Empirical Studies in Hospital Emergency Departments

This dissertation focuses on the operational impacts of crowding in hospital emergency departments. The body of this work is comprised of three essays. In the first essay, Waiting Patiently: An Empirical Study of Queue Abandonment in an Emergency Department, we study queue abandonment, or left without being seen. We show that abandonment is not only influenced by wait time, but also by the queue length and the observable queue flows during the waiting exposure. We show that patients are sensitive to being jumped in the line and that patients respond differently to people more sick and less sick moving through the system. This study shows that managers have an opportunity to impact abandonment behavior by altering what information is available to waiting customers. In the second essay, Doctors Under Load: An Empirical Study of State-Dependent Service Times in Emergency Care, we show that when crowded, multiple mechanisms in the emergency department act to retard patient treatment, but care providers adjust their clinical behavior to accelerate the service. We identify two mechanisms that providers use to accelerate the system: early task initiation and task reduction. In contrast to other recent works, we find the net effect of these countervailing forces to be an increase in service time when the system is crowded. Further, we use simulation to show that ignoring state-dependent service times leads to modeling errors that could cause hospitals to overinvest in human and physical resources. In the final essay, The Financial Consequences of Lost Demand and Reducing Boarding in Hospital Emergency Departments, we use discrete event simulation to estimate the number of patients lost to Left Without Being Seen and ambulance diversion as a result of patients waiting in the emergency department for an inpatient bed (known as boarding). These lost patients represent both a failure of the emergency department to meet the needs of those seeking care and lost revenue for the hospital. We show that dynamic bed management policies that proactively cancel some non-emergency patients when the hospital is near capacity can lead to reduced boarding, increased number of patients served, and increased hospital revenue

Waiting Patiently: An Empirical Study of Queue Abandonment in an Emergency Department

We study queue abandonment from a hospital emergency department. We show that abandonment is influenced by the queue length and the observable queue flows during the waiting exposure, even after controlling for wait time. For example, observing an additional person in the queue or an additional arrival to the queue leads to an increase in abandonment probability equivalent to a 25-minute or 5-minute increase in wait time, respectively. We also show that patients are sensitive to being “jumped” in the line and that patients respond differently to people more sick and less sick moving through the system. This customer response to visual queue elements is not currently accounted for in most queuing models. Additionally, to the extent the visual queue information is misleading or does not lead to the desired behavior, managers have an opportunity to intervene by altering what information is available to waiting customers

Electronic Health Record-Based Surveillance for Community Transmitted COVID-19 in the Emergency Department

Introduction: SARS-CoV-2, a novel coronavirus, manifests as a respiratory syndrome (COVID-19) and is the cause of an ongoing pandemic. The response to COVID-19 in the United States has been hampered by an overall lack of diagnostic testing capacity. To address uncertainty about ongoing levels of SARS-CoV-2 community transmission early in the pandemic, we aimed to develop a surveillance tool using readily available emergency department (ED) operations data extracted from the electronic health record (EHR). This involved optimizing the identification of acute respiratory infection (ARI)-related encounters and then comparing metrics for these encounters before and after the confirmation of SARS-CoV-2 community transmission.Methods: We performed an observational study using operational EHR data from two Midwest EDs with a combined annual census of over 80,000. Data were collected three weeks before and after the first confirmed case of local SARS-CoV-2 community transmission. To optimize capture of ARI cases, we compared various metrics including chief complaint, discharge diagnoses, and ARI-related orders. Operational metrics for ARI cases, including volume, pathogen identification, and illness severity, were compared between the pre- and post-community transmission timeframes using chi-square tests of independence.Results: Compared to our combined definition of ARI, chief complaint, discharge diagnoses, and isolation orders individually identified less than half of the cases. Respiratory pathogen testing was the top performing individual ARI definition but still only identified 72.2% of cases. From the pre to post periods, we observed significant increases in ED volumes due to ARI and ARI cases without identified pathogen.Conclusion: Certain methods for identifying ARI cases in the ED may be inadequate and multiple criteria should be used to optimize capture. In the absence of widely available SARS-CoV-2 testing, operational metrics for ARI-related encounters, especially the proportion of cases involving negative pathogen testing, are useful indicators for active surveillance of potential COVID-19 related ED visits

EPICOG-SCH: A brief battery to screen cognitive impact of schizophrenia in stable outpatients

Brief batteries in schizophrenia, are needed to screen for the cognitive impact of schizophrenia. We aimed to validate and co-norm the Epidemiological Study of Cognitive Impairment in Schizophrenia (EPICOG-SCH) derived brief cognitive battery. A cross-sectional outpatient evaluation was conducted of six-hundred-seventy-two patients recruited from 234 centers. The brief battery included well-known subtests available worldwide that cover cognitive domains related to functional outcomes: WAIS-III-Letter-Number-Sequencing-LNS, Category Fluency Test-CFT, Logical-Memory Immediate Recall-LM, and Digit-Symbol-Coding-DSC. CGI-SCH Severity and WHO-DAS-S were used to assess clinical severity and functional impairment, respectively. Unit Composite Score (UCS) and functional regression-weighted Composite Scores (FWCS) were obtained; discriminant properties of FWCS to identify patients with different levels of functional disability were analyzed using receiver-operating characteristic (ROC) technique. The battery showed good internal consistency, Cronbach's alpha = 0.78. The differences between cognitive performance across CGI-SCH severity level subscales ranged from 0.5 to 1 SD. Discriminant capacity of the battery in identifying patients with up to moderate disability levels showed fair discriminant accuracy with areas under the curve (AUC) > 0.70, p < 0.0001. An FWCS mean cut-off score ≥ 100 showed likelihood ratios (LR) up to 4.7, with an LR+ of 2.3 and a LR− of 0.5. An FWCS cut-off ≥ 96 provided the best balance between sensitivity (0.74) and specificity (0.62). The EPICOG-SCH proved to be a useful brief tool to screen for the cognitive impact of schizophrenia, and its regression-weighted Composite Score was an efficient complement to clinical interviews for confirming patients' potential functional outcomes and can be useful for monitoring cognition during routine outpatient follow-up visits

Levels of acid sphingomyelinase (ASM) in Caenorhabditis elegans in microgravity

Both Amyotrophic Lateral Sclerosis (ALS) patients and astronauts in spaceflight suffer from muscle atrophy. Previous research suggests that the enzyme acid sphingomyelinase (ASM) may be involved in the pathogenesis of ALS, but it is not known if ASM influences muscle atrophy in microgravity. In this study, C. elegans were exposed to microgravity conditions on the International Space Station (ISS) within the confines of a Fluid Mixing Enclosure (FME). Return of the FME yielded 72,050 live nematodes, the first demonstration of C. elegans survival of space travel in an FME. After the nematodes returned to Earth, in much larger numbers than seen in previous FME experiments, the size and ASM expression levels in experimental worms were compared to control Earth-bound worms. C. elegans that returned from the ISS were larger in both length and cross-sectional area than the control worms, and they exhibited decreased expression of ASM-1 and ASM-2 proteins. Further research must be conducted to elucidate the role of ASM in muscle atrophy, as there were many limitations to this study. Understanding the role of ASM in muscle atrophy may lead to the discovery of novel targets for treatment of both ALS and muscle atrophy in microgravity. This study was a student led initiative and undertaken as a project within the Student Spaceflight Experiment Program (SSEP), under the auspices of the National Center for Earth and Space Science Education and the Arthur C Clarke Institute for Space Education

Anti-TNF-α treatment for deep endometriosis-associated pain: a randomized placebo-controlled trial

BACKGROUND: Endometriosis is associated with an inflammatory response. Hence infliximab, an anti-TNF-alpha monoclonal antibody, might relieve pain. METHODS: A randomized placebo-controlled trial was designed with 21 women with severe pain and a rectovaginal nodule of at least 1 cm. After 1 month of observation, three infusions of infliximab (5 mg/kg) or placebo were given. Surgery was performed 3 months later and follow-up continued for 6 months. The primary end-point was pain (dysmenorrhea, deep dyspareunia and non-menstrual pain) rated at each visit by the clinician and on a daily basis by the patient who in addition scored pain by visual analog pain scale and analgesia intake. Secondary end-points included the volume of the endometriotic nodule, pelvic tenderness and the visual appearance of endometriotic lesions at laparoscopy. RESULTS: Pain severity decreased during the treatment by 30% in both the placebo (P < 0.001) and infliximab groups (P < 0.001). However, no effect of infliximab was observed for any of the outcome measures. After surgery, pain scores decreased in both groups to less than 20% of the initial value. CONCLUSIONS: Infliximab appears not to affect pain associated with deep endometriosis. Treatment is associated with an important placebo effect. After surgery, pain decreases to less than 20%. Trials registration number ClinicalTrials.gov: NCT00604864

Quantifying uncertainty, variability and likelihood for ordinary differential equation models

<p>Abstract</p> <p>Background</p> <p>In many applications, ordinary differential equation (ODE) models are subject to uncertainty or variability in initial conditions and parameters. Both, uncertainty and variability can be quantified in terms of a probability density function on the state and parameter space.</p> <p>Results</p> <p>The partial differential equation that describes the evolution of this probability density function has a form that is particularly amenable to application of the well-known method of characteristics. The value of the density at some point in time is directly accessible by the solution of the original ODE extended by a single extra dimension (for the value of the density). This leads to simple methods for studying uncertainty, variability and likelihood, with significant advantages over more traditional Monte Carlo and related approaches especially when studying regions with low probability.</p> <p>Conclusions</p> <p>While such approaches based on the method of characteristics are common practice in other disciplines, their advantages for the study of biological systems have so far remained unrecognized. Several examples illustrate performance and accuracy of the approach and its limitations.</p

Novel insight into the reaction of nitro, nitroso and hydroxylamino benzothiazinones and of benzoxacinones with Mycobacterium tuberculosis DprE1

Abstract Nitro-substituted 1,3-benzothiazinones (nitro-BTZs) are mechanism-based covalent inhibitors of Mycobacterium tuberculosis decaprenylphosphoryl-β-D-ribose-2′-oxidase (DprE1) with strong antimycobacterial properties. We prepared a number of oxidized and reduced forms of nitro-BTZs to probe the mechanism of inactivation of the enzyme and to identify opportunities for further chemistry. The kinetics of inactivation of DprE1 was examined using an enzymatic assay that monitored reaction progress up to 100 min, permitting compound ranking according to k inact/K i values. The side-chain at the 2-position and heteroatom identity at the 1-position of the BTZs were found to be important for inhibitory activity. We obtained crystal structures with several compounds covalently bound. The data suggest that steps upstream from the covalent end-points are likely the key determinants of potency and reactivity. The results of protein mass spectrometry using a 7-chloro-nitro-BTZ suggest that nucleophilic reactions at the 7-position do not operate and support a previously proposed mechanism in which BTZ activation by a reduced flavin intermediate is required. Unexpectedly, a hydroxylamino-BTZ showed time-dependent inhibition and mass spectrometry corroborated that this hydroxylamino-BTZ is a mechanism-based suicide inhibitor of DprE1. With this BTZ derivative, we propose a new covalent mechanism of inhibition of DprE1 that takes advantage of the oxidation cycle of the enzyme

Who Benefits From Teams? Comparing Workers, Supervisors, and Managers

This paper offers a political explanation for the diffusion and sustainability of team-based work systems by examining the differential outcomes of team structures for 1200 workers, supervisors, and middle managers in a large unionized telecommunications company. Regression analyses show that participation in self-managed teams is associated with significantly higher levels of perceived discretion, employment security, and satisfaction for workers and the opposite for supervisors. Middle managers who initiate team innovations report higher employment security, but otherwise are not significantly different from their counterparts who are not involved in innovations. By contrast, there are no significant outcomes for employees associated with their participation in offline problem-solving teams