A qualitative exploration of patient flow in a developing Caribbean emergency department

Objectives Emergency departments (EDs) are complex adaptive systems and improving patient flow requires understanding how ED processes work. This is important for developing countries where flow concerns are compounded by resource constraints. The Caribbean is one region with developing emergency care systems and limited research in the area. This study aimed to explore the patient flow process in an emergency department in Trinidad and Tobago, identifying organizational factors influencing patient flow. Methods Multiple qualitative methods, including non-participant observations, observational process mapping and informal conversational interviews were used to explore patient flow. The process maps were generated from the observational process mapping. Thematic analysis was used to analyze the data. Setting The study was conducted at a major tertiary level emergency department in Trinidad and Tobago. Participants Patient and staff journeys in the emergency department were observed. Results Six broad categories were identified- 1) ED organizational work processes, 2) ED design and layout, 3) material resources, 4) nursing staff levels, roles, skill mix and use 5) non-clinical ED staff and 6) external clinical and non-clinical departments. The study findings were combined with existing literature to produce a model of factors influencing ED patient flow. Barriers and facilitators to patient flow were highlighted. Conclusion The knowledge gained may be used to strengthen the emergency care system in the local context. The model of ED patient flow may be used to systematically examine factors influencing patient flow, informing policy and practice. However, the study findings should be validated in other settings

Qualitative exploration of patient flow in a Caribbean emergency department

Objectives Emergency departments (EDs) are complex adaptive systems and improving patient flow requires understanding how ED processes work. This study aimed to explore the patient flow process in an ED in Trinidad and Tobago, identifying organisational factors influencing patient flow. Methods Multiple qualitative methods, including non-participant observations, observational process mapping and informal conversational interviews were used to explore patient flow. The process maps were generated from the observational process mapping. Thematic analysis was used to analyse the data. Setting The study was conducted at a major tertiary level ED in Trinidad and Tobago. Participants Patient and staff journeys in the ED were directly observed. Results Six broad categories were identified: (1) ED organisational work processes, (2) ED design and layout, (3) material resources, (4) nursing staff levels, roles, skill mix and use, (5) non-clinical ED staff and (6) external clinical and non-clinical departments. Within each category there were individual factors that appeared to either facilitate or hinder patient flow. Organisational processes such as streaming, front loading of investigations and the transfer process were pre-existing strategies in the ED while staff actions to compensate for limitations with flow were more intuitive. A conceptual framework of factors influencing ED patient flow is also presented. Conclusion The knowledge gained may be used to strengthen the emergency care system in the local context. However, the study findings should be validated in other settings

Simulation optimisation to inform economic evaluations of sequential therapies for chronic conditions: a case study in Rheumatoid Arthritis

This thesis investigates the problem of treatment sequencing within health economic evaluations. For some chronic conditions, sequences of treatments can be used. When there are a lot of alternative treatments, then the number of possible sequences becomes very large. When undertaking an economic evaluation, it may not be feasible to estimate the costs and benefits of every alternative treatment sequence. The objective of the thesis is to test the feasibility of simulation optimisation methods to find an optimal or set of near-optimal sequences of disease modifying treatments for rheumatoid arthritis in an economic evaluation framework. A large number of economic evaluations have been undertaken to estimate the costs and benefits associated with different treatments for rheumatoid arthritis. Many of these have not considered the downstream sequence of treatments provided, and no published study has considered identifying the best, or optimal, treatment sequence. The published evidence is therefore of limited applicability if the objective is to maximise patient benefit while constrained by a finite budget. It is plausible that decision-makers have developed sub-optimal guidance for rheumatoid arthritis, and this could extend to other chronic conditions. A simulation model can provide an expectation of the population mean costs and benefits for alternative treatment sequences. These models are routinely used to inform health economic evaluations. However, they can be computationally expensive to run, and therefore the evaluation of potentially millions of treatment sequences is not feasible. However, simulation optimisation methods exist to identify a good solution from a simulation model within a feasible period of time. Using these methods within an economic evaluation of treatment sequences has not previously been investigated. In this thesis I highlight the importance of the treatment sequencing problem, review and assess relevant simulation optimisation methods, and implement a simulated annealing algorithm to explore its feasibility and appropriateness. From the implementation case study within rheumatoid arthritis, simulation optimisation via simulated annealing appears to be a feasible method to identify a set of good treatment sequences. However, the method requires a significant amount of time to implement and execute, which may limit its appropriateness for health resource allocation decision making. Further research is required to investigate the generalisability of the method, and further consideration regarding its use in a decision-making context is important