Applying multi-phase DES approach for modelling the patient journey through accident and emergency departments

Accident and Emergency departments (A&ED) are in charge of providing access to patients requiring urgent acute care. A&ED are difficult to model due to the presence of interactions, different pathways and the multiple outcomes that patients may undertake depending on their health status. In addition, public concern has focused on the presence of overcrowding, long waiting times, patient dissatisfaction and cost overruns associated with A&ED. There is then a need for tackling these problems through developing integrated and explicit models supporting healthcare planning. However, the studies directly concentrating on modelling the A&EDs are largely limited. Therefore, this paper presents the use of a multi-phase DES framework for modelling the A&ED and facilitating the assessment of potential improvement strategies. Initially, the main components, critical variables and different states of the A&ED are identified to correctly model the entire patient journey. In this step, it is also necessary to characterize the demand in order to categorize the patients into pipelines. After this, a discrete-event simulation (DES) model is developed. Then, validation is conducted through the 2-sample t test to demonstrate whether the model is statistically comparable with the real-world A&ED department. This is followed by the use of Markov phase-type models for calculating the total costs of the whole system. Finally, various scenarios are explored to assess their potential impact on multiple outcomes of interest. A case study of a mixed-patient environment in a private A&E department is provided to validate the effectiveness of the multi-phase DES approach

Overcrowding in emergency department: an international issue

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Children's emergency department use for asthma, 2001-2010

Objectives Although the emergency department (ED) provides essential care for severely ill or injured children, past research has shown that children often visit the ED for potentially preventable illnesses, including asthma. We sought to determine how children's rate of ED visits for asthma has changed over the last decade and to analyze what factors are associated with a child's potentially preventable ED visit for asthma. Methods We retrospectively analyzed ED visits by children aged 2 to 17 from 2001 to 2010 using data from the National Hospital Ambulatory Medical Care Survey. Visits were classified as potentially preventable asthma visits by mapping ICD-9-CM diagnosis codes to the Agency for Healthcare Research and Quality's asthma pediatric quality indicator. We examined trends in the annual rate of ED visits for asthma per 1000 children using a weighted linear regression model. Finally, we used multivariate logistic regression to determine what demographic, clinical, and structural factors were associated with a child's ED visit being for a potentially preventable asthma crisis. Results The rate of children's ED visits for asthma increased 13.3% between 2001 and 2010, from 8.2 to 9.3 visits per 1000 children (P =.26). ED visits by children who were younger, male, racial or ethnic minorities, insured with Medicaid/Children's Health Insurance Program, and visiting between 11 pm and 7 am were more likely to be for potentially preventable asthma crises. Conclusions Although the overall rate of potentially preventable ED visits for asthma did not significantly change over the last decade, racial, insurance-based, and other demographic disparities in the likelihood of a preventable asthma-related ED visit persist

Variation in charges for emergency department visits across California

Study objective Previous studies have shown that charges for inpatient and clinic procedures vary substantially; however, there are scant data on variation in charges for emergency department (ED) visits. Outpatient ED visits are typically billed with current procedural terminology-coded levels to standardize the intensity of services received, providing an ideal element on which to evaluate charge variation. Thus, we seek to analyze the variation in charges for each level of ED visits and examine whether hospital- and market-level factors could help predict these charges. Methods Using 2011 charge data provided by every nonfederal California hospital to the Office of Statewide Health Planning and Development, we analyzed the variability in charges for each level of ED visits and used linear regression to assess whether hospital and market characteristics could explain the variation in charges. Results Charges for each ED visit level varied widely; for example, charges for a level 4 visit ranged from $275 to$6,662. Government hospitals charged significantly less than nonprofit hospitals, whereas hospitals that paid higher wages, served higher proportions of Medicare and Medicaid patients, and were located in areas with high costs of living charged more. Overall, our models explained only 30% to 41% of the between-hospital variation in charges for each level of ED visits. Conclusion Our findings of extensive charge variation in ED visits add to the literature in demonstrating the lack of systematic charge setting in the US health care system. These widely varying charges affect the hospital bills of millions of uninsured patients and insured patients seeking care out of network and continue to play a role in many aspects of health care financing. © 2014 by the American College of Emergency Physicians