The impact of alternate level of care on access block and operational strategies to reduce emergency wait times: a multi-center simulation study
Tóm tắt
Lengthy emergency department (ED) wait times caused by hospital access block is a growing concern for the Canadian health care system. Our objective was to quantify the impact of alternate-level-of-care on hospital access block and evaluate the likely effects of multiple interventions on ED wait times. Discrete-event simulation models were developed to simulate patient flows in EDs and acute care of six Canadian hospitals. The model was populated with administrative data from multiple sources (April 2017–March 2018). We simulated and assessed six different intervention scenarios' impact on three outcome measures: (1) time waiting for physician initial assessment, (2) time waiting for inpatient bed, and (3) patients who leave without being seen. We compared each scenario's outcome measures to the baseline scenario for each ED. Eliminating 30% of medical inpatients' alternate-level-of-care days reduced the mean time waiting for inpatient bed by 0.25 to 4.22 h. Increasing ED physician coverage reduced the mean time waiting for physician initial assessment (∆ 0.16–0.46 h). High-quality care transitions targeting medical patients lowered the mean time waiting for inpatient bed for all EDs (∆ 0.34–6.85 h). Reducing ED visits for family practice sensitive conditions or improving continuity of care resulted in clinically negligible reductions in wait times and patients who leave without being seen rates. A moderate reduction in alternate-level-of-care hospital days for medical patients could alleviate access block and reduce ED wait times, although the magnitude of reduction varies by site. Increasing ED physician staffing and aligning physician capacity with inflow demand could also decrease wait time. Operational strategies for reducing ED wait times should prioritize resolving output and throughput factors rather than input factors.
Tài liệu tham khảo
Polevoi SK, Quinn JV, Kramer NR. Factors associated with patients who leave without being seen. Acad Emerg Med. 2005;12:232–6.
Singer AJ, Thode HC Jr, Viccellio P, et al. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18:1324–9.
Sun BC, Hsia RY, Weiss RE, et al. Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med. 2013;61:605-611.e6.
Guttmann A, Schull MJ, Vermeulen MJ, et al. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario. Canada BMJ. 2011. https://doi.org/10.1136/bmj.d2983.
Tropea J, Sundararajan V, Gorelik A, et al. Patients who leave without being seen in emergency departments: an analysis of predictive factors and outcomes. Acad Emerg Med. 2012;19:439–47.
Affleck A, Parks P, Drummond A, et al. Emergency department overcrowding and access block. CJEM. 2013;15:359–84.
Innes GD, Sivilotti MLA, Ovens H, et al. Emergency overcrowding and access block: A smaller problem than we think. CJEM. 2019;21:177–85.
Mason S, Mountain G, Turner J, et al. Innovations to reduce demand and crowding in emergency care; a review study. Scand J Trauma Resusc Emerg Med. 2014;22:55.
Morris ZS, Boyle A, Beniuk K, et al. Emergency department crowding: towards an agenda for evidence-based intervention. Emerg Med J. 2012;29:460–6.
Pines JM, Hilton JA, Weber EJ, et al. International perspectives on emergency department crowding. Acad Emerg Med. 2011;18:1358–70.
Laker LF, Torabi E, France DJ, et al. Understanding emergency care delivery through computer simulation modeling. Acad Emerg Med. 2018;25:116–27.
Mohiuddin S, Busby J, Savović J, et al. Patient flow within UK emergency departments: a systematic review of the use of computer simulation modelling methods. BMJ Open. 2017;7: e015007.
Salmon A, Rachuba S, Briscoe S, et al. A structured literature review of simulation modelling applied to Emergency Departments: Current patterns and emerging trends. Oper Res Health Care. 2018;19:1–13.
Wiler JL, Griffey RT, Olsen T. Review of modeling approaches for emergency department patient flow and crowding research. Acad Emerg Med. 2011;18:1371–9.
Canadian Institute for Health Information. Alternate level of care in Canada. Ottawa, Ont.: CIHI 2009. https://secure.cihi.ca/estore/productFamily.htm?pf=PFC3264&lang=en&media=0. Accessed 14 Jul 2021.
Sutherland JM, Crump RT. Alternative level of care: Canada’s hospital beds, the evidence and options. Healthc Policy. 2013;9:26–34.
Costa AP, Poss JW, Peirce T, et al. Acute care inpatients with long-term delayed-discharge: evidence from a Canadian health region. BMC Health Serv Res. 2012;12:172.
Saskatchewan ED Waits and Patient Flow Initiative. Emergency Department Waits and Patient Flow Initiative Fall 2015 Newsletter. Saskatchewan Health Quality Council. 2015. https://www.hqc.sk.ca/Portals/0/documents/ReducingERWaitsImprovingFlow/Emerg-Dept-Waits-Update-Fall-2015.pdf. Accessed 16 Jul 2017.
Moskop JC, Sklar DP, Geiderman JM, et al. Emergency department crowding, part 1–concept, causes, and moral consequences. Ann Emerg Med. 2009;53:605–11.
Canadian Institute for Health Information. Understanding Emergency Department Wait Times: Access to Inpatient Beds and Patient Flow. Ottawa: CIHI; 2007.
Canadian Institute for Health Information. Sources of potentially avoidable emergency department visits. Ottawa, ON: CIHI 2014. https://secure.cihi.ca/free_products/ED_Report_ForWeb_EN_Final.pdf. Accessed 13 July 2021.
Canadian Institute for Health Information. Continuity of care with family medicine physicians: why it matters. Ottawa, ON: CIHI 2015. https://secure.cihi.ca/free_products/UPC_ReportFINAL_EN.pdf. Accessed 15 July 2021.
Asplin BR, Magid DJ, Rhodes KV, et al. A conceptual model of emergency department crowding. Ann Emerg Med. 2003;42:173–80.
Arain M, Campbell MJ, Nicholl JP. Impact of a GP-led walk-in centre on NHS emergency departments. Emerg Med J. 2015;32:295–300.
Gonçalves-Bradley DC, Lannin NA, Clemson LM, et al. Discharge planning from hospital. Cochrane Database Syst Rev. 2016. https://doi.org/10.1002/14651858.CD000313.pub5.
Doupe MB, Chateau D, Chochinov A, et al. Comparing the effect of throughput and output factors on emergency department crowding: a retrospective observational cohort study. Ann Emerg Med. 2018;72:410–9.
Grant KL, Bayley CJ, Premji Z, et al. Throughput interventions to reduce emergency department crowding: a systematic review. Can J Emerg Med. 2020;22:864–74.
Savage DW, Woolford DG, Weaver B, et al. Developing emergency department physician shift schedules optimized to meet patient demand. CJEM. 2015;17:3–12.
Schull MJ, Kiss A, Szalai J-P. The effect of low-complexity patients on emergency department waiting times. Ann Emerg Med. 2007;49(257–64):264.e1.
Weinick RM, Burns RM, Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics. Health Aff. 2010;29:1630–6.
Uscher-Pines L, Pines J, Kellermann A, et al. Emergency department visits for nonurgent conditions: systematic literature review. Am J Manag Care. 2013;19:47–59.
Martsolf G, Fingar KR, Coffey R, et al. Association between the opening of retail clinics and low-acuity emergency department visits. Ann Emerg Med. 2017;69:397-403.e5.
Salisbury C, Hollinghurst S, Montgomery A, et al. The impact of co-located NHS walk-in centres on emergency departments. Emerg Med J. 2007;24:265–9.
Chalder M, Sharp D, Moore L, et al. Impact of NHS walk-in centres on the workload of other local healthcare providers: time series analysis. BMJ. 2003;326:532.
Doran KM, Colucci AC, Hessler RA, et al. An intervention connecting low-acuity emergency department patients with primary care: effect on future primary care linkage. Ann Emerg Med. 2013;61:312-321.e7.
Mumma BE, McCue JY, Li C-S, et al. Effects of emergency department expansion on emergency department patient flow. Acad Emerg Med. 2014;21:504–9.
Sayah A, Lai-Becker M, Kingsley-Rocker L, et al. Emergency department expansion versus patient flow improvement: impact on patient experience of care. J Emerg Med. 2016;50:339–48.
Canadian Institute for Health Information. Inpatient hospitalization, surgery and newborn statistics, 2018–2019. 2020. https://secure.cihi.ca/free_products/DAD-HMDB-childbirth-quick-stats-2018-2019-en-web.xlsx. Accessed 15 Nov 2022.
Canadian Institute for Health Information. Inpatient Hospitalization, Surgery and Newborn Statistics, 2020–2021. 2022. https://www.cihi.ca/sites/default/files/document/dad-hmdb-childbirth-2020-2021-data-tables-en.xlsx. Accessed 15 Nov 2022.
Saskatchewan Ministry of Health. Ministry of Health 2016–17 Annual Report. Government of Saskatchewan 2017. https://publications.saskatchewan.ca/api/v1/products/25499/formats/107117/download. Accessed 25 June 2022.
Saskatchewan Ministry of Health. Ministry of Health 2017–18 Annual Report. Government of Saskatchewan https://publications.saskatchewan.ca/api/v1/products/25499/formats/114304/download. Accessed 24 June 2022.