Bottleneck Detection and Reduction Using Simulation Modeling to Reduce Overcrowding of Hospital Emergency Department

Overcrowding is a common problem in hospital emergency departments (EDs) where the ED service cannot meet care demands within reasonable time frames. This paper introduces a quantitative approach using computer simulation modeling for hospital decision makers to explore trade-offs between efficiency, workload and capacity of EDs. A computer simulation model is built based on the ED of a local hospital to improvement efficiency of the ED patient flow. Bottlenecks of the emergency care process are detected using the built model. The ED performance is examined by applying alternative strategies to reduce patient waiting time and length of stay. The proposed method can be applied to improve the operation efficiency of healthcare systems in the current pandemic, COVID -19

Protocol for developing a set of performance measures to monitor and evaluate delirium care quality for older adults in the emergency department using a modified e-Delphi process

Introduction Older adults are at high risk of developing delirium in the emergency department (ED). Delirium associated with an ED visit is independently linked to poorer outcomes such as increased length of hospital stay and mortality. Performance measures (PMs) are needed to identify variations in the quality of delirium care to help focus improvement efforts where they are most needed. A preliminary list of 11 quality statements and 24 PMs was developed based on a synthesis of high-quality clinical practice guidelines. The purpose of this study is to gain consensus on a subset of PMs that can be used to evaluate delirium care quality for older ED patients.Methods and analysis This protocol for a modified e-Delphi study is informed by the Guidance on Conducting and REporting DElphi Studies. Clinical experts from across Canada and internationally will be recruited through peer referral, professional organisations and social media calls for expressions of interest. A minimum of 17 participants will be recruited. The primary survey for each round will consist of closed-ended questions with the opportunity to provide comments to justify decisions and clarify understanding. Using 9-point Likert scales, participants will rate each quality statement according to the concepts of importance and actionability, then its associated PMs according to the concept of necessity. Results will be fed back to participants in subsequent rounds. A priori stopping criteria have been defined in terms of consensus and stability. A minimum of three rounds will be undertaken to allow participants to have feedback, revise previous responses, then stabilise responses.Ethics and dissemination Ethical approval was provided at the University of Manitoba Health Research Ethics Board (ID HS25728 (H2022:340)). Informed consent will be obtained electronically using the Research Electronic Data Capture secure online platform. Knowledge translation and dissemination will be done through traditional (eg, conference presentations, peer-reviewed publications) and non-traditional (eg, ED Grand Rounds) strategies

Field torso-warming modalities : a comparative study using a human model

Objective: To compare four field-appropriate torso warming modalities, that do not require AC electrical power, using a human model of non-shivering hypothermia. Methods: Five subjects, serving as their own controls, were cooled four times in 8ºC water, for 10-30 minutes. Shivering was inhibited by Buspirone (30 mg) taken orally prior to cooling and IV Meperidine (1.25 mg/kg) at the end of immersion. Subjects were hoisted out of the water, dried, insulated and then underwent 120 min of either: spontaneous warming only; a charcoal heater on the chest; two flexible hot water bags (total4 liters of water at55°C, replenished every 20 minutes) applied to the chest and upper back; or two chemical heat pads applied to the chest and upper back. Supplemental meperidine (maximum cumulative dose of 3.5 mg/kg) was administered as required to inhibit shivering. Results:  Post-cooling afterdrop was compared to spontaneous warming (2.2°C) less for chemical heat pads (1.5°C) and hot water bags (1.6°C, p < 0.05), and was1.8°C with the charcoal heater.  Subsequent core rewarming rates, the hot water bags (0.7°C/h) and the charcoal heater (0.6°C/h), tended to be higher than chemical heat pads (0.2°C/h, p = 0.055) and was significantly greater than spontaneous warming (0.1°C/h, p < 0.05). Conclusion: In subjects with shivering suppressed, greater sources of external heat were effective in attenuating core temperature afterdrop whereas sustained sources of external heat effectively established core rewarming. Depending on scenario and available resources, we advice to use charcoal heaters, chemical heat pads or hot water bags as effective means for treating cold patients in the field or during transport to definitive care

Interventions and strategies involving primary healthcare professionals to manage emergency department overcrowding: a scoping review

Objectives To conduct a scoping review to identify and summarise the existing literature on interventions involving primary healthcare professionals to manage emergency department (ED) overcrowding.Design A scoping review.Data sources A comprehensive database search of Medline (Ovid), EMBASE (Ovid), Cochrane Library (Wiley) and CINAHL (EBSCO) databases was conducted (inception until January 2020) using peer-reviewed search strategies, complemented by a search of grey literature sources.Eligibility criteria Interventions and strategies involving primary healthcare professionals (PHCPs: general practitioners (GPs), nurse practitioners (NPs) or nurses with expanded role) to manage ED overcrowding.Methods We engaged and collaborated, with 13 patient partners during the design and conduct stages of this review. We conducted this review using the JBI guidelines. Two reviewers independently selected studies and extracted data. We conducted descriptive analysis of the included studies (frequencies and percentages).Results From 23 947 records identified, we included 268 studies published between 1981 and 2020. The majority (58%) of studies were conducted in North America and were predominantly cohort studies (42%). The reported interventions were either ‘within ED’ (48%) interventions (eg, PHCP-led ED triage or fast track) or ‘outside ED’ interventions (52%) (eg, after-hours GP clinic and GP cooperatives). PHCPs involved in the interventions were: GP (32%), NP (26%), nurses with expanded role (16%) and combinations of the PHCPs (42%). The ‘within ED’ and ‘outside ED’ interventions reported outcomes on patient flow and ED utilisation, respectively.Conclusions We identified many interventions involving PHCPs that predominantly reported a positive impact on ED utilisation/patient flow metrics. Future research needs to focus on conducting well-designed randomized controlled trials (RCTs) and systematic reviews to evaluate the effectiveness of specific interventions involving PHCPs to critically appraise and summarise evidence on this topic