Prioritizing Patients for Emergency Evacuation From a Healthcare Facility

The success of a healthcare facility evacuation depends on communication and decision-making at all levels of the organization, from the coordinators at incident command to the clinical staff who actually carry out the evacuation. One key decision is the order in which each patient is chosen for evacuation. While the typical planning assumption is that all patients are to be evacuated, there may not always be adequate time or resources available to move all patients. In these cases, prioritizing or ordering patients for evacuation becomes an extremely difficult decision to make. These decisions should be based on the current state of the facility, but without knowledge of the current patient roster or available resources, these decisions may not be as beneficial as possible. Healthcare facilities usually consider evacuation a last-resort measure, and there are often system redundancies in place to protect against having to completely evacuate all patients from a facility. Perhaps this is why there is not a great deal of research dedicated to improving patient transfers. In addition, the question of patient prioritization is a highly ethical one. Based on a literature review of 1) suggested patient prioritization strategies for evacuation planning as well as 2) the actual priorities given in actual facility evacuations indicates there is a lack of consensus as to whether critical or non-critical care patients should be moved away from a facility first in the event of a complete emergency evacuation. In addition, these policies are \u27all-or-nothing\u27 policies, implying that once a patient group is given priority, this entire group will be completely evacuated before any patients from the other group are transferred. That is, if critical care patients are given priority, all critical care patients will be transferred away from the facility before any non-critical care patient. The goal of this research is to develop a decision framework for prioritizing patient evacuations, where unique classifications of patient health, rates of evacuation, and survivability all impact the choice. First, I provide several scenarios (both in terms of physical processing estimates as well as competing, ethically-motivated objectives) and offer insights and observations into the creation of a prioritization policy via dynamic programming. Dynamic programming is a problem-solving technique to recursively optimize a series of decisions. The results of the dynamic programming provide optimal prioritization policies, and these are tested with simulation analysis to observe system performance under many of the same scenarios. Because the dynamic programming decisions are based on the state of the system, simulation also allows the testing of time-based decisions. The results from the dynamic programming and simulation, as well as the structural properties of the simulation are used to create assumptions about how evacuations could be improved. The question is not whether patient priorities should be assigned - but how patient priorities should be assigned. Associated with assigning value to patients are a variety of ethical dilemmas. In this research, I attempt to address patient prioritization from an ethical perspective by discussing the basic principles and the potential dilemmas associated with such decisions. The results indicate that an all-or-nothing, or a \u27greedy\u27 policy as discussed in the literature may not always be optimal for patient evacuations. In some cases, a switching policy may occur. Switching policies begin by evacuating patients from one classification and then switch to begin evacuations from the second patient class. A switch can only be made once; after a switch is made, all remaining patients from the new group should be evacuated. When there are no more patients of that group remaining in the system, the remaining patients from the class that was initially given priority should be evacuated. In the case of critical and non-critical care patients, switching policies first give priority to non-critical care patients. When the costs of holding patients in the system are not included in the models - and the decisions are just based on maximizing the number of saved lives - the switching policies may perform as good or better than the greedy policies suggested in the literature. In addition, when holding costs are not included, it is easier to predict whether the optimal policy is a greedy policy or a switching policy. Prioritization policies can change based on the utility achieved from evacuating individual patients from each class, as well as for other competing objective functions. This research examines a variety of scenarios - maximizing saved lives, minimizing costs, etc. - and provides insights on how the selection of an objective impacts the choice. Another insight of this research is how multiple evacuation teams should be allocated to patients. In the event that there is more than one evacuation team dedicated to moving a group of patients, the two teams should be allocated to the same patient group instead of being split between the multiple patient groups

Justice, Claims and Prioritarianism: Room for Desert?

Does individual desert matter for distributive justice? Is it relevant, for purposes of justice, that the pattern of distribution of justice’s “currency” (be it well-being, resources, preference-satisfaction, capabilities, or something else) is aligned in one or another way with the pattern of individual desert? This paper examines the nexus between desert and distributive justice through the lens of individual claims. The concept of claims (specifically “claims across outcomes”) is a fruitful way to flesh out the content of distributive justice so as to be grounded in the separateness of persons. A claim is a relation between a person and a pair of outcomes. If someone is better off in one outcome than a second, she has a claim in favor of the first. If she is equally well off in the two outcomes, she has a null claim between the two. In turn, whether one outcome is more just than a second depends upon the pattern of claims between them. In prior work, I have elaborated the concept of claims across outcomes, and have used it to provide a unified defense of the Pareto and Pigou-Dalton axioms. Adding some further, plausible, axioms, we arrive at prioritarianism. Here, I consider the possibility of desert-modulated claims—whereby the strength of an individual’s claim between two outcomes is determined not only by her well-being levels in the two outcomes, and her well-being difference between them, but also by her desert. This generalization of the notion of claims suggests a new axiom of justice: Priority for the More Deserving, requiring that, as between two individuals at the same well-being level, a given increment in well-being be allocated to the more deserving one. If individual desert is intrapersonally fixed, this new axiom, together with a desert-modulated version of the Pigou-Dalton principle, and the Pareto axioms, yields a desert-modulated prioritarian account of distributive justice. Trouble arises, however, if an individual’s desert level can be different in different outcomes. In this case of intrapersonally variable desert, Priority for the More Deserving can conflict with the Pareto axioms (both Pareto indifference and strong Pareto). This conflict, I believe, is sufficient reason to abandon the proposal to make claim strength a function of individual desert on top of well-being levels and differences. If distributive justice is truly sensitive to each individual’s separate perspective—if the justice ranking of outcomes is built up from the totality of individual rankings—we should embrace the Pareto axioms as axioms of justice and reject Priority for the More Deserving. In short: desert-modulated prioritarianism is a nonstarter. Rawls was right to sever distributive justice from desert

Permanent Legal Immigration to the United States: Policy Overview

Four major principles currently underlie U.S. policy on legal permanent immigration: the reunification of families, the admission of immigrants with needed skills, the protection of refugees, and the diversity of admissions by country of origin. These principles are embodied in federal law, the Immigration and Nationality Act (INA) first codified in 1952. The Immigration Amendments of 1965 replaced the national origins quota system (enacted after World War I) with per-country ceilings, and the statutory provisions regulating permanent immigration to the United States were last revised significantly by the Immigration Act of 1990. The critiques of the permanent legal immigration system today are extensive, but there is no consensus on the specific direction the reforms of the law should take. As the Congress considers comprehensive immigration reform (CIR), many maintain that revision of the legal immigration system should be one of the major components of a CIR proposal. This primer on legal permanent immigration law, policies, and trends provides a backdrop for the policy options and debates that may emerge as Congress considers a revision of the legal immigration system

Strategies for a centralized single product multiclass M/G/1 make-to-stock queue

Make-to-stock queues are typically investigated in the M/M/1 settings. For centralized single-item systems with backlogs, the multilevel rationing (MR) policy is established as optimal and the strict priority (SP) policy is a practical compromise, balancing cost and ease of implementation. However, the optimal policy is unknown when service time is general, i.e., for M/G/1 queues. Dynamic programming, the tool commonly used to investigate the MR policy in make-to-stock queues, is less practical when service time is general. In this paper we focus on customer composition: the proportion of customers of each class to the total number of customers in the queue. We do so because the number of customers in M/G/1 queues is invariant for any nonidling and nonanticipating policy. To characterize customer composition, we consider a series of two-priority M/G/1 queues where the first service time in each busy period is different from standard service times, i.e., this first service time is exceptional. We characterize the required exceptional first service times and the exact solution of such queues. From our results, we derive the optimal cost and control for the MR and SP policies for M/G/1 make-to-stock queues

Evaluation of the Job Outcome Target Pilots: findings from the qualitative study

This report presents the results of a qualitative evaluation of the pilot of the Job Outcome Target (JOT) in seven Jobcentre Plus Districts, covering the first six months of the pilot's operation from January to July 2005. The research comprised interviews and focus groups with Jobcentre Plus managers and staff, employers, providers and customers in the JOT pilot districts in three stages, beginning one month before the start of the pilots. The evaluators' conclusion is that the qualitative evidence supports the view that JOT is a feasible alternative approach to the Job Entry Target (JET) as a system for performance measurement and management for Jobcentre Plus. Many of the desired behavioural changes among Jobcentre Plus staff were observed, including greater team working, an enhanced focus on the quality rather than quantity of interventions with customers and encouragement of appropriate customers to use self-help channels. In addition, JOT led almost immediately to the reduction or discontinuation of activities that were felt to be wasteful of resources under JET, notably the extensive use of the Adviser Discretion Fund and speculative submissions to ensure that job entries are validated. No evidence was found of negative impacts of JOT on customers, providers or employers, a finding corroborated by quantitative analysis. The report suggests that, should JOT be rolled out nationally, a programme of communication, training and support, building on the lessons of the pilot, would be necessary in order to ensure that behavioural changes associated with JOT develop into more deep-seated cultural change within Jobcentre Plus