the unplanned patient. simulation of flow between the ed and the … · 2019-01-08 · ihi...
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The unplanned patient.
Simulation of flow between the ED and the hospital
D. Van Sassenbroeck MD, PhD, MSc
AZ Maria Middelares Gent
Beds: 550
Physicians: 166
Employees: 1.626
Admissions: 25.293
Day clinic: 23.080
2012 2015
Will the new emergency department be large enough ?
2013
22000 patients
# patients: + 3 %/y in the last 8 years
+ 4,5 – 8% in the last 3 years
40% of all admissions
Base principle for admissions: unplanned is via the ED
2014 2015
Resuscitation 2 2
Diagnostic 5 6
Paediatric 2 2
Observation 10 4
Triage/intake 0 1
Fast track 3 5
Psychiatric 1 1
# positions 23 21
# beds 19 14
Will the new emergency department be large enough ?
Capacity:
~ number of new patients
~ lenght of stay (LOS)
~ pattern of presentation
# new patients/d LOS capacity pattern
1 24h 1
2 12h 1 serial
8 6h 2 serial
Will the new emergency department be large enough ?
Discrete Event Modeling
Descibes how an object (patient) moves in an environment via a series
of subsequent processes
Input: Time: step by step sequence of processes
Every proces takes time (lenght of stay, intervention time)
Different pathways: by chance
start
Proces 2
(time)
stop Pattern over
time
Proces 1
(time)
chance
Output:
capacity generates waiting times (bottlenecks)
‘What if’ analysis
start
Process 2
(time)
stop Pattern over
time
Process 1
(time)
chance
10000
11000
12000
13000
14000
15000
16000
17000
18000
19000
20000
2000 2002 2004 2006 2008 2010 2012
observed (2)
observed (1)
+2,5% projectie groei
0
1
2
3
4
5
6
7
8
0 2 4 6 8 10 12 14 16 18 20 22 24
tijd (u)
# n
ieu
we
ptn
/u
2008
projectie 2015
projectie 2020
projectie 2025
59ptn/d
start
Process 2
(time)
stop Pattern over
time
Process 1
(time)
chance
# occupied ED beds at any moment
median 7/14
P90 12/14
23% day/y >14 beds needed
3% pts/d without a free bed upon arrival
For 59 pts/d
No reserved beds for pediatrics
No observation beds
No secundary transfers via ED
Max boarding time is 1 hour
No diagnostics for 10% of the admitted pts
The ED is too small!
So, long live the Acute Observation Ward !
Observation is by definition the use of appropriate
monitoring, diagnostic testing, therapy, and assessment of
patient symptoms, signs, laboratory tests, and response to
therapy for the purpose of determining whether a patient
will require further treatment as an inpatient or can be
discharged form the hospital setting.
The duration of observation status is expected to be from
8-24 hours. Prior studies indicate that observation unit care
can improve outcomes and improve cost effectiveness
compared to routine care.
The ED is too small!
So, long live the Acute Observation Ward !
Observation Medicine -
Science and Solutions
September 11-12, 2014
Somerset Inn, Troy, MI
On-line Registration is Now
Available!
So, long live the Acute Observation Ward !
But how large should it be ?
New discrete event simulation model
4734 ED patients
57% ambulatory
43% admissions
33% special (ICU, CCU/MC, stroke, ped, psy)
67% AOW (= 29% ED population)
<12h 5%
12-24h 1%
24-36h 16%
36-48h 4%
>48h 74%
How large ?
P25 27
P50 35
P75 40
P90 46
Max 55
So, long live the Acute Observation Ward !
home
ward
AOW special
Overcrowding = outflow problem, problem of hospital organisation,
inefficient planning
N Engl J Med 355;13, 2006
IHI Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings.
JCI Accreditation Standards for Hospitals, 5th Edition
Welkom!
[…]Resultaten als minder opnamestops, rust op verpleegafdelingen, kortere
verpleegduur en snellere diagnostiek worden steeds vaker aangetoond.
Vraagstukken als de ideale opleiding tot AOA-verpleegkundige, de
achilleshiel: de doorstroming naar de verpleegafdeling en mogelijkheden
om patiëntveiligheid verder te vergroten met een AOA zijn zeer actueel.
http://www.acuteopnameafdeling.nl/
And now, 2014
1. Special: ICU, CCU/MC, stroke, pediatrics, psychiatrics
2. Pathology absolutely restircted to one ward
e.g. Parkinson with problems in swallowing
capacity planning required
input by both physicians, surgeons and head nurses
3. Relatively restricted pathology
Hosptial beds divided according to activity of specialism
4. Acute observation ward
standard diagnostic problems,
e.g. Atypical chest pain, atypical abdominal pain,
commotio cerebri
estimated LOS in the hospital < 48h
conclusion
1/ Capaciteit planning involves planning for both the expected and
the unexpected patient
2/ structure – process – result (Donabedian)
conclusion
1/ Capaciteit planning involves planning for both the expected and
the unexpected patient
2/ structure – process – result (Donabedian)