Development of an observational instrument to determine variations in the patient care process and patient flow among emergency physicians and internists at the emergency department

BACKGROUND: The increasing demand for acute care and restructuring of hospitals resulting in emergency department (ED) closures and fewer inpatient beds are reasons to improve ED efficiency. The approach towards the patient care process varies among doctors. The objective of this study was to determine variations in the patient care process and patient flow among emergency physicians (EP’s) and internists at the ED of Leiden University Medical Centre (LUMC), the Netherlands. METHODS: An observational instrument was developed during a pilot study at the LUMC ED, following observations of activities performed by EP’s and internists. The instrument divides all different types of activities a clinician can perform on the ED into eight categories. Using the observational instrument, their activities were observed and registered for 10 separate days. Primary outcomes were defined as the time spend on the eight separate activity categories, the total length of stay (LOS) and the number of patients seen during an interval. Secondary outcomes were general observations of working routine features that determine patient flow at the ED. The obtained data were analyzed into SPSS. RESULTS: Ten doctors were observed during a total of ± 36 hours in which 42 patients were seen. Although EP’s were observed for a shorter period of time than internists (13:48 vs. 22:10 hrs, -38%), they saw more patients (26 vs. 16, +62%). EP’s tended to spend a higher proportion of their time on patient contact than internists (27.2% vs. 17.3%, p = 0.06). Both groups dedicated the highest proportion of their time to documentation (31.5% and 33.4%, p = 0.75) and had little communication with ED nurses (3.7% and 2.4% p = 0.57). The average LOS of internal patients was higher than that of EP’s patients (5.25 ± sd 1:33 and 2.26 ± sd 1:32 hours). Internists occupied more treatment rooms at the same time (2.41 vs. 2.08, p < 0.00) and followed a more sequential working routine. CONCLUSIONS: This paper describes the determination of variations in the ED care process and patient flow among EP’s and internists by an observational instrument. A pilot study with the instrument showed variations in the patient care process and patient flow among the two groups at the LUMC ED

Designing cyclic appointment schedules for outpatient clinics with scheduled and unscheduled patient arrivals

We present a methodology to design appointment systems for outpatient clinics and diagnostic facilities that offer both walk-in and scheduled service. The developed blueprint for the appointment schedule prescribes the number of appointments to plan per day and the moment on the day to schedule the appointments. The method consists of two models that are linked by an algorithm; one for the day process that governs scheduled and unscheduled arrivals on the day and one for the access process of scheduled arrivals. Appointment schedules that balance the waiting time at the facility for unscheduled patients and the access time for scheduled patients, are calculated iteratively using the outcomes of the two models. The method is of general nature and can therefore also be applied to scheduling problems in other sectors than health care

Appointments for care pathways the Geox/D/1 queue with slot reservations

Motivated by the increasing popularity of care pathways in outpatient clinics, where some patients complete a significant part of the path in one day, hospitals aim to optimize the flow of these patients by prioritizing them in the appointment planning process. This paper considers the Geo$^x /D/1$ queue with slot reservations that serves regular patients and priority patients. Priority patients reserve a time slot in a reservation window and are blocked when all slots in the reservation window are occupied by other priority patients. The reservation window models the advance reservation of service slots by patients on a care pathway. We model the Geo$^x /D/1$ queue as a $M/G/1$-type queue and apply a matrix-analytic approach, which simplifies to a matrix-geometric solution. We use the vector generating functions to derive the patients’ waiting times. Numerical experiments illustrate the influence of the reservation window on the number of regular and priority patients present and the blocking probabilities for priority patients

Making an Impact on Healthcare Logistics

This handbook provides our take on optimization of logistics processes in healthcare and on the gap that exists between theory and practice. We will bridge that gap as all theoretical results presented in this book have actually been implemented in the healthcare domain. We are driven by a desire to improve the healthcare system, by effectively making an impact with Operations Research (OR). We discuss specific projects that have addressed major challenges for healthcare Operations Research. We present our solution approaches, our approaches to implement the results in practice, and the impact on healthcare organizations. In addition, we discuss the problems we encountered when implementing the results in practice and how we addressed them. In this introductory chapter, we discuss the ecosystem of our research center CHOIR (Center for Healthcare Operations Improvement & Research) and demonstrate how we have an impact on healthcare logistics

Designing cyclic appointment schedules for outpatient clinics with scheduled and unscheduled patient arrivals

We present a methodology to design appointment systems for outpatient clinics and diagnostic facilities that offer both walk-in and scheduled service. The developed blueprint for the appointment schedule prescribes the number of appointments to plan per day and the moment on the day to schedule the appointments. The method consists of two models; one for the day process that governs scheduled and unscheduled arrivals on the day and one for the access process of scheduled arrivals. Appointment schedules that balance the waiting time at the facility for unscheduled patients and the access time for scheduled patients are calculated iteratively using the outcomes of the two models. Two methods to calculate appointment schedules, complete enumeration and a heuristic procedure, are compared in various numerical experiments. Furthermore, an appointment schedule for the CT-scan facility at the Academic Medical Center Amsterdam, The Netherlands, is developed to demonstrate the practical merits of the methodology. The method is of general nature and can therefore also be applied to scheduling problems in other sectors than health care