Performance analysis and scheduling strategies for ambulatory surgical facilities

Ambulatory surgery is a procedure that does not require an overnight hospital stay and is cost effective and efficient. The goal of this research is to develop an ASF operational model which allows management to make key decisions. This research develops and utilizes the simulation software ARENA based model to accommodate: (a) Time related uncertainties – Three system uncertainties characterize the problem (ii) Surgery time variance (ii) Physician arrival delay and (iii) Patient arrival delay; (b) Resource Capture Complexities – Patient flows vary significantly and capture/utilize both staffing and/or physical resources at different points and varying levels; and (c) Processing Time Differences – Patient care activities and surgical operation times vary by type and have a high level of variance between patient acuity within the same surgery type. A multi-dimensional ASF non-clinical performance objective is formulated and includes: (i) Fixed Labor Costs – regular time staffing costs for two nurse groups and medical/tech assistants, (i i) Overtime Labor Costs – staffing costs beyond the regular schedule, (i i i) Patient Delay Penalty – Imputed costs of waiting time experienced patients, and (iv) Physician Delay Penalty – Imputed costs of physicians having to delay surgical procedures due to ASF causes (limited staffing, patient delays, blocked OR, etc.). Three ASF decision problems are studied: (i) Optimize Staffing Resources Levels - Variations in staffing levels though are inversely related to patient waiting times and physician delays. The decision variable is the number of staff for three resource groups, for a given physician assignment and surgery profile. The results show that the decision space is convex, but decision robustness varies by problem type. For the problems studied the optimal levels provided 9% to 28% improvements relative to the baseline staffing level. The convergence rate is highest for less than optimal levels of Nurse-A. The problem is thus amenable to a gradient based search. (ii) Physician Block Assignment - The decision variables are the block assignments and the patient arrivals by type in each block. Five block assignment heuristics are developed and evaluated. Heuristic #4 which utilizes robust activity estimates (75% likelihood) and generates an asymmetrical resource utilization schedule, is found to be statistically better or equivalent to all other heuristics for 9 out of the 10 problems and (iii) Patient Arrival Schedule – Three decision variables in the patient arrival control (a) Arrival time of first patient in a block (b) The distribution and sequence of patients for each surgery type within the assigned windows and (c) The inter arrival time between patients, which could be constant or varying. Seven scheduling heuristics were developed and tested. Two heuristics one based on Palmers Rule and the other based on the SPT (Shortest Processing Time) Rule gave very strong results

Operating theatre planning and scheduling in real-life settings.Problem analysis, models, and solution procedures

Falta palabras claveNowadays health care organizations experience an increasing pressure in order to provide their services at the lowest possible costs as a response to the combination of restrictive budgets, increasing waiting lists, and the aging of the population. In general, hospital resources are expensive and scarce, being the operating theatre the most critical and expensive resource. In most hospitals, the operating theatre is a complex system composed of operating rooms (ORs) together with their specialized equipment, preoperative and postoperative facilities and, finally, a diversity of human resources, including surgeons, anesthetists, nurses, etc. To handle such complexity, decisions related to operating theatre management are usually decomposed into three hierarchical decision levels, i.e.: strategic, tactical and operational. At the strategic level, hospital managers set the volume and the mix of surgeries that will be performed over a long-term horizon (typically, a year) to keep up acceptable size of waiting lists while achieving cost targets, thus making long-term decisions related to the dimensioning of surgical facilities (e.g. build new ORs, adding new recovery beds, etc.), the hiring of surgical staff (e.g. surgeons, nurses, etc.), the purchase of novel surgical devices, and the amount of operating theatre resources required by surgical specialties to perform their surgeries (OR time, number of beds, etc.). Once decisions at strategic level have been made, the operating theatre resources are allocated over a medium-term planning horizon (ranging from few weeks to 6 months) in the tactical level. Since the OR is both a bottleneck and the most expensive facility for most hospitals, surgical specialties are first assigned to OR days (i.e. a pair of an OR and a day) over the planning horizon, until the OR time allocated to each surgical specialty in the strategic level is reached. Then, the above assignment defines aggregate resource requirements for specialties, such as the demand of nurses, drugs, diagnostic procedures, laboratory tests, etc. Finally, the working shifts of human resources and their workload (e.g. the number of surgeries allocated to each surgeon) are defined over the medium-term planning horizon in order to achieve the volume of surgeries set by hospital managers. Finally, the surgical schedule is determined over a short-term planning horizon (ranging from few days to few weeks) at the operational level. The operational level is usually solved into two steps. The first step involves the determination of the date and the OR for a set of surgeries in the waiting list; while in the second step, a sequence of surgeries for each OR within each day in the planning horizon is obtained. Note that only a set of surgeries will be performed during the planning horizon due to capacity constraints (both facilities and human resources). The decomposition of the operational level into the two aforementioned steps intends to reduce the complexity of the resulting problem, although the quality of the so-obtained surgery schedule may be reduced due to the high interdependence among these two steps, being the integrated approach a popular topic of research. At the operational level, a feature greatly influencing the performance is the uncertainty in the surgical activities, as frequently large discrepancies between the scheduled duration and the real duration of the surgeries appear, together with the availability of the resources reserved for emergency arrivals. Despite the importance and the complexity of these hierarchical levels, decisions in practice are usually made according to the decision makers’ experience without considering the underlying optimization problems. Furthermore, the lack of usage of decision models and solution procedures causes the decision makers to consume long times on performing management tasks (e.g. determine the surgical schedule, react to unforeseen events, carry out what-if analyses, etc.), instead of healthcare tasks. The context discussed above stresses the need to provide healthcare decision makers with advanced operations research techniques (i.e. models and solution procedures) in order to improve the efficiency of the operating theatre resources and the quality of the healthcare services at the operational level. This Thesis is aimed at this goal

Communicating organisational outcomes using simple performance indicators: a case study using ACT elective surgery waiting lists

This research explores the communication consequences of using simple, numerical information to convey information about the performance of large, public-sector organisations. To control the scope of the research, both practically and theoretically, the case study is based on publically available material, in other words, the material accessible by a lay, rather than a specialist audience. The formal publication and public reporting in the local newspaper of elective surgery waiting times in the Australian Capital Territory (ACT) public health system during 2010 and 2011 is used as a detailed case study. The theoretical basis for the research is drawn from three main disciplinary streams: performance indicators and evaluation; public health and public health policy; and communicating about and with numerical information. Each of these broad areas is itself multi-disciplinary, with research findings published across many different outlets. When I began this research in mid-2011 there was little overlap between the insights from the different discipline groups canvassed in this literature review. In particular, the application of communication theories to performance indicators had yet to be systematically explored. Research in the period 2011-2016 clarifies issues within each of the broad areas but there is still very little synthesis between them. The overall goal of the research is twofold: to characterise and systematically describe the way numerical performance indicators are used; and to develop a framework for determining how difficult to understand a numerical performance indicator is likely to be. The resulting model for analysing the communication effectiveness of using different types of statistical constructs as performance indicators can be used both as a tool for designing performance indicators and as a tool for analysing communication problems related to numerical performance indicators

OPERATIONS MANAGEMENT TOOLS APPLIED TO THE OPERATING ROOM: A REVIEW OF CURRENT CONCEPTS AND A SINGLE CENTRE EXPERIENCE

Operations management tools can be applied to the operating room setting in order to improve throughput of the system. This is important because of the limitation of resources and funds available to hospitals in the public healthcare system. Hospitals must deal with variability in demand and uncertainty surrounding scheduling; these considerations can be placed in a queuing theory framework to better design processing capacity to minimize wait times and maximize utilization. Lean techniques can be used to identify and reduce waste in processes. A single centre experience is presented to demonstrate real-world application of these tools and to suggest foci for potential improvement in other centres

The portuguese public hospitals performance evolution before and during the SARS-CoV-2 Pandemic (2017–2022)

COVID-19 is a disease caused by SARS-CoV-2, which has spread worldwide since the beginning of 2020. Several pharmaceutical and non-pharmaceutical strategies were proposed to contain the virus, including vaccination and lockdowns. One of the consequences of the pandemic was the denial or delay of access to convenient healthcare services, but also potentially the increase in adverse events within those services, like the number of hospital infections. Therefore, the main question here is about what happened to the performance of Portuguese public hospitals. The main goal of this work was to test if the Portuguese public hospitals' performance has been affected by the SARS-CoV-2 pandemic. We used the Benefit-of-Doubt method integrated with the Malmquist Index to analyze the performance evolution over time. Then, we employed a multiple regression model to test whether some pandemic-related variables could explain the performance results. We considered a database of 40 Portuguese public hospitals evaluated from January 2017 to May 2022. The period 2017 to 2019 corresponds to the baseline (pre-pandemic), against which the remaining period will be compared (during the pandemic). We also considered fourteen variables characterizing hospital quality, divided into three main performance definitions (efficiency and productivity; access; safety and care appropriateness). As potential explanatory variables, we consider seven dimensions, including vaccination rate and the need for intensive care for COVID-19-infected people. The results suggest that COVID-19 pandemic features help explain the drop in access after 2020, but not the evolution of safety and appropriateness of care, which surprisingly increased the whole time.info:eu-repo/semantics/publishedVersio

Vision based trajectory planning for robotic assisted fetal surgery treatint TTTS

Medical Robots is the field focused on improving and making easier the work of medical personnel in certain interventions with the help of robotic systems. Because of this, although some of them are already in use, there is a large number of R&D projects, especially in soft tissues. In this case, this project deals with the improvement of fetal surgery, more specifically in the treatment of Twin-to-Twin Transfusion Syndrome. TTTS is a syndrome that affects pregnancy in twins. When it occurs, during the development of fetuses, there is an interconnection between the blood vessels of both in points called anastomosis. These connections cause the exchange of blood flow between both fetuses and, if it is not treated by fetal surgery, results in the death of both twins. A teleoperated robotic system is being developed in the ESAII laboratory to provide help and assistance to the surgeon during these surgeries. In this project an automation of the robotic system is implemented. It is done by means of using the work environment information collected and Computer Vision tools. The objective is to create an automatic movement of the robot through the fastest and safest path from one point to other over the placenta´s surface. This report details everything about the project development. It is also described the main topics related to the project as the global robotic system, designed and made in the ESAII laboratory of the UPC; the fetal surgery and the current state of the art around this type of medical robots

In-office Eustachian tube balloon dilation under local anesthesia as a response to operating room restrictions associated with the COVID-19 pandemic.

OBJECTIVE To evaluate the feasibility of local anesthesia for Eustachian tube balloon dilation as an in-office procedure for the treatment of Eustachian tube dilatory dysfunction as a response to the restriction measures of the coronavirus disease 2019 pandemic. METHOD Patients with Eustachian tube dilatory dysfunction refractory to nasal steroids undergoing Eustachian tube balloon dilation in local anesthesia were enrolled in a prospective observational cohort between May 2020 and April 2022. The patients were assessed by using the Eustachian tube dysfunction questionnaire (ETDQ-7) score and Eustachian tube mucosal inflammation scale. They underwent clinical examination, tympanometry, and pure tone audiometry. Eustachian tube balloon dilation was performed in-office under local anesthesia. The perioperative experience of the patients was recorded using a 1-10 visual analog scale (VAS). RESULTS Thirty patients (47 Eustachian tubes) underwent the operation successfully. One attempted dilation was aborded because the patient displayed anxiety. Local anesthesia was performed by using topical lidocaine and nasal packing for all patients. Three patients required an infiltration of the nasal septum and/or tubal nasopharyngeal orifice. The mean time of the operation was 5.7 min per Eustachian tube dilation. The mean level of discomfort during the intervention was 4.7 (on a 1-10 VAS scale). All patients returned home immediately after the intervention. The only reported complication was a self-limiting subcutaneous emphysema. CONCLUSION Eustachian tube balloon dilation can be performed under local anesthesia and is well tolerated by most patients. In the patients reported in this study, no major complications occurred. In order to free operation room capacities, the intervention can be performed in an in-office setting with satisfactory patient feedback

Acute Coronary Syndromes

This book has been written with the intention of providing an up-to-the minute review of acute coronary syndromes. Atherosclerotic coronary disease is still a leading cause of death within developed countries and not surprisingly, is significantly rising in others. Over the past decade the treatment of these syndromes has changed dramatically. The introduction of novel therapies has impacted the outcomes and surviving rates in such a way that the medical community need to be up to date almost on a "daily bases". It is hoped that this book will provide a timely update on acute coronary syndromes and prove to be an invaluable resource for practitioners seeking new and innovative ways to deliver the best possible care to their patients

General Anesthesia as a Multimodal Individualized Clinical Concept

In this book, a series of modern multimodal monitoring techniques during general anesthesia are presented, with a focus on patient-oriented anesthesia based on the individual needs of each patient reflected in the degree of hypnosis, the nociception–antinociception balance, and neuromuscular transmission. Moreover, a series of secondary implications for hemodynamic status, post-anesthetic recovery, and patient satisfaction are highlighted