Discharge delay from the post anaesthesia care unit : a nursing perspective

Background: The Post Anaesthesia Care Unit (PACU) is a critical junction between the operating theatre and the wards. It is essential for the close monitoring of patients before they are discharged to their destination wards for recovery. Many clinical and non-clinical factors influence the flow of patient discharge from the PACU to the wards. This study explores PACU nurses’ perceptions of non-clinical factors causing discharge delays and how these impact the work of nurses. Method: In this study, a descriptive qualitative methodology was implemented. This methodology is widely used in nursing and health care research as it provides a descriptive analysis of a phenomenon with straightforward descriptions of experience and perceptions. Data were collected from ten PACU nurses via in-depth, semi-structured, recorded, individual interviews. Thematic analysis using the work of Braun and Clarke was applied to gain rich insight into PACU nurses’ views, values and experiences concerning discharge delay influenced by non-clinical factors. Findings: Four themes related to discharge delay were identified: ‘accepted as part of the day’, ‘wards are never ready’, ‘feeling frustrated, powerless and stressed’ and ‘empathy for patients’. The analysis of interview transcripts demonstrated that PACU nurses constantly experienced discharge delays because ward beds or ward nurses were not readily available for admitting post-operative patients from the PACU. The findings also revealed PACU nurses’ perceptions of non-clinical discharge delay and how this event may induce stress, frustration and feelings of hopelessness at work. Participants expressed that discharge delay caused them stress and negative emotions or ‘bad feelings’ and challenged their ability to show compassion for patients. Conclusion: PACU nurses perceive discharge delays due to non-clinical factors as compromising their work. Their perspective on discharge delay indicates the need to improve relevant non-clinical factors to minimise PACU nurses’ work stress and to help facilitate the discharge experience of patients and nurses

Online simulation for the operational management of inpatient beds

In many modern hospitals, resources such as beds, theatre time, medical equipment and staff are shared between patients who require immediate care and must be dealt with as they arrive (emergency patients), and those whose care requirements are known to the hospital some time in advance (elective patients). Caring for these two types of patients poses a logistical challenge, since some portion of each resource must be set aside for emergency patients when planning for the number and type of elective patients to admit. Failing to strike this balance can result in negative outcomes, such as patient-stays on non-ideal wards, or increased waiting time for elective procedures (in the case of public health services). The potential benefits of using discrete event simulation (DES) models in healthcare are well established, and they are often preferred to other modelling approaches because of their ability to emulate the randomness seen in real systems, at a level of detail which is necessary for models to be convincing. However, their use is often limited to strategic or tactical decision making, and few have attempted to produce models which can help hospitals with short-term (operational) decision making. This is where Online Discrete Event Simulation (ODES) can help. An ODES (also known as symbiotic simulation) takes all the components of a DES model, and adds the ability to load the state of the real system at run-time to make predictions about how the real system might evolve in the short-term. This thesis reports the development of a whole-hospital, proof-of-concept ODES to assess the impact of elective admissions decisions, on wards which are shared with emergency patients. The model is parameterised by analysing 18 months of patient administrative data from an Australian General Hospital. Since ODES is a relatively new method, this research focuses on formalising the model development process, resulting in a new “black-box” validation method for handling conditionally distributed simulation outputs. Additionally, a new probabilistic routing method is developed to better represent inter-ward dependencies during peaks in bed demand. A statistical analysis of the relationship between ward transfers and ward occupancy is conducted on real hospital data to parameterise so-called “Dynamic Transition Matrices” for this purpose. Finally, the ODES is used to demonstrate how additional patient-level information (which might only become available after admission) can affect the predicted bed census. Clinicians’ discharge date estimates fit this criterion, and the case is made for more scientific use of this type of information, as part of an operational ODES model

Redesigning the Barranquilla's public emergency care network to improve the patient waiting time

Tesis por compendio[ES] La oportunidad en la atención es uno de los críticos de mayor relevancia en la satisfacción de los pacientes que acuden a los servicios de Urgencias. Por tal motivo, las instituciones prestadoras de servicio y las organizaciones gubernamentales deben propender conjuntamente por una atención cada vez más oportuna a costos operacionales razonables. En el caso de la Red Pública en Servicios de Urgencias de Barrannquilla, compuesta por 8 puntos de atención y 2 hospitales, la tendencia marca un continuo crecimiento de la oportunidad en la atención con una tasa de 3,08 minutos/semestre y una probabilidad del 93,13% de atender a los pacientes después de una espera mayor a 30 minutos. Lo anterior se constituye en un síntoma inequívoco de la incapacidad de la Red para satisfacer los estándares de oportunidad establecidos por el Ministerio de Salud, hecho que podría desencadenar el desarrollo de sintomatologías de mayor complejidad, el incremento de la probabilidad de mortalidad, el requerimiento de servicios clínicos más complejos (hospitalización y cuidados intensivos) y el aumento de los costos asociados al servicio. En consecuencia, la presente tesis doctoral presenta el rediseño de la Red Pública en Servicios de Urgencias anteriormente mencionada a fin de otorgar a la población diana un servicio eficiente y altamente oportuno donde tanto las instituciones prestadoras del servicio como los organismos gubernamentales converjan efectivamente. Para ello, fue necesaria la ejecución de 4 grandes fases a través de las cuales se consolidó una propuesta orientada al desarrollo efectivo y sostenible de las operaciones de la Red. Primero, se caracterizó la Red Pública de Servicios de Urgencias en Salud considerando su comportamiento actual en términos de demanda y oportunidad de la atención. Luego, a través de una revisión sistemática de la literatura, se identificaron los enfoques metodológicos que se han implementado para la mejora de la oportunidad y otros indicadores de rendimiento asociados al servicio de Urgencias. Posteriormente, se diseñó una metodología para la creación de redes de Urgencias eficientes y sostenibles la cual luego se validó en la Red Pública sudamericana a fin de disminuir la oportunidad de atención promedio en Urgencias y garantizar la distribución equitativa de los beneficios financieros derivados de la colaboración. Finalmente, se construyó un modelo multicriterio que permitió evaluar el rendimiento de los departamentos de Urgencia e impulsó la creación de estrategias de mejora focalizadas en incrementar su respuesta ante la demanda cambiante, los críticos de satisfacción y las condiciones de operación estipuladas en la ley. Los resultados de esta aplicación evidenciaron que los pacientes que acceden a la Red tienden a esperar en promedio 201,6 min con desviación de estándar de 81,6 min antes de ser atendidos por urgencia. Por otro lado, de acuerdo con la revisión de literatura, la combinación de técnicas de investigación de operaciones, ingeniería de la calidad y analítica de datos es ampliamente recomendada para abordar este problema. En ese sentido, una metodología basada en modelos colaterales de pago, simulación de procesos y lean seis sigma fue propuesta y validada generando un rediseño de Red cuya oportunidad de atención promedio podría disminuir entre 6,71 min y 9,08 min con beneficios financieros promedio de US$29,980/nodo. En último lugar, un modelo compuesto por 8 criterios y 35 sub-criterios fue diseñado para evaluar el rendimiento general de los departamentos de Urgencias. Los resultados del modelo evidenciaron el rol crítico de la infraestructura (Peso global = 21,5i garantir la distribució equitativa dels beneficis financers derivats de la col´laboració. Finalment, es va construir un model multicriteri que va permetre avaluar el rendiment dels departaments d'Urgència i va impulsar la creació d'estratègies de millora focalitzades en incrementar la seva resposta davant la demanda canviant, els crítics de satisfacció i les condicions d'operació estipulades en la llei. Els resultats d'aquesta aplicació van evidenciar que els pacients que accedeixen a la Xarxa tendeixen a esperar de mitjana 201,6 min amb desviació d'estàndard de 81,6 min abans de ser atesos per urgència. D'altra banda, d'acord amb la revisió de literatura, la combinació de tècniques d'investigació d'operacions, enginyeria de la qualitat i analítica de dades és àmpliament recomanada per abordar aquest problema. En aquest sentit, una metodologia basada en models col´laterals de pagament, simulació de processos i llegeixin 6 sigma va ser proposada i validada generant un redisseny de Xarxa la oportunitat d'atenció mitjana podria disminuir entre 6,71 min i 9,08 min amb beneficis financers mitjana d'US$ 29,980 / node. En darrer lloc, un model compost per 8 criteris i 35 sub-criteris va ser dissenyat per avaluar el rendiment general dels departaments d'Urgències. Els resultats de el model evidenciar el paper crític de la infraestructura (Pes global = 21,5%) en el rendiment dels departaments d'Urgència i la naturalesa interactiva de la Seguretat de l'Pacient (C + R = 12,771).[EN] Waiting time is one of the most critical measures in the satisfaction of patients admitted within emergency departments. Therefore, hospitals and governmental organizations should jointly aim to provide timely attention at reasonable costs. In the case of Barranquilla's Pubic Emergency Service Network, composed by 8 Points of care (POCs) and 2 hospitals, the trend evidences a continuous growing of the waiting time with a rate of 3,08 min/semester and a 93,13% likelihood of serving patients after waiting for more than 30 minutes. This is an unmistakable symptom of the network inability for satisfying the standards established by the Ministry of Health, which may trigger the development of more complex symptoms, increase in the death rate, requirement for more complex clinical services (hospitalization and intensive care unit) and increased service costs. This doctoral dissertation then illustrates the redesign of the aforementioned Public Emergency Service Network aiming at providing the target population with an efficient and highly timely service where both hospitals and governmental institutions effectively converge. It was then necessary to implement a 4-phase methodology consolidating a proposal oriented to the effective and sustainable development of network operations. First, the Public Emergency Service Network was characterized considering its current behavior in terms of demand and waiting time. A systematic literature review was then undertaken for identifying the methodological approaches that have been implementing for improving the waiting time and other performance indicators associated with the emergency care service. Following this, a methodology for the creation of efficient and sustainable emergency care networks was designed and later validated in the Southamerican Public network for lessening the average waiting time and ensuring the equitable distribution of profits derived from the collaboration. Ultimately, a multicriteria decision-making model was created for assessing the performance of the emergency departments and propelling the design of improvement strategies focused on bettering the response against the changing demand conditions, critical to satisfaction and operational conditions. The results evidenced that the patients accessing to the network tend to wait 201,6 min on average with a standard deviation of 81,6 min before being served by the emergency care unit. On the other hand, based on the reported literature, it is highly suggested to combine Operations Research (OR) methods, quality-based techniques, and data-driven approaches for addressing this problem. In this sense, a methodology based on collateral payment models, Discrete-event simulation, and Lean Six Sigma was proposed and validated resulting in a redesigned network whose average waiting time may diminish between 6,71 min and 9,08 min with an average profit US$29,980/node. Lately, a model comprising of 8 criteria and 35 sub-criteria was designed for evaluating the overall performance of emergency departments. The model outcomes revealed the critical role of Infrastructure (Global weight = 21,5%) in ED performance and the interactive nature of Patient Safety (C + R = 12,771).Ortíz Barrios, MÁ. (2020). Redesigning the Barranquilla's public emergency care network to improve the patient waiting time [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/156215TESISCompendi

A Mixed-Method Study on the Walkability of Streets in Hospital-Anchored Neighborhoods

The field of healthcare design is adopting planning and design principles from the Healthy Communities movement to connect hospitals to their adjacent communities. This research explores the impact of neighborhood and street design on the walkability of Hospital-Anchored Neighborhoods (HANs), a concept integrating hospitals and satellite services with their surrounding communities to enhance public health. Walkability, a crucial marker of healthy and vibrant communities, was investigated through a mixed-method study across three HANs. A comprehensive Walkability Framework with 17 built environment dimensions was developed from the literature to inform data collection utilizing GIS archival data, ethnographic observations, street audits, and interviews. Findings indicate that multiple factors influence walkability at the neighborhood, street, building, and experiential levels. The walkability scores differed from those provided by the Environmental Protection Agency’s National Walkability Index. 6 of the 7 street-level dimensions (compactness, mixed-uses, imageability, enclosure, human scale, and transparency of streets, but not complexity) were correlated with pedestrian counts. Out of 40 street features studied, 27 significantly influenced the number of pedestrians on the street. Active and inactive building uses also showed significant variance in pedestrian counts. Furthermore, pedestrian interviews highlighted convenience, comfort, and safety, not visual attraction, as key experiential factors influencing walkability. This research underscores the importance of built environment factors in creating walkable streets on health campuses. It advocates for including specific design features, active street life planning, pleasant outdoor experiences, and safety measures. This study presents a Street Walkability Framework and evidence-based design guidelines to improve walkability in Hospital-Anchored Neighborhoods

Emergency Department Efficiency in an Academic Hospital: A Simulation Study

Gemstone Team HOPE (Hospital Optimal Productivity Enterprise)This study examined the effects of the resident education model on the efficiency of a teaching hospital emergency department. Patient data was collected from the University of Maryland Medical Center in Baltimore, MD. This data consisted of both patient information physically collected in the emergency department, as well as historical patient information accessed through the hospital’s electronic databases. Simulation modeling was then used to analyze in a statistically significant manner the effects of the resident education model on patient throughput in the emergency department. We determined that the presence of residents in the ED improves patient throughput for both high-priority and low-priority patients. However, this improvement is higher for lowpriority patients than for high-priority patients, which is a novel result. Future studies will entail determining how replacing residents with other types of personnel, such as nurse practitioners or other types of physicians, affects patient throughput