The Impact of Delays on Service Times in the Intensive Care Unit

Mainstream queueing models are frequently employed in modeling healthcare delivery in a number of settings, and they further are used in making operational decisions for the same. The vast majority of these queueing models ignore the effects of delay experienced by a patient awaiting care. However, long delays may have adverse effects on patient outcomes and can potentially lead to a longer length of stay (LOS) when the patient ultimately does receive care. This work sets out to understand these delay issues from an operational perspective. Using data of more than 57,000 emergency department (ED) visits,we use an instrumental variable approach to empirically measure the impact of delays in intensive care unit (ICU) admission, i.e., ED boarding, on the patient's ICU LOS for multiple patient types. Capturing these empirically observed effects in a queueing model is challenging because the effect introduces potentially long-range correlations in service and interarrival times. We propose a queueing model that incorporates these measured delay effects and characterizes approximations to the expected work in the system when the service time of a job is adversely impacted by the delay experienced by that job. Our approximation demonstrates an effect of system load on work that grows much faster than the traditional 1/(1 - ρ) relationship seen in most queueing systems. As such, it is imperative that the relationship of delays and LOS be better understood by hospital managers so that they can make capacity decisions that prevent even seemingly moderate delays from causing dire operational consequences. Key words: Delay effects, queueing, HealthcareNational Science Foundation (U.S.) (CAREER Grant CMMI-1054034

Taxonomic classification of planning decisions in health care: a review of the state of the art in OR/MS

We provide a structured overview of the typical decisions to be made in resource capacity planning and control in health care, and a review of relevant OR/MS articles for each planning decision. The contribution of this paper is twofold. First, to position the planning decisions, a taxonomy is presented. This taxonomy provides health care managers and OR/MS researchers with a method to identify, break down and classify planning and control decisions. Second, following the taxonomy, for six health care services, we provide an exhaustive specification of planning and control decisions in resource capacity planning and control. For each planning and control decision, we structurally review the key OR/MS articles and the OR/MS methods and techniques that are applied in the literature to support decision making

A survey of health care models that encompass multiple departments

In this survey we review quantitative health care models to illustrate the extent to which they encompass multiple hospital departments. The paper provides general overviews of the relationships that exists between major hospital departments and describes how these relationships are accounted for by researchers. We find the atomistic view of hospitals often taken by researchers is partially due to the ambiguity of patient care trajectories. To this end clinical pathways literature is reviewed to illustrate its potential for clarifying patient flows and for providing a holistic hospital perspective

The impact of a new regional air ambulance service on a large general hospital

Background: Helicopter air ambulance crews are influenced in their selection of the destination hospital for their patients by several factors including: distance from the scene; facilities, on site specialties, and senior cover of the receiving hospital; and the proximity of the helicopter landing area to the emergency department (ED). Only a limited number of hospitals have landing sites adjacent to the ED from which patients can be taken directly into the department (primary landing sites). Helicopter crews will often elect to over fly hospitals that do not have primary landing sites because secondary land transfers will add delays in delivering patients. Birmingham Heartlands Hospital has an elevated helideck adjacent to the ED. In October 2003, the Warwickshire and Northamptonshire Air Ambulance (WNAA) service was launched; the hospital sits on the western periphery of the area served by the service. Methods: Prospective data was collated on all patients brought by WNAA to Heartlands Hospital between 1 October 2003 and 31 August 2004. Results: In the 10 month period after the launch of the service, the helicopter delivered 83 patients to the ED; 74 of these were "off patch". This additional workload generated 163 ward days, 19 operative procedures, and 85 intensive care unit, high dependency unit, or coronary care unit days. The direct costs of this additional workload approached £160 000. Conclusions: In future discussions on the cost effectiveness of air ambulances, it will be important to consider both the direct and indirect costs to the receiving hospitals arising from the redistribution of emergency workload. Abbreviations: ED, emergency department; HDU, high dependency unit; HEMS, helicopter emergency medical service; ICU, intensive care unit; ISS, injury severity score; WNAA, Warwickshire and Northamptonshire Air Ambulance; WMCAA, West Midlands County Air Ambulance

Improving Patient Satisfaction with the Virtual Handoff Process through the Utilization of Educational Pamphlets in the Emergency Department

Boarding patients in the emergency room while waiting to transfer the patient to the proper unit can be harmful to clinical care and have significant financial opportunity costs. At one local hospital it was found that on average patients were being boarded in the emergency room (ED) for approximately 85 minutes waiting to be transferred. Several barriers that caused this delay were found including, delay in room cleaning, nurse staff shortage, and inability to give report to the nurse receiving the patient. In an attempt to combat this delay which may be caused by a difficulty in giving patient report, this organization is rolling out a virtual bedside handoff process. While virtual technology is not a new concept, there are many patients that may not be comfortable with the technology. The purpose of the evidence-based project was to provide a written educational pamphlet that details the how’s and why’s of the virtual handoff process to the patient to be given upon admission. The goal of the educational pamphlet was to increase the patients’ satisfaction with the process. A pre-survey was given to a group of patients after they experienced the virtual handoff process to assess their comfort level. These results were compared to the post-survey results of patients that received the educational pamphlet prior to experiencing the virtual handoff process. Ten pre-surveys and seven post-surveys were analyzed utilizing SPSS and descriptive statistics. The analysis concluded that the participants who received the educational pamphlet felt more prepared for the virtual handoff process

The snowball effect of customer slowdown in critical many-server systems

Customer slowdown describes the phenomenon that a customer's service requirement increases with experienced delay. In healthcare settings, there is substantial empirical evidence for slowdown, particularly when a patient's delay exceeds a certain threshold. For such threshold slowdown situations, we design and analyze a many-server system that leads to a two-dimensional Markov process. Analysis of this system leads to insights into the potentially detrimental effects of slowdown, especially in heavy-traffic conditions. We quantify the consequences of underprovisioning due to neglecting slowdown, demonstrate the presence of a subtle bistable system behavior, and discuss in detail the snowball effect: A delayed customer has an increased service requirement, causing longer delays for other customers, who in turn due to slowdown might require longer service times.Comment: 23 pages, 8 figures -- version 3 fixes a typo in an equation. in Stochastic Models, 201

Will COVID-19 mark the end of an egalitarian NHS?

The exceptional circumstances brought about by the COVID-19 pandemic have affected the traditional organisation of healthcare resources allocation in the UK. Since its inception, the National Health Service (NHS) has aimed to regulate risks of ill health in the population by providing an equal and universal provision of healthcare services to residents based on their health status rather than their ability to pay. The rapid spread of this new virus has, however, triggered a shift in paradigm from an egalitarian allocation of healthcare resources to a utilitarian approach, which has led to discussions about society’s greatest taboos: death and dying and the economic value of individuals’ health

Ridesharing as an Alternative to Ambulance Transport for Voluntary Psychiatric Patients in the Emergency Department

Introduction: Emergency department (ED) crowding is a growing problem. Psychiatric patients have long ED lengths of stay awaiting placement and transportation to a psychiatric facility after disposition.Methods: Retrospective analysis of length of ED stay after disposition for voluntary psychiatric patients before and after the use of Lyft ridesharing services for inter-facility transport.Results: Using Lyft transport to an outside crisis center shortens time to discharge both statistically and clinically from 113 minutes to 91 minutes (p = 0.028) for voluntary psychiatric patients. Discharge time also decreased for involuntary patients from 146 minutes to 127 minutes (p = 0.0053).Conclusion: Ridesharing services may be a useful alternative to medical transportation for voluntary psychiatric patients