Applying Systems Engineering Reduces Radiology Transport Cycle Times in the Emergency Department

Root Cause Analysis of Delayed Emergency Department Computed Tomography Scans

Introduction

A solution for emergency department (ED) congestion remains elusive. As reliance on imaging grows, computed tomography (CT) turnaround time has been identified as a major bottleneck. In this study we sought to identify factors associated with significantly delayed CT in the ED.

Methods

We performed a retrospective analysis of all CT imaging completed at an urban, tertiary care ED from May 1-July 31, 2021. During that period, 5,685 CTs were performed on 4,344 patients, with a median time from CT order to completion of 108 minutes (Quartile 1 [Q1]: 57 minutes, Quartile 3 [Q3]: 182 minutes, interquartile range [IQR]: 125 minutes). Outliers were defined as studies that took longer than 369 minutes to complete (Q3 + 1.5 × IQR). We systematically reviewed outlier charts to determine factors associated with delay and identified five factors: behaviorally non-compliant or medically unstable patients; intravenous (IV) line issues; contrast allergies; glomerular filtration rate (GFR) concerns; and delays related to imaging protocol (eg, need for IV contrast, request for oral and/or rectal contrast). We calculated confidence intervals (CI) using the modified Wald method. Inter-rater reliability was assessed with a kappa analysis.

Results

We identified a total of 182 outliers (4.2% of total patients). Fifteen (8.2%) cases were excluded for CT time-stamp inconsistencies. Of the 167 outliers analyzed, 38 delays (22.8%, 95% confidence interval [CI] 17.0-29.7) were due to behaviorally non-compliant or medically unstable patients; 30 (18.0%, 95% CI 12.8-24.5) were due to IV issues; 24 (14.4%, 95% CI 9.8-20.6) were due to contrast allergies; 21 (12.6%, 95% CI 8.3-18.5) were due to GFR concerns; and 20 (12.0%, 95% CI 7.8-17.9) were related to imaging study protocols. The cause of the delay was unknown in 55 cases (32.9%, 95% CI 26.3-40.4).

Conclusion

Our review identified both modifiable and non-modifiable factors associated with significantly delayed CT in the ED. Patient factors such as behavior, allergies, and medical acuity cannot be controlled. However, institutional policies regarding difficult IV access, contrast administration in low GFR settings, and study protocols may be modified, capturing up to 42.6% of outliers.

Improving radiology: a whole-system opportunity

In this article, we set out the current context and case for change in radiology in England and how quality-improvement approaches can support the development of sustainable Imaging services and networks to meet the challenges faced now and in the future.

Effects of Lean Interventions Supported by Digital Technologies on Healthcare Services: A Systematic Review

Despite the increasing utilization of lean practices and digital technologies (DTs) related to Industry 4.0, the impact of such dual interventions on healthcare services remains unclear. This study aims to assess the effects of those interventions and provide a comprehensive understanding of their dynamics in healthcare settings. The methodology comprised a systematic review following the PRISMA guidelines, searching for lean interventions supported by DTs. Previous studies reporting outcomes related to patient health, patient flow, quality of care, and efficiency were included. Results show that most of the improvement interventions relied on lean methodology followed by lean combined with Six Sigma. The main supporting technologies were simulation and automation, while emergency departments and laboratories were the main settings. Most interventions focus on patient flow outcomes, reporting positive effects on outcomes related to access to service and utilization of services, including reductions in turnaround time, length of stay, waiting time, and turnover time. Notably, we found scarce outcomes regarding patient health, staff wellbeing, resource use, and savings. This paper, the first to investigate the dual intervention of DTs with lean or lean–Six Sigma in healthcare, summarizes the technical and organizational challenges associated with similar interventions, encourages further research, and promotes practical applications.

An application of quality function deployment and SERVQUAL approaches to enhance the service quality in radiology centres

Purpose

Meeting the patients' requirements as customers of the health care sector is crucially important as a social responsibility. According to the resource constraints, only an efficient utilisation of health services can provide that purpose. This study aims to develop a quantitative assessment framework for radiology centres as a vital section in healthcare to translate the patients' requirements into service quality specifications. This would help to achieve quality improvement by emphasising the voice of customers.

Design/methodology/approach

A literature review is conducted to specify the service quality criteria and the patients' requirements related to healthcare and hospitals. Based on the experts' opinions, these criteria and requirements are later customised for the radiology centres. Moreover, the requirements are categorised into five dimensions of SERVQUAL. The interrelations between service elements are also determined through expert group consensus using Pearson correlation. Afterwards, by applying the QFD method, the relations between the requirements and criteria are explored. Additionally, a customer satisfaction survey is executed in Tehran public hospitals to prioritise these requirements and provide an importance-satisfaction analysis.

Findings

Based on the result of the case study, service elements are prioritised for improvement, and practical suggestions are provided using the Delphi technique for quality improvement. In addition, a cause-and-effect diagram is presented to highlight the improvement area and provide enhancement suggestions.

Originality/value

This study is the first empirical attempt to benefit from the VOC in evaluating and enhancing the quality of service delivered to radiology patients. In doing so, the study applies a hybrid approach of QFD and SERVQUAL as well as other tools to highlight the improvement area and provide enhancement suggestions. The findings can be readily used by the practitioners.

When patients get stuck: A systematic literature review on throughput barriers in hospital-wide patient processes

Hospital productivity is of great importance to policymakers, and previous research demonstrates that improved hospital productivity can be achieved by directing more focus towards patient throughput at healthcare organizations. There is also a growing body of literature on patient throughput barriers hampering the flow of patients. These projects rarely, however, encompass complete hospitals. Therefore, this paper provides a systematic literature review on hospital-wide patient process throughput barriers by consolidating the substantial body of studies from single settings into a hospital-wide perspective. Our review yielded a total of 2207 articles, of which 92 were finally selected for analysis. The results reveal long lead times, inefficient capacity coordination and inefficient patient process transfer as the main barriers at hospitals. These are caused by inadequate staffing, lack of standards and routines, insufficient operational planning and a lack in IT functions. As such, this review provides new perspectives on whether the root causes of inefficient hospital patient throughput are related to resource insufficiency or inefficient work methods. Finally, this study develops a new hospital-wide framework to be used by policymakers and healthcare managers when deciding what improvement strategies to follow to increase patient throughput at hospitals.

The Role of Value Stream Mapping in Healthcare Services: A Scoping Review

Lean healthcare aims to manage and improve the processes in the healthcare sector by eliminating everything that adds no value by improving quality of services, ensuring patient safety and facilitating health professionals’ work to achieve a flexible and reliable organization. Value Stream Mapping (VSM) is considered the starting point of any lean implementation. Some papers report applications of VSM in healthcare services, but there has been less attention paid to their contribution on sustainability indicators. The purpose of this work is to analyze the role of VSM in this context. To do so, a scoping review of works from recent years (2015 to 2019) was done. The results show that most applications of VSM reported are in the tertiary level of care, and the United States of America (USA) is the country which leads most of the applications published. In relation with the development of VSM, a heterogeneity in the maps and the sustainability indicators is remarkable. Moreover, only operational and social sustainability indicators are commonly included. We can conclude that more standardization is required in the development of the VSM in the healthcare sector, also including the environmental indicators.

Lean-driven interventions, including a dedicated radiologist, improve diagnostic imaging turnaround time and radiology report time at the emergency department

PURPOSE

Emergency departments (EDs) worldwide face crowding, which negatively affects patient care. Diagnostic imaging plays a major role in management of ED patients and contributes to patients' length of stay at the ED. In this study, the impact of Lean-driven interventions on the imaging process at the ED was assessed.

METHODS

During a 6-month multimodal intervention period, Lean-driven interventions and a dedicated radiologist present at the ED were implemented during peak hours (12 a.m.-8 p.m.). Data concerning patient population, radiology department turnaround time (RDTT), radiology report time (RRT), and examination time (ET) for ED patients were compared with a control period of 6 months 1 year earlier.

RESULTS

RDTT, RRT, and ET were significantly shorter in the intervention period compared with those in the control period. Median RDTT was respectively 36 min (interquartile range (IQR) 24-56) and 70 min (IQR 39-127), RRT 11 min (IQR 6-21) and 37 min (IQR 15-88), and ET 22 min (IQR 14-35) and 23 min (14-38).

CONCLUSION

Lean-driven interventions on the imaging process at the ED significantly reduced RDTT, RRT, and ET.

The Impact of an Emergency Department Upgrade to Level I Trauma Status on the Timeliness of Nontrauma Computed Tomography Scans

BACKGROUND

Resources such as computed tomography (CT) scanners are sometimes shared when separate adult and pediatric emergency departments (EDs) exist in proximity.

OBJECTIVES

To assess the impact of American College of Surgeons Level I trauma verification of an adult ED on the timeliness of nontrauma CT scans in a pediatric and adult ED that share a CT scanner.

METHODS

ED patient records were retrospectively reviewed to determine the time from order to completion of nontrauma CT scans. We compared the timeliness of CT scan completion between the year leading up to the adult ED being verified as a Level I Trauma Center (2015), and the 2 subsequent years (2016-2017).

RESULTS

The median time for nontrauma CT completion in the adult ED prior to Level I verification was 39 min, compared with 50 min and 49 min for the subsequent 2 years (p < 0.001). Similarly, the median time for completion of nontrauma CT scans in the pediatric ED increased from 33 min to 41 min and 39 min (p < 0.001). The proportion of patients who received CT scans within 30 min from order decreased after adult ED trauma upgrade, from 40% in 2015 to 30% and 32% (p < 0.001) in the 2 subsequent years. The pediatric ED showed similar results, with 48% of patients receiving CT scans within 30 min in 2015, compared with 34% in 2016 and 35% in 2017 (p < 0.001).

CONCLUSIONS

Level I trauma verification of the adult ED adversely affected the timeliness of nontrauma CT scans in the EDs.

Lean Process Improvement in the Emergency Department

Lean engineering is based on a process improvement strategy originally developed at Toyota and has been used in many different industries to maximize efficiency by minimizing waste. Lean improvement projects are frequently instituted in emergency departments in an effort to improve processes and thereby improve patient care. Such projects have been undertaken with success in many emergency departments in order to improve metrics such as door-to-provider time, left without being seen rate, and patient length of stay. By reducing waste in the system, Lean processes aim to maximize efficiency and minimize delay and redundancy to the extent possible.

Methodological Approaches to Support Process Improvement in Emergency Departments: A Systematic Review

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.

Effects of Lean Healthcare on Patient Flow: A Systematic Review

OBJECTIVES

To assess the effects of lean healthcare (LH) on patient flow in ambulatory care and determine whether waiting time and length of stay (LOS) decrease after LH interventions.

METHODS

A systematic review was performed with close adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched for studies of healthcare organizations applying LH interventions within ambulatory care published between 2002 and 2018. Six databases and grey literature sources were used. Two reviewers independently screened and assessed each study. When consensus was difficult to reach, a third reviewer intervened. Finally, a summary of findings was generated.

RESULTS

Out of 5627 studies, 40 were included. Regarding LOS for all patients, 19 out of 22 studies reported a decrease. LOS for discharged patients decreased in 11 out of 13 studies, whereas LOS for admitted patients was reduced in 6 out of 7 studies. Waiting time for patients before seeing a healthcare professional decreased in 24 out of 26 studies. Waiting time to treatment and waiting time for appointments were minimized in 4 and 2 studies, respectively. Patients who left without being seen by a doctor decreased in 9 out of 12 studies. Finally, patient and staff satisfaction were measured in 8 and 2 studies, respectively, with each reporting improvements.

CONCLUSIONS

According to our findings, LH helped to reduce waiting time and LOS in ambulatory care, mainly owing to its focus on identifying and minimizing non-value added (NVA) activities. Nevertheless, evidence of the impact of LH on patient/staff satisfaction and the translation of the obtained benefits into savings is scarce among studies.

Applying lean management to reduce radiology turnaround times for emergency department

Given the high impact of emergency department (ED) on the quality of care delivered by an hospital, and the many challenges it is facing (eg, overcrowding, excessive waiting time, cost containment, and increasing demand from patients), innovative managerial approaches should be adopted in order to develop safer and more efficient healthcare in this setting. The current study focuses on an application of lean thinking to reduce radiology turnaround times for ED, with the final aim to highlight the key factors enabling the adoption of lean thinking in this context. A research framework has been developed in the literature to analyse lean projects in healthcare and it has been adapted to study the case selected in an Italian hospital. In particular, organizational aspects, phases, and activities of the applied methodology, tools and procedures, and the achieved outcomes have been analysed. The study reports how radiology turnaround times for ED can be significantly reduced applying lean management principles and techniques. The achieved results contribute not only to comply with the regulation, but also to enhance the quality of care delivered to the patient; moreover, staff communication, involvement, and process awareness are favoured by the realization of similar projects promoting the diffusion of a lean culture.

Use of Lean Six Sigma methodology shows reduction of inpatient waiting time for peripherally inserted central catheter placement

AIM

The aim of this study was to assess the use of Lean Six Sigma methodology to improve the turnaround time (TAT) for inpatient peripherally inserted central catheter (PICC) placement.

MATERIALS AND METHODS

Value stream mapping was used to analyse the workflow process for inpatient PICC placement and to divide it into its component parts. Unnecessary steps were eliminated and variation minimised in the remaining processes. The TAT for PICC line placement was recorded for the 6 months prior to implementation of changes, and subsequently, at the 6-month and 2-year follow-up points.

RESULTS

Prior to implementing the changes, the mean TAT for PICC line placement was 3.74±3.28 days (95% confidence interval [CI]=3.3-4.17). Six months after implementation, the mean TAT was 1.89±1.82 days (95% CI=1.72-2.06, p<0.0001). The reduction was sustained such that at 2 years post-implementation the mean TAT was 1.88±1.87 days (95% CI=1.78-1.99, p<0.0001). This was achieved despite a 13.8% increase in overall interventional radiological activity.

CONCLUSION

By applying Lean Six Sigma methodology to the complex multifactorial processes involved from ordering a PICC to its final insertion, it was possible to identify areas for improvement and to introduce simple, effective measures that resulted in a significant sustained decrease in the TAT without additional resources.

Emergency Radiology: Current Challenges and Preparing for Continued Growth

The escalation of imaging volumes in the emergency department and intensifying demands for rapid radiology results have increased the demand for emergency radiology. The provision of emergency radiology is essential for nearly all radiology practices, from the smallest to the largest. As our radiology specialty responds to the challenge posed by the triple threat of providing 24-7 coverage, high imaging volumes, and rapid turnaround time, various questions regarding emergency radiology have emerged, including its definition and scope, unique operational demands, quality and safety concerns, impact on physician well-being, and future directions. This article reviews the current challenges confronting the subspecialty of emergency radiology and offers insights into preparing for continued growth.

Gauging potential risk for patients in pediatric radiology by review of over 2,000 incident reports

BACKGROUND

Incident reporting can be used to inform imaging departments about adverse events and near misses.

OBJECTIVE

To study incident reports submitted during a 5-year period at a large pediatric imaging system to evaluate which imaging modalities and other factors were associated with a greater rate of filed incident reports.

MATERIALS AND METHODS

All incident reports filed between 2013 and 2017 were reviewed and categorized by modality, patient type (inpatient, outpatient or emergency center) and use of sedation/anesthesia. The number of incident reports was compared to the number of imaging studies performed during that time period to calculate an incident report rate for each factor. Statistical analysis of whether there were differences in these rates between factors was performed.

RESULTS

During the study period, there were 2,009 incident reports filed and 1,071,809 imaging studies performed for an incident report rate of 0.19%. The differences in rates by modality were statistically significant (P=0.0001). There was a greater rate of incident reports in interventional radiology (1.54%) (P=0.0001) and in magnetic resonance imaging (MRI) (0.62%) (P=0.001) as compared to other imaging modalities. There was a higher incident report rate for inpatients (0.34%) as compared to outpatient (0.1%) or emergency center (0.14%) (P=0.0001). There was a higher rate of incident reports for patients under sedation (1.27%) as compared to non-sedated (0.12%) (P=0.0001).

CONCLUSION

Using incident report rates as a proxy for potential patient harm, the areas of our pediatric radiology service that are associated with the greatest potential for issues are interventional radiology, sedated patients, and inpatients. The areas associated with the least risk are ultrasound (US) and radiography. Safety improvement efforts should be focused on the high-risk areas.

Assessing bottlenecks in Emergency Department flow of patients with abdominal pain

INTRODUCTION

Abdominal pain has a wide range of possible causes, which may lead to difficulties in diagnosing and lengthy Emergency Department (ED) stays. In this study, bottlenecks in ED processes of patients with abdominal pain were identified.

METHODS

Time-points of patients who presented to a Dutch ED with abdominal pain were observed and documented. The institutional review board approved the study.

RESULTS

In total, 3015 min of patient time were observed in 54 patients. Median length of stay (LOS) was 218 min for admitted patients, and 168 min for discharged patients. For 65 patients (27.4%), LOS exceeded 4 h. Delays were found during the diagnostic process, when multiple physicians were needed in order to make a decision, and during departure.

CONCLUSIONS

Our study concerning individual patients' time-points provides important insight into delays in the patient journey of patients with abdominal pain. Flow improvement can be achieved by focusing on these bottlenecks, for example by minimizing diagnostic delays and by simultaneous specialists' consultations for patients who need more than one physician. The optimization of ED flow for patients with abdominal pain depends on coordinated efforts between ED staff, medical specialists, radiology and laboratory staff, staff from inpatient units, and hospital supporting services.