detection during the COVID-19 peak period (February 2020) and the post-COVID-19 peak period (March to July 2020).

Results

The COVID-19 pandemic almost brought endoscopic activity and cancer detection to a standstill. Diagnostic procedure and endoscopic resection showed the greatest reduction. With the decline in COVID-19 infections, endoscopic activity gradually returned to previous level in July. However, the detection rate of gastric cancer resumed in September, whereas colorectal cancer resumed in August. The monthly detection rates of gastric and colorectal cancers decreased from their initial peaks of 2.98 % and 6.45 %, respectively, and finally were even lower than the average in 2019. Similarly, the mean age of patients who received endoscopy also declined as the detection rates resumed. The increasing colonoscopies allowed the missing colorectal cancer patients to be caught up. In contrast, it was expected that 6.69 % of gastric cancer patients were missed and did not receive needed endoscopy.

Conclusions

The recovery of cancer detection occurred later than that of endoscopic activity, especially for gastric cancer. Older people were vulnerable to the continuous impact of COVID-19 pandemic than young people for seeking medical services. Urgent efforts are required to recover and maintain cancer services before subsequent waves of the COVID-19 pandemic.

Rectal cancer presentation during the COVID-19 pandemic: Are decreasing screening rates leading to an increase in acute presentations?

Nearly 23 million adults ages 50-75 are overdue for colorectal cancer (CRC) screening. In March 2020, the Centers for Medicare & Medicaid issued guidance that all non-urgent procedures be delayed due to the COVID-19 pandemic. Screening delays may have effects on the presentation of rectal cancer and the natural history of the disease. The aim of this study was to determine if procedural suspension due to the COVID-19 pandemic was associated with an increased proportion of acute presentations or more advanced stage at diagnosis for patients with rectal cancer. We conducted a single-center, retrospective review of adult patients with new or recurrent rectal adenocarcinoma from 2016-2021. We compared patients presenting before (pre-COVID) to those diagnosed after (COVID) March 1, 2020. Of 208 patients diagnosed with rectal cancer, 163 were diagnosed pre-COVID and 45 patients in the COVID group. Cohorts did not differ among age, sex, race, insurance status, marital status, rurality, or BMI. There was no difference in stage at presentation with the majority diagnosed with stage III disease (40.0% vs 33.3%, p = 0.26). Similar proportions of patients presented acutely (67.5% vs 64.4%, p = 0.71). Presenting symptoms were also similar between cohorts. On adjusted analysis, male sex, white race, and uninsured status were found to have significant impact acuity of presentation, while diagnosis before or after the onset of the pandemic remained non-significant (OR 1.25, 95% CI0.57-2.72; p = 0.59). While screening rates have decreased during the COVID pandemic, patients with rectal cancer did not appear to have an increased level of acuity or stage at presentation. These findings could result from the indolent nature of the disease and may change as the pandemic progresses.

Influence of COVID-19 and employees’ response to deviations on employee enactment

Developing countries’ economies are in shambles as a result of the coronavirus. Developing countries like Bangladesh began opening its business sector in May 2020 in order to preserve the economy. To mitigate the effect of coronavirus, the government has implemented “new normal” guidelines for businesses. The primary goals of this research are to determine how the COVID-19 pandemic has influenced employee performance and to determine the workers’ perspectives regarding the changes that have been made to their everyday lives. To complete this research, employee performance was assessed using the employee response to change (ERC) method. Employees from many sectors have been studied. For this research, 300 people from various sectors were surveyed online at random. The study was quantitative as well as exploratory. It was based solely on original data. The research used a non-probability sampling approach to collect data. The survey questionnaire was sent to those who replied via Google Forms. Results and visual representations are found using SPSS software and Microsoft Excel. COVID-19 and the reaction to employee changes have a considerable detrimental influence on employee performance, according to all of the study’s findings. The employee’s focus, communication, and attention to work are all adversely affected by these “new normal” alterations

The Association of the First Surge of the COVID-19 Pandemic with the High- and Low-Value Outpatient Care Delivered to Adults in the USA

BACKGROUND

The first surge of the COVID-19 pandemic entirely altered healthcare delivery. Whether this also altered the receipt of high- and low-value care is unknown.

OBJECTIVE

To test the association between the April through June 2020 surge of COVID-19 and various high- and low-value care measures to determine how the delivery of care changed.

DESIGN

Difference in differences analysis, examining the difference in quality measures between the April through June 2020 surge quarter and the January through March 2020 quarter with the same 2 quarters' difference the year prior.

PARTICIPANTS

Adults in the MarketScan® Commercial Database and Medicare Supplemental Database.

MAIN MEASURES

Fifteen low-value and 16 high-value quality measures aggregated into 8 clinical quality composites (4 of these low-value).

KEY RESULTS

We analyzed 9,352,569 adults. Mean age was 44 years (SD, 15.03), 52% were female, and 75% were employed. Receipt of nearly every type of low-value care decreased during the surge. For example, low-value cancer screening decreased 0.86% (95% CI, -1.03 to -0.69). Use of opioid medications for back and neck pain (DiD +0.94 [95% CI, +0.82 to +1.07]) and use of opioid medications for headache (DiD +0.38 [95% CI, 0.07 to 0.69]) were the only two measures to increase. Nearly all high-value care measures also decreased. For example, high-value diabetes care decreased 9.75% (95% CI, -10.79 to -8.71).

CONCLUSIONS

The first COVID-19 surge was associated with receipt of less low-value care and substantially less high-value care for most measures, with the notable exception of increases in low-value opioid use.

Assessing the impact of COVID-19 measures on COPD management and patients: a simulation-based decision support tool for COPD services in the UK

OBJECTIVES

To develop a computer-based decision support tool (DST) for key decision makers to safely explore the impact on chronic obstructive pulmonary disease (COPD) care of service changes driven by restrictions to prevent the spread of COVID-19.

DESIGN

The DST is powered by discrete event simulation which captures the entire patient pathway. To estimate the number of COPD admissions under different scenario settings, a regression model was developed and embedded into the tool. The tool can generate a wide range of patient-related and service-related outputs. Thus, the likely impact of possible changes (eg, COVID-19 restrictions and pandemic scenarios) on patients with COPD and care can be estimated.

SETTING

COPD services (including outpatient and inpatient departments) at a major provider in central London.

RESULTS

Four different scenarios (reflecting the UK government's Plan A, Plan B and Plan C in addition to a benchmark scenario) were run for 1 year. 856, 616 and 484 face-to-face appointments (among 1226 clinic visits) are expected in Plans A, B and C, respectively. Clinic visit quality in Plan A is found to be marginally better than in Plans B and C. Under coronavirus restrictions, lung function tests decreased more than 80% in Plan C as compared with Plan A. Fewer COPD exacerbation-related admissions were seen (284.1 Plan C vs 395.1 in the benchmark) associated with stricter restrictions. Although the results indicate that fewer quality-adjusted life years (in terms of COPD management) would be lost during more severe restrictions, the wider impact on physical and mental health must also be established.

CONCLUSIONS

This DST will enable COPD services to examine how the latest developments in care delivery and management might impact their service during and beyond the COVID-19 pandemic, and in the event of future pandemics.

Pre-endoscopy coronavirus disease 2019 screening and severe acute respiratory syndrome coronavirus-2 nucleic acid amplification testing in the Veterans Affairs healthcare system: clinical practice patterns, outcomes, and relationship to procedure volume

BACKGROUND AND AIMS

The coronavirus disease 2019 (COVID-19) pandemic has had profound impacts worldwide, including on the performance of GI endoscopy. We aimed to describe the performance and outcomes of pre-endoscopy COVID-19 symptom and exposure screening and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) nucleic acid amplification testing (NAAT) across the national Veterans Affairs healthcare system and describe the relationship of SARS-CoV-2 NAAT use and resumption of endoscopy services.

METHODS

COVID-19 screening and NAAT results from March 2020 to April 2021 were analyzed to determine use, performance characteristics of screening, and association between testing and endoscopic volume trends.

RESULTS

Of 220,891 completed endoscopies identified, 115,890 (52.5%) had documented preprocedure COVID-19 symptom and exposure screenings and 154,127 (69.8%) had preprocedure NAAT results within 7 days before scheduled endoscopy. Of 131,894 total canceled endoscopies, 26,475 (20.1%) had screening data and 28,505 (21.6%) had SARS-CoV-2 NAAT results. Overall, positive NAAT results were reported in 1.8% of all individuals tested and in 1.3% of those who screened negative. Among completed and canceled endoscopies, COVID-19 screening had a 34.6% sensitivity (95% confidence interval [CI], 32.4%-36.8%) and 96.4% specificity (95% CI, 96.2%-96.5%) when compared with NAAT. COVID-19 screening had a positive predictive value of 15.0% (95% CI, 14.0%-16.1%) and a negative predictive value of 98.7% (95% CI, 98.7%-98.8%). There was a very weak correlation between monthly testing and monthly endoscopy volume by site (Spearman rank correlation coefficient = .09).

CONCLUSIONS

These findings have important implications for decisions about preprocedure testing, especially given breakthrough infections among vaccinated individuals during the SARS-CoV-2 delta and omicron variant surge.

Using simulation modelling and systems science to help contain COVID-19: A systematic review

This study systematically reviews applications of three simulation approaches, that is, system dynamics model (SDM), agent-based model (ABM) and discrete event simulation (DES), and their hybrids in COVID-19 research and identifies theoretical and application innovations in public health. Among the 372 eligible papers, 72 focused on COVID-19 transmission dynamics, 204 evaluated both pharmaceutical and non-pharmaceutical interventions, 29 focused on the prediction of the pandemic and 67 investigated the impacts of COVID-19. ABM was used in 275 papers, followed by 54 SDM papers, 32 DES papers and 11 hybrid model papers. Evaluation and design of intervention scenarios are the most widely addressed area accounting for 55% of the four main categories, that is, the transmission of COVID-19, prediction of the pandemic, evaluation and design of intervention scenarios and societal impact assessment. The complexities in impact evaluation and intervention design demand hybrid simulation models that can simultaneously capture micro and macro aspects of the socio-economic systems involved.

A critical review of implementing lean and simulation to improve resource utilization and patient experience in outpatient clinics

Purpose

The purpose of this paper is to explore and critically review the existing literature on applications of Lean Methodology (LM) and Discrete-Event Simulation (DES) to improve resource utilization and patient experience in outpatient clinics. In doing, it is aimed to identify how to implement LM in outpatient clinics and discuss the advantages of integrating both lean and simulation tools towards achieving the desired outpatient clinics outcomes.

Design/methodology/approach

A theoretical background of LM and DES to define a proper implementation approach is developed. The search strategy of available literature on LM and DES used to improve outpatient clinic operations is discussed. Bibliometric analysis to identify patterns in the literature including trends, associated frameworks, DES software used, and objective and solutions implemented are presented. Next, an analysis of the identified work offering critical insights to improve the implementation of LM and DES in outpatient clinics is presented.

Findings

Critical analysis of the literature on LM and DES reveals three main obstacles hindering the successful implementation of LM and DES. To address the obstacles, a framework that integrates DES with LM has been recommended and proposed. The paper provides an example of such a framework and identifies the role of LM and DES towards improving the performance of their implementation in outpatient clinics.

Originality/value

This study provides a critical review and analysis of the existing implementation of LM and DES. The current roadblocks hindering LM and DES from achieving their expected potential has been identified. In addition, this study demonstrates how LM with DES combined to achieve the desired outpatient clinic objectives.

Simulation Study of the Impact of COVID-19 Policies on the Efficiency of a Smart Clinic MRI Service

The present study examines the impact of the policies against the proliferation of SARS-CoV-2 on outpatient facilities through a direct comparison of the key performance indicators measured in an ordinary and pandemic scenario. The subject of the analysis is a diagnostic imaging department of a Smart Clinic (SC) of Gruppo San Donato (GSD). The operations are virtually replicated through a Discrete-Event Simulation (DES) software called FlexSim Healthcare. Operational and productivity indicators are defined and quantified. As hypothesized, anti-contagious practices affect the normal execution of medical activities and their performance, resulting in an unpleasant scenario compared to the baseline one. A reduction in the number of diagnoses by 19% and a decrease in the utilization rate of the diagnostic machine by 21% are shown. Consequently, the development of strategies that restore balance and improve the execution of outpatient activities in a pandemic setting is necessary.

Discrete-Event Simulation Modeling in Healthcare: A Comprehensive Review

Discrete-event simulation (DES) is a stochastic modeling approach widely used to address dynamic and complex systems, such as healthcare. In this review, academic databases were systematically searched to identify 231 papers focused on DES modeling in healthcare. These studies were sorted by year, approach, healthcare setting, outcome, provenance, and software use. Among the surveys, conceptual/theoretical studies, reviews, and case studies, it was found that almost two-thirds of the theoretical articles discuss models that include DES along with other analytical techniques, such as optimization and lean/six sigma, and one-third of the applications were carried out in more than one healthcare setting, with emergency departments being the most popular. Moreover, half of the applications seek to improve time- and efficiency-related metrics, and one-third of all papers use hybrid models. Finally, the most popular DES software is Arena and Simul8. Overall, there is an increasing trend towards using DES in healthcare to address issues at an operational level, yet less than 10% of DES applications present actual implementations following the modeling stage. Thus, future research should focus on the implementation of the models to assess their impact on healthcare processes, patients, and, possibly, their clinical value. Other areas are DES studies that emphasize their methodological formulation, as well as the development of frameworks for hybrid models.

Patient Throughput Initiatives in Ambulatory Care Organizations during the COVID-19 Pandemic: A Systematic Review

BACKGROUND AND OBJECTIVES

Ambulatory (outpatient) health care organizations continue to respond to the COVID-19 global pandemic using an array of initiatives to provide a continuity of care for both COVID-19 and non-COVID-19 patients. The purpose of this study is to systematically identify the facilitators and barriers experienced by outpatient health care organizations in an effort to maintain effective and efficient patient throughput during the pandemic.

MATERIALS AND METHODS

This study systematically reviewed articles focused on initiatives taken by ambulatory care organizations to maintain optimal outpatient throughput levels while balancing pandemic precautions, published during 2020.

RESULTS

Among the 30 articles that met the inclusion criteria, three initiatives healthcare organizations have taken to maintain throughput were identified: the use (and enhanced use) of telehealth, protocol development, and health care provider training. The research team also identified three barriers to patient throughput: lack of telehealth, lack of resources, and overall lack of knowledge.

CONCLUSIONS

To maintain patient throughput during the COVID-19 pandemic, healthcare organizations need to develop strategies such as the use of virtual consultation and follow-up, new guidelines to move patients along the care delivery value-chain, and ongoing training of providers. Additionally, the availability of required technology for telehealth, availability of resources, and adequate knowledge are vital for continuous patient throughput to ensure continuity of care during a pandemic.

Success Rate of Wire Control-Assisted ERCP Sphincterotomy Versus Non-assisted ERCP Cannulation of Common Bile Duct in a Secondary Care Unit During the First COVID-19 Peak: A Retrospective Observational Study of 281 Patients

Background

The British Society of Gastroenterology (BSG) recommended that during the COVID-19 pandemic, endoscopy units perform endoscopic retrograde cholangiopancreatography (ERCP) for obstructive biliary pathologies in an emergency. We assessed the local performance of ERCP during the first wave of COVID-19 at our local endoscopy center, in particular the technique to common bile duct (CBD) cannulation.

Methodology

All ERCP procedures performed from January to June 2020 were retrospectively assessed and compared with procedures performed between January and June 2019 at the Royal Lancaster Infirmary. The indications for ERCP, success rate, and complications were studied separately. Correlation analysis was conducted using Spearman's rank correlation coefficient. The binary logistic regression model was used to compute the factors associated with successful ERCP. Significance was established when the two-sided P-value < 0.05. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software version 25 for Windows (SPSS Inc., Chicago, IL, USA, 2017).

Results

A total of 281 ERCP were included in this study, with 169 and 112 performed during the first six months of 2019 and 2020, respectively. A statistically significant (0.0087) higher proportion of cases with liver dysfunction presented for ERCP before the COVID-19 outbreak (152, 89.94%). All patients before COVID-19 underwent wire control-assisted ERCP, while 82 (73.21%) received assisted ERCP during the first wave (P < 0.001). There was no statistically significant difference (P = 0.10) in the number of patients who underwent sphincterotomy before and during the first wave of COVID-19, with 97 (57.39%) and 76 (67.85%), respectively. The success rate of ERCP before COVID-19 was relatively high, accounting for 146 (86.39%) patients in contrast to 87 (77.67%) patients during the first wave (P = 0.074). Sphincterotomy (β = 2.800, P = 0.028) and stent insertion (β = 0.852, P = 0.046) were statistically significant predictors of ERCP outcomes. There was no statistically significant impact of cholangitis on the success of ERCP (β = 1.672, P = 0.109).

Conclusion

The first wave of COVID-19 had a statistically proven negative impact on the expected standards of ERCP performance. Although the complication rate was significantly higher during the first wave case difficulty, the American Society of Anesthesia (ASA) status was not assessed on an individual basis. Both ASA status and case difficulty are now included in our endoscopy selection process. We recommend adding the complexity of cases and ASA to the local and national recording databases. This is a rare study on UK-based hospitals.

Modeling the impact of COVID-19 on Retina Clinic Performance

BACKGROUND

COVID-19, a highly contagious respiratory virus, presents unique challenges to ophthalmology practice as a high-volume, office-based specialty. In response to the COVID-19 pandemic, many operational changes were adopted in our ophthalmology clinic to enhance patient and provider safety while maintaining necessary clinical operations. The aim of this study was to evaluate how measures adopted during the pandemic period affected retina clinic performance and patient satisfaction, and to model future clinic flow to predict operational performance under conditions of increasing patient and provider volumes.

METHODS

Clinic event timestamps and demographics were extracted from the electronic medical records of in-person retina encounters from March 15 to May 15, 2020 and compared with the same period in 2019 to assess patient flow through the clinical encounter. Patient satisfaction was evaluated by Press Ganey patient experience surveys obtained from randomly selected outpatient encounters. A discrete-events simulation was designed to model the clinic with COVID-era restrictions to assess operational performance under conditions of increasing patient and provider volumes.

RESULTS

Retina clinic volume declined by 62 % during the COVID-19 health emergency. Average check-in-to-technician time declined 79 %, total visit length declined by 46 %, and time in the provider phase of care declined 53 %. Patient satisfaction regarding access nearly doubled during the COVID-period compared with the prior year (p < 0.0001), while satisfaction with overall care and safety remained high during both periods. A model incorporating COVID-related changes demonstrated that wait time before rooming reached levels similar to the pre-COVID era by 30 patients-per-provider in a 1-provider model and 25 patients-per-provider in a 2-provider model (p < 0.001). Capacity to maintain distancing between patients was exceeded only in the two 2-provider model above 25 patients-per-provider.

CONCLUSIONS

Clinic throughput was optimized in response to the COVID-19 health emergency. Modeling these clinic changes can help plan for eventual volume increases in the setting of limits imposed in the COVID-era.

Perspective gastrointestinal endoscopy infection control strategy against COVID-19: Workflow and space management for the operation of endoscopic centers

This Editorial refers to the article by S. Zhang et al., p 577‐586 of this issue.

The Impact of the COVID-19 Pandemic on Gastrointestinal Endoscopy Activity in a Tertiary Care Center from Northeastern Romania

BACKGROUND

The outbreak of the coronavirus disease 2019 (COVID-19) has led to significant changes in endoscopy units worldwide, with potential impact on patients' welfare as well as on endoscopy training. We aimed to assess the real-life impact of COVID-19 on the endoscopy unit in a tertiary care center from Romania.

METHODS

A 6.5-month period during the COVID-19 pandemic was compared to a similar period from 2019.

RESULTS

A 6.2-fold decrease of endoscopic procedures was noted. Colonoscopies were reduced from 916 to 42, p < 0.001; flexible sigmoidoscopies from 189 to 14, p = 0.009; upper gastrointestinal (GI) endoscopies from 2269 to 401, p = 0.006; and ERCP from 234 to 125, p < 0.001. The percentage of emergency procedures increased (38.8% vs. 26.2%, p < 0.001), as well as the rate of endoscopies performed for upper GI bleeding (42.5% vs. 24.4%, respectively, p < 0.001). The detection of cancers was considerably reduced (57 compared to 249, p = 0.001). There were fewer complications and higher success rates (7.6% vs. 19.2%, p < 0.001, and 94.2% vs. 90.7%, respectively). Fellows participation was also reduced from 90% to 40.9% (p < 0.001).

CONCLUSIONS

The COVID-19 pandemic has significantly altered the workflow of the endoscopy unit, lowering the number of procedures performed and potentially compromising the early detection of cancers.

Simulation and Improvement of Patients' Workflow in Heart Clinics during COVID-19 Pandemic Using Timed Coloured Petri Nets

The COVID-19 epidemic has spread across the world within months and creates multiple challenges for healthcare providers. Patients with cardiovascular disease represent a vulnerable population when suffering from COVID-19. Most hospitals have been facing difficulties in the treatment of COVID-19 patients, and there is a need to minimise patient flow time so that staff health is less endangered, and more patients can be treated. This article shows how to use simulation techniques to prepare hospitals for a virus outbreak. The initial simulation of the current processes of the heart clinic first identified the bottlenecks. It confirmed that the current workflow is not optimal for COVID-19 patients; therefore, to reduce waiting time, three optimisation scenarios are proposed. In the best situation, the discrete-event simulation of the second scenario led to a 62.3% reduction in patient waiting time. This is one of the few studies that show how hospitals can use workflow modelling using timed coloured Petri nets to manage healthcare systems in practice. This technique would be valuable in these challenging times as the health of staff, and other patients are at risk from the nosocomial transmission.