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Cildoz M, Ibarra A, Mallor F. Acuity-based rotational patient-to-physician assignment in an emergency department using electronic health records in triage. Health Informatics J 2023; 29:14604582231167430. [PMID: 37068379 DOI: 10.1177/14604582231167430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
Emergency department (ED) operational metrics generated by a new acuity-based rotational patient-to-physician assignment (ARPA) algorithm are compared with those obtained with a simple rotational patient assignment (SRPA) system aimed only at an equitable patient distribution. The new ARPA method theoretically guarantees that no two physicians' assigned patient loads can differ by more than one, either partially (by acuity levels) or in total; whereas SRPA guarantees only the latter. The performance of the ARPA method was assessed in practice in the ED of the main public hospital (Hospital Compound of Navarra) in the region of Navarre in Spain. This ED attends over 140 000 patients every year. Data analysis was conducted on 9,063 ED patients in the SRPA cohort, and 8,892 ED patients in the ARPA cohort. The metrics of interest are related both to patient access to healthcare and physician workload distribution: patient length of stay; arrival-to-provider time; ratio of patients exceeding the APT target threshold; and range of assigned patients across physicians by priority levels. The transition from SRPA to ARPA is associated with improvements in all ED operational metrics. This research demonstrates that ARPA is a simple and useful strategy for redesigning front-end ED processes.
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Affiliation(s)
- Marta Cildoz
- Institute of Smart Cities, Public University of Navarre, Pamplona, Spain
| | | | - Fermin Mallor
- Institute of Smart Cities, Public University of Navarre, Pamplona, Spain
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Stefánsdóttir NT, Nilsen P, Lindstroem MB, Andersen O, Powell BJ, Tjørnhøj-Thomsen T, Kirk JW. Implementing a new emergency department: a qualitative study of health professionals' change responses and perceptions. BMC Health Serv Res 2022; 22:447. [PMID: 35382815 PMCID: PMC8985264 DOI: 10.1186/s12913-022-07805-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background The aim of the study is two-fold. It explores how managers and key employees at the Emergency Department (ED) and specialist departments in a university hospital in the Capital Region of Denmark respond to the planned change to a new ED, and how they perceive the change involved in the implementation of the new ED. The study investigates what happens when health professionals are confronted with implementation of policy that changes their organization and everyday work lives. Few studies provide in-depth investigations of health professionals’ reactions to the implementation of new EDs, and particularly how they influence the implementation of a nationwide organizational change framed within a political strategy. Methods The study used semi-structured individual interviews with 51 health professionals involved in implementation activities related to an organizational change of establishing a new ED with new patient pathways for acutely ill patients. The data was deductively analyzed using Leon Coetsee’s theoretical framework of change responses, but the analysis also allowed for a more inductive reading of the material. Results Fourteen types of responses to establishing a new ED were identified and mapped onto six of the seven overall change responses in Coetsee’s framework. The participants perceived the change as particularly three changes. Firstly, they wished to create the best possible acute patient pathway in relation to their specialty. Whether the planned new ED would redeem this was disputed. Secondly, participants perceived the change as relocation to a new building, which both posed potentials and worries. Thirdly, both hopeful and frustrated statements were given about the newly established medical specialty of emergency medicine (EM), which was connected to the success of the new ED. Conclusions The study showcases how implementation processes within health care are not straightforward and that it is not only the content of the implementation that determines the success of the implementation and its outcomes but also how these are perceived by managers and employees responsible for the process and their context. In this way, managers must recognize that it cannot be pre-determined how implementation will proceed, which necessitates fluid implementation plans and demands implementation managements skills.
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Affiliation(s)
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Linköping University, 581 83, Linköping, Sweden
| | - Mette Bendtz Lindstroem
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | - Ove Andersen
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark.,Emergency Department, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark.,Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School and School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Tine Tjørnhøj-Thomsen
- Department of Health and Social Context, National Institute of Public Health, University of Southern Denmark, 1455, Copenhagen K, Denmark
| | - Jeanette Wassar Kirk
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark.,Department of Public Health, Nursing, Aarhus University, 8000, Aarhus C, Denmark
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Patel VL, Denton CA, Soni HC, Kannampallil TG, Traub SJ, Shapiro JS. Physician Workflow in Two Distinctive Emergency Departments: An Observational Study. Appl Clin Inform 2021; 12:141-152. [PMID: 33657633 DOI: 10.1055/s-0040-1722615] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES We characterize physician workflow in two distinctive emergency departments (ED). Physician practices mediated by electronic health records (EHR) are explored within the context of organizational complexity for the delivery of care. METHODS Two urban clinical sites, including an academic teaching ED, were selected. Fourteen physicians were recruited. Overall, 62 hours of direct clinical observations were conducted characterizing clinical activities (EHR use, team communication, and patient care). Data were analyzed using qualitative open-coding techniques and descriptive statistics. Timeline belts were used to represent temporal events. RESULTS At site 1, physicians, engaged in more team communication, followed by direct patient care. Although physicians spent 61% of their clinical time at workstations, only 25% was spent on the EHR, primarily for clinical documentation and review. Site 2 physicians engaged primarily in direct patient care spending 52% of their time at a workstation, and 31% dedicated to EHRs, focused on chart review. At site 1, physicians showed nonlinear complex workflow patterns with a greater frequency of multitasking and interruptions, resulting in workflow fragmentation. In comparison, at site 2, a less complex environment with a unique patient assignment system, resulting in a more linear workflow pattern. CONCLUSION The nature of the clinical practice and EHR-mediated workflow reflects the ED work practices. Physicians in more complex organizations may be less efficient because of the fragmented workflow. However, these effects can be mitigated by effort distribution through team communication, which affords inherent safety checks.
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Affiliation(s)
- Vimla L Patel
- Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York, New York, United States
| | - Courtney A Denton
- Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York, New York, United States
| | - Hiral C Soni
- Biomedical Informatics, College of Health Solutions, Arizona State University, Phoenix, Arizona, United States
| | - Thomas G Kannampallil
- Department of Anesthesiology and Institute for Informatics, Washington University School of Medicine, Saint Louis, Missouri, United States
| | - Stephen J Traub
- Department of Emergency Medicine, Mayo Clinic, Phoenix, Arizona, United States
| | - Jason S Shapiro
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
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Abstract
Emergency department (ED) operations reflect the intersection of factors external and internal to the ED itself, with unique problems posed by community and academic environments. ED crowding is primarily caused by a lack of inpatient beds for patients admitted through the ED. Changes to front-end operations, such as point-of-care testing and putting physicians in triage, can yield benefits in throughput, but require individual cost analyses. Balancing physician workloads can lead to substantial improvements in throughput. Observation pathways can reduce crowding while maintaining safety. Physician and nurse well-being is an underappreciated topic within operations, and demands close attention and further research.
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Abstract
Early assignment of patients to specific treatment teams improves length of stay, rate of patients leaving without being seen, patient satisfaction, and resident education. Multiple variations of patient assignment systems exist, including provider-in-triage/team triage, fast-tracks/vertical pathways, and rotational patient assignment. The authors discuss the theory behind patient assignment systems and review potential benefits of specific models of patient assignment found in the current literature.
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Benabbas R, Shah R, Zonnoor B, Mehta N, Sinert R. Impact of triage liaison provider on emergency department throughput: A systematic review and meta-analysis. Am J Emerg Med 2020; 38:1662-1670. [PMID: 32505473 DOI: 10.1016/j.ajem.2020.04.068] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Emergency department (ED) overcrowding is linked to poor outcome and decreases patient satisfaction. Strategies to control Emergency department (ED) overcrowding has been subject of research. STUDY OBJECTIVES The objective of this systematic review and meta-analysis was to investigate the impact of triage liaison providers (TLPs) on the ED throughput. METHODS We searched PubMed, EMBASE, and Web of Science up to April 2019 for studies done in the United States. Primary outcomes were number of patients left without being seen (LWBS) and patients' emergency department length of stay (ED-LOS). ED-LOS data was pooled using mean difference with random effect model. Risk Ratio (RRs) for LWBS was calculated with random effect model with 95% confidence interval (95% CI). RESULTS Twelve studies encompassing 329,340patients were included in the meta-analysis. Implementation of the TLP system using attending physicians was associated with a decrease in risk of LWBS 0.62 (95% CI 0.54, 0.71), The change in ED-LOS after implementation of TLP was too heterogeneous to pool the data with the mean ΔED-LOS ranging from -82 to +20 min. Stratification of studies by disposition, admitted versus discharged, did not decrease the heterogeneity. CONCLUSION Implementation of TLP can decrease the rate of LWBS however this review is inconclusive about the effect of TLP on ED-LOS due to the high heterogeneity observed in the literature.
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Affiliation(s)
- Roshanak Benabbas
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, United States of America; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, United States of America.
| | - Rushabh Shah
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, United States of America; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, United States of America
| | - Bobak Zonnoor
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, United States of America; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, United States of America
| | - Ninfa Mehta
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, United States of America; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, United States of America
| | - Richard Sinert
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, United States of America; Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, United States of America
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Vankipuram A, Patel VL, Traub S, Shortliffe EH. Overlaying multiple sources of data to identify bottlenecks in clinical workflow. J Biomed Inform 2019; 100S:100004. [PMID: 34384582 DOI: 10.1016/j.yjbinx.2019.100004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 02/12/2019] [Accepted: 02/14/2019] [Indexed: 11/30/2022]
Abstract
The pursuit of increased efficiency and quality of clinical care based on the analysis of workflow has seen the introduction of several modern technologies into medical environments. Electronic health records (EHRs) remain central to analysis of workflow, owing to their wide-ranging impact on clinical processes. The two most common interventions to facilitate EHR-related workflow analysis are automated location tracking using sensor-based technologies and EHR usage data logs. However, to maximize the potential of these technologies, and especially to facilitate workflow redesign, it is necessary to overlay these quantitative findings on the contextual data from qualitative methods such as ethnography. Such a complementary approach promises to yield more precise measures of clinical workflow that provide insights into how redesign could address inefficiencies. In this paper, we categorize clinical workflow in the Emergency Department (ED) into three types (perceived, real and ideal) to create a structured approach to workflow redesign using the available data. We use diverse data sources: sensor-based location tracking through Radio-Frequency Identification (RFID), summary EHR usage data logs, and data from physician interviews augmented by direct observations (through clinician shadowing). Our goal is to discover inefficiencies and bottlenecks that can be addressed to achieve a more ideal workflow state relative to its real and perceived state. We thereby seek to demonstrate a novel data-driven approach toward iterative workflow redesign that generalizes for use in a variety of settings. We also propose types of targeted support or adjustments to offset some of the inefficiencies we noted.
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Affiliation(s)
- Akshay Vankipuram
- Department of Biomedical Informatics, Arizona State University, Scottsdale, AZ, United States.
| | - Vimla L Patel
- Department of Biomedical Informatics, Arizona State University, Scottsdale, AZ, United States; The New York Academy of Medicine, New York, NY, United States
| | | | - Edward H Shortliffe
- Department of Biomedical Informatics, Arizona State University, Scottsdale, AZ, United States; Department of Biomedical Informatics, Columbia University, New York City, NY, United States
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Denton CA, Soni HC, Kannampallil TG, Serrichio A, Shapiro JS, Traub SJ, Patel VL. Emergency Physicians' Perceived Influence of EHR Use on Clinical Workflow and Performance Metrics. Appl Clin Inform 2018; 9:725-733. [PMID: 30208497 DOI: 10.1055/s-0038-1668553] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Over the last decade, electronic health records (EHRs) have shaped clinical practice. In this article, we investigated the perceived effects of EHR use on clinical workflow and meaningful use (MU) performance metrics. MATERIALS AND METHODS Semistructured interviews were conducted with 20 (n = 20) physicians at two urban emergency departments. Interview questions focused on time spent on EHR use, changes in clinical practices with EHR use, and the effect of MU performance metrics on clinical workflow. Qualitative coding using grounded theory and descriptive analyses were performed to provide descriptive insights. RESULTS Physicians reported that EHRs improved their clinical workflow, especially on MU-related activities including door-to-doctor time and admit decision time. EHR use also affected physicians work efficiency, quality of care provided, and overall patient safety. CONCLUSION Physicians' perception of EHRs is likely to influence their practices. With negative perceptions of EHR usability problems, positive aspects of EHR use, including the influence on MU performance metrics, may be overridden.
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Affiliation(s)
- Courtney A Denton
- Center for Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York, New York, United States
| | - Hiral C Soni
- Department of Biomedical Informatics, Arizona State University, Phoenix, Arizona, United States
| | - Thomas G Kannampallil
- Department of Family Medicine, University of Illinois at Chicago, Illinois, United States
| | - Anna Serrichio
- Center for Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York, New York, United States
| | - Jason S Shapiro
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Stephen J Traub
- Department of Emergency Medicine, Mayo Clinic, Phoenix, Arizona, United States
| | - Vimla L Patel
- Center for Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York, New York, United States.,Department of Biomedical Informatics, Arizona State University, Phoenix, Arizona, United States
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Vankipuram A, Traub S, Patel VL. A method for the analysis and visualization of clinical workflow in dynamic environments. J Biomed Inform 2018; 79:20-31. [DOI: 10.1016/j.jbi.2018.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 11/28/2022]
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Traub SJ, Saghafian S, Bartley AC, Buras MR, Stewart CF, Kruse BT. The durability of operational improvements with rotational patient assignment. Am J Emerg Med 2018; 36:1367-1371. [PMID: 29331271 DOI: 10.1016/j.ajem.2017.12.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/14/2017] [Accepted: 12/20/2017] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION Previous work has suggested that Emergency Department rotational patient assignment (a system in which patients are algorithmically assigned to physicians) is associated with immediate (first-year) improvements in operational metrics. We sought to determine if these improvements persisted over a longer follow-up period. METHODS Single-site, retrospective analysis focused on years 2-4 post-implementation (follow-up) of a rotational patient assignment system. We compared operational data for these years with previously published data from the last year of physician self-assignment and the first year of rotational patient assignment. We report data for patient characteristics, departmental characteristics and facility characteristics, as well as outcomes of length of stay (LOS), arrival to provider time (APT), and rate of patients who left before being seen (LBBS). RESULTS There were 140,673 patient visits during the five year period; 138,501 (98.7%) were eligible for analysis. LOS, APT, and LBBS during follow-up remained improved vs. physician self-assignment, with improvements similar to those noted in the first year of implementation. Compared with the last year of physician self-assignment, approximate yearly average improvements during follow-up were a decrease in median LOS of 18min (8% improvement), a decrease in median APT of 21min (54% improvement), and a decrease in LBBS of 0.69% (72% improvement). CONCLUSION In a single facility study, rotational patient assignment was associated with sustained operational improvements several years after implementation. These findings provide further evidence that rotational patient assignment is a viable strategy in front-end process redesign.
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Affiliation(s)
- Stephen J Traub
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States; College of Medicine, Mayo Clinic, Rochester, MN, United States.
| | | | - Adam C Bartley
- Division of Health Systems Informatics, Mayo Clinic, Rochester, MN, United States
| | - Matthew R Buras
- Division of Health Sciences Research, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Christopher F Stewart
- Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States; College of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Brian T Kruse
- College of Medicine, Mayo Clinic, Rochester, MN, United States; Department of Emergency Medicine, Mayo Clinic Florida, Jacksonville, FL, United States
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