Search

Objective: Optimising patient flow is becoming an increasingly critical issue as patient demand fluctuates in healthcare systems with finite capacity. Simulation provides a powerful tool to fine‐tune policies and investigate their impact before any costly intervention. Methods: A hospital‐wide discrete event simulation is developed to model incoming flow from ED and elective units in a busy metropolitan hospital. The impacts of two different policies are investigated using this simulation model: (i) varying inpatient bed configurations and a load sharing strategy among a cluster of wards within a medical department and (ii) early discharge strategies on inpatient bed access. Several clinically relevant bed configurations and early discharge scenarios are defined and their impact on key performance metrics are quantified. Results: Sharing beds between wards reduced the average and total ED length of stay (LOS) by 21% compared to having patients queue for individual wards. The current baseline performance level could be maintained by using fewer beds when the load sharing approach was imposed. Earlier discharge of inpatients resulted in reducing average patient ED LOS by approximately 16% and average patient waiting time by 75%. Specific time‐based discharge targets led to greater improvements in flow compared to blanket approaches of discharging all patients 1 or 2 hours earlier. Conclusions: ED access performance for admitted patients can be improved by modifying downstream capacity or inpatient discharge times. The simulation model was able to quantify the potential impacts of such policies on patient flow and to provide insights for future strategic planning. [ABSTRACT FROM AUTHOR]

Background and Aims: Policy makers and health system managers are seeking evidence on the risks involved for patients associated with after‐hours care. This study of approximately 1 million patients who were admitted to the 25 largest public hospitals in Queensland Australia sought to quantify mortality and readmission differences associated with after‐hours hospital admission. Methods: Logistic regression was used to assess whether there were any differences in mortality and readmissions based on the time inpatients were admitted to hospital (after‐hours versus within hours). Patient and staffing data, including the variation in physician and nursing staff numbers and seniority were included as explicit predictors within patient outcome models. Results: After adjusting for case‐mix confounding, statistically significant higher mortality was observed for patients admitted on weekends via the hospital's emergency department compared to within hours. This finding of elevated mortality risk after‐hours held true in sensitivity analyses which explored broader definitions of after‐hours care: an "Extended" definition comprising a weekend extending into Friday night and early Monday morning; and a "Twilight" definition comprising weekends and weeknights. There were no significant differences in 30‐day readmissions for emergency or elective patients admitted after‐hours. Increased mortality risks for elective patients was found to be an evening/weekend effect rather than a day‐of‐week effect. Workforce metrics that played a role in observed outcome differences within hours/after‐hours were more a time of day rather than day of week effect, i.e. staffing impacts differ more between day and night than the weekday versus weekend. Conclusion: Patients admitted after‐hours have significantly higher mortality than patients admitted within hours. This study confirms an association between mortality differences and the time patients were admitted to hospital, and identifies characteristics of patients and staffing that affect those outcomes. [ABSTRACT FROM AUTHOR]

Objective Despite significant workflow reform to comply with the federally mandated National Emergency Access Target ( NEAT), Australian public hospitals continue to face significant barriers in achieving good ED patient flow. This study was undertaken to identify and analyse the impact of individual waypoints on an ED patient's journey and identify which waypoints act as bottlenecks to a hospital's 4 h ED disposition performance. Methods This study involves retrospective analysis and simulation employing 2 years of ED administrative data from a sample of two major and two large metropolitan hospitals in Queensland, Australia. The main outcome measures included waypoint wait times (Treatment Delay and Departure Delay), ED length of stay ( EDLOS) and compliance with the NEAT target, measured for all (overall NEAT) and admitted (Admitted NEAT) patients. Variations in outcome measures were analysed as functions of hour of day, day of week, departure status and triage category. Simulations identified the impact of potential ED workflow changes in the context of NEAT performance. Results Departure Delay accounted for 60 and 20% of EDLOS across large and major metropolitan hospitals, respectively. Higher gains in NEAT compliance are associated with improvements in departure delay rather than treatment delay. Simulation identified that halving Departure Delay improves Admitted NEAT by up to 22 and 4% at large and major metropolitan hospitals, respectively. Conclusions The results reinforces the need for a whole-of-hospital effort to address flow bottlenecks, and identify moving a patient from emergency to inpatient care as the critical bottleneck in ED system performance. [ABSTRACT FROM AUTHOR]

Objective The objective of this research is to identify optimal inpatient discharge time targets to help hospitals reduce crowding, improve patient flow through the ED and balance staff workload. Methods Fifteen months of emergency and inpatient records from a large quaternary teaching hospital were used to reconstruct patient pathways from hospital presentation to discharge. Discrete event simulation was used to assess operationally realistic discharge scenarios on flow performance. Main output measures included National Emergency Access Target (NEAT) performance (an ED performance metric), time spent waiting for a bed, hospital length of stay (LOS) and occupancy. Results Similar levels of improvement in NEAT performance (16%), and reductions in average bed occupancy (1.5%) and inpatient bed wait time (25%) were observed across the simulation that discharged 80% patients before 11 a.m. and one that spread the target between 10 a.m. and 2 p.m. Individual inpatient wards returned potential improvements in NEAT performance (median 10%, interquartile range (IQR) 7%), and reductions in hospital LOS (median 1%, IQR 1%) and average occupancy (median 1%, IQR 2%) across the discharge scenarios. Conclusions Conventional discharge targets like '80% by 11 a.m.' and others that spread targets across the day to balance staff workload freed up the equivalent of nine available beds for incoming patient flow, significantly reducing time spent waiting for an inpatient bed, hospital LOS and occupancy, and delivering much needed improvements in NEAT performance. While different strategies and workload distributions may suit individual hospital services, the study makes a strong case for improving 'early in the day' discharge timeliness to deliver better ED flow. [ABSTRACT FROM AUTHOR]

Objectives The study aims to investigate the effect of time of day and ED occupancy on the ability of EDs to admit or discharge patients within 4 h in accordance with the National Emergency Access Target (NEAT), and to compare this with corresponding levels of access block, the measure for ED performance before NEAT. Methods: This is a retrospective analysis of 5 years of ED data from 30 reporting public hospitals in Queensland, Australia. Relationships between these and variations in time of day and occupancy were explored using a Poisson generalised linear model. The main outcome measures are cases of NEAT non-compliance (ED length of stay >4 h for all patients [i.e. admitted and non-admitted] leaving the ED) and access block (ED length of stay >8 h for admitted patients). Results: NEAT performance is found to be dependent on hospital size, and levels vary significantly for admitted and non-admitted patients. A higher proportion of patients breach NEAT during early mornings and low occupancy periods, a trend not observed with the previous access block metric. NEAT non-compliance is also found to rise between 13.00 hours and 17.00 hours, a period when the proportion of access block cases typically drops. Conclusions: EDs face rising levels of NEAT non-compliance at times when corresponding access block levels have traditionally not been a concern. A higher proportion of patients breach the target during periods that would intuitively not be flagged as flow bottlenecks. The findings support the need for service level analysis and new solutions to guide workflow reform and maximise NEAT compliance. [ABSTRACT FROM AUTHOR]

Objectives To investigate the effect of hospital occupancy levels on inpatient and ED patient flow parameters, and to simulate the impact of shifting discharge timing on occupancy levels. Methods Retrospective analysis of hospital inpatient data and ED data from 23 reporting public hospitals in Queensland, Australia, across 30 months. Relationships between outcome measures were explored through the aggregation of the historic data into 21 912 hourly intervals. Main outcome measures included admission and discharge rates, occupancy levels, length of stay for admitted and emergency patients, and the occurrence of access block. The impact of shifting discharge timing on occupancy levels was quantified using observed and simulated data. Results The study identified three stages of system performance decline, or choke points, as hospital occupancy increased. These choke points were found to be dependent on hospital size, and reflect a system change from 'business-as-usual' to 'crisis'. Effecting early discharge of patients was also found to significantly ( P < 0.001) impact overcrowding levels and improve patient flow. Conclusions Modern hospital systems have the ability to operate efficiently above an often-prescribed 85% occupancy level, with optimal levels varying across hospitals of different size. Operating over these optimal levels leads to performance deterioration defined around occupancy choke points. Understanding these choke points and designing strategies around alleviating these flow bottlenecks would improve capacity management, reduce access block and improve patient outcomes. Effecting early discharge also helps alleviate overcrowding and related stress on the system. [ABSTRACT FROM AUTHOR]

Objective: We explored the relationship between the National Emergency Access Target (NEAT) compliance rate, defined as the proportion of patients admitted or discharged from emergency departments (EDs) within 4 hours of presentation, and the risk-adjusted in-hospital mortality of patients admitted to hospital acutely from EDs.Design, Setting and Participants: Retrospective observational study of all de-identified episodes of care involving patients who presented acutely to the EDs of 59 Australian hospitals between 1 July 2010 and 30 June 2014.Main Outcome Measure: The relationship between the risk-adjusted mortality of inpatients admitted acutely from EDs (the emergency hospital standardised mortality ratio [eHSMR]: the ratio of the numbers of observed to expected deaths) and NEAT compliance rates for all presenting patients (total NEAT) and admitted patients (admitted NEAT).Results: ED and inpatient data were aggregated for 12.5 million ED episodes of care and 11.6 million inpatient episodes of care. A highly significant (P < 0.001) linear, inverse relationship between eHSMR and each of total and admitted NEAT compliance rates was found; eHSMR declined to a nadir of 73 as total and admitted NEAT compliance rates rose to about 83% and 65% respectively. Sensitivity analyses found no confounding by the inclusion of palliative care and/or short-stay patients.Conclusion: As NEAT compliance rates increased, in-hospital mortality of emergency admissions declined, although this direct inverse relationship is lost once total and admitted NEAT compliance rates exceed certain levels. This inverse association between NEAT compliance rates and in-hospital mortality should be considered when formulating targets for access to emergency care. [ABSTRACT FROM AUTHOR]