Service time, waiting time, good practices and areas for improvement in the UP Health Service during the 2020 COVID-19 pandemic: A five-day cross-sectional study

Background@#The COVID-19 pandemic has emphasized the critical task of the UP Health Service in recognizing and addressing the primary care needs of health care workers and support staff of the Philippine General Hospital. This helps in effective staff management and engendering trust in the hospital that performs critical functions in the pandemic response.@*Objectives@#To determine the service and waiting time in the facilities of the UPHS and describe good practices and areas for improvement for better service delivery at the UPHS during the COVID-19 pandemic@*Methods@#A cross-sectional study using patient flow analysis of processes in the non-COVID, COVID, and swabbing areas of the UPHS was conducted from June 1 to 5, 2020. All clinic visits by PGH employees and health care workers, including consultations and procedure for swabbing, were included in the study. Average service and waiting time in three areas of the UPHS were measured and analyzed from recorded time points using Microsoft Excel. Daily observations recorded on field notes were transcribed and analyzed using MaxQDA Analytics Pro 2020.@*Results@#A total of 604 PGH employee visits in the three main service areas of the UPHS were recorded during the 5-day study period. The average total service time was 25 (SD±17) minutes in the non-COVID clinic and 12 (SD±5) minutes in the COVID clinic. The mean swabbing time was 2 (SD±3) minutes. The average waiting time was longest in the COVID clinic at 46 (SD±39) minutes, followed by the swabbing area at 33 (SD± 32) minutes, and was shortest in the non-COVID clinic at 10 (SD±17) minutes. Good practices were observed in the areas of communication and coordination among the UPHS team, staff complementation, and application of telehealth solutions. Meanwhile, improvements may be made in identifying a practical and robust queuing system, enforcing firmer infection prevention and control measures and providing clearer patient instructions and cues especially during patient surge.@*Conclusion@#The average service time in the non-COVID, COVID and swabbing areas of the UPHS, were 25, 12 and 2 minutes, respectively. The average waiting time was longest in the COVID clinic, followed by the swabbing and non-COVID areas. Good practices were observed in terms of leadership, communication, staff complementation and feedback process while infection control and prevention measures, queuing system for crowd control and patient instructions can be further improved.

Factors associated with length of stay in the Emergency Department: A narrative review

@#BACKGROUND: Increasing demand and complex procedures may associate with the length of stay (LOS) in the Emergency Department (ED). Prolonged LOS may decrease the quality of ED care and increase patient harm. Therefore, it is pivotal to analyze factors that may contribute to ED LOS. OBJECTIVE: This review aimed to identify and discuss factors that contribute to the Emergency Department length of stay (ED LOS) to improve the quality of care. METHODS: Relevant healthcare databases including PubMed and CINAHL were searched using the combinations of search terms: length of stay, length of visit, emergency department, emergency room, and patient flow. Inclusion criteria included publications between 2007-2017. RESULTS: A total of 24 relevant papers was selected. The literature indicates that three main factors are associated with ED LOS: input (older patients and acuity level), throughput (diagnostic tests and or radiology, specialist consultation), and output (need for admission and boarding time). CONCLUSION: Input, throughput, and output factors are contributed to ED LOS. Further review is necessary to determine organizational factors that may contribute ED LOS including the number of health staff, staff workload, flow studies, and health system.

A implantação do Núcleo Interno de Regulação em Hospital Público Terciário ­ A experiência do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo / Implementation of the Internal Regulation Committee in a Tertiary Public Hospital ­ The experience of General Hospital of Ribeirão Preto Medical School of the University of São Paulo

RESUMO Introdução: O Núcleo Interno de Regulação (NIR) é uma das estratégias de gestão criadas pela Política Nacional de Atenção Hospitalar do Ministério da Saúde em 2013. Visa a organização do acesso à consultas, serviços diagnósticos e terapêuticos e aos leitos de internação, sendo fundamental o conhecimento do perfil epidemiológico e ajuste de seus processos de trabalho de modo a garantir o fluxo no sistema de saúde. Como as normas para implantação só foram realizadas em 2018, vários serviços implantaram o NIR sem diretrizes e há necessidade de se avaliar o grau de implantação. Objetivo: Avaliar o nível de implantação do NIR em duas unidades de um complexo hospitalar público terciário. Metodologia: Estudo de avaliação, exploratório, descritivo e longitudinal, realizado em duas unidades de internação hospitalar público terciário implantadas no primeiro semestre de 2016 (Unidade de Emergência) e no primeiro semestre de 2017 (Unidade Campus). Resultados: Devido à natureza de sua vocação (eletivo ou urgência), observou-se perfil epidemiológico distinto nas unidades, embora tenha sido possível a construção de processo e análise de SWOT integrada para efeitos de tomada de decisão e planejamento. De acordo com os pilares propostos pelo Manual, ambas em maior ou menor grau apresentam iniciativas recomendadas. Mas, por outro lado, os entrevistados reforçam a necessidade de maior investimento para aprimorar o processo. Conclusão: É necessário o estabelecimento de uma política de implantação dos NIR's com referenciais objetivos que possam ser pontuados e permitam o acompanhamento temporal do seu desenvolvimento. (AU)

ABSTRACT Introduction: The Internal Regulation Committee (IRC) is one of the management strategies created by the National Health Care Policy of the Ministry of Health in 2013. It aims to organize the access to consultations, diagnostic and therapeutic services and to hospital beds. It is necessary to know the epidemiological profile to adjust its processes to guarantee the flow in the healthcare system. As the standards for implementation were only established in 2018, several services implemented the ICR without guidelines, and there is a need to evaluate the degree of implementation. Objective: To evaluate the level of NIR implantation in two units of a public tertiary hospital complex. Methodology: Exploratory, descriptive and longitudinal study, carried out in two tertiary public hospitalization units implanted in the first half of 2016 (Emergency Unit) and the first half of 2017 (Campus Unit). Results:Due to the nature of their vocation (elective or emergency), a distinct epidemiological profile was observed, although it was possible to construct an integrated SWOT process and analysis for decision--making and planning purposes. According to the principles proposed by the Manual, both presented recommended initiatives to a greater or lesser degree. However, on the other hand, the units inter-viewed reinforce the need for more investment to improve the process. Conclusion: It is necessary to establish a policy for the implementation of NIRs with objective checklists that can be set and allow the temporal monitoring of their development (AU)

Analysis of the impact of county medical alliance on patient flows under the NRCMS: A case study of Dingyuan county of Anhui Province / 中国卫生政策研究

Objective:This study is conducted to analyze the impact of county medical alliance on patient flows under the NRCMS in Dingyuan county of Anhui province. Methods: data on patient-flow were collected through the NRCMS information platform and related policy documents for 2015-2016, and interviews were conducted to study the main reform practices in the county medical alliance. Results: The patient flow under the NRCMS varied in the way of 1) the total number of inpatients seeking treatment outside of the county decreased by 3.31%;2) the treat-ment volume of county-level hospitals and township health centers were increasing,and the latter one is growing faster than the former,meanwhile,the treatment volume of the village clinics declined,and 3) the hospitalization expenses per inpatient for patients who seek treatment outside the county are much higher than the expenses incurred within the county. Conclusions:the development of county-level medical alliance has influence on patients with common disea-ses who used to seek treatment by helping to reduce the number of inpatients outside the county and reduce the pres-sure of the new rural cooperative fund. However, significant problems still exist such as shortage of talented practi-tioners,and lagging development of information technology system.

An agent-based simulation combined with group decision-making technique for improving the performance of an emergency department

This study presents an agent-based simulation modeling in an emergency department. In a traditional approach, a supervisor (or a manager) allocates the resources (receptionist, nurses, doctors, etc.) to different sections based on personal experience or by using decision-support tools. In this study, each staff agent took part in the process of allocating resources based on their observation in their respective sections, which gave the system the advantage of utilizing all the available human resources during the workday by being allocated to a different section. In this simulation, unlike previous studies, all staff agents took part in the decision-making process to re-allocate the resources in the emergency department. The simulation modeled the behavior of patients, receptionists, triage nurses, emergency room nurses and doctors. Patients were able to decide whether to stay in the system or leave the department at any stage of treatment. In order to evaluate the performance of this approach, 6 different scenarios were introduced. In each scenario, various key performance indicators were investigated before and after applying the group decision-making. The outputs of each simulation were number of deaths, number of patients who leave the emergency department without being attended, length of stay, waiting time and total number of discharged patients from the emergency department. Applying the self-organizing approach in the simulation showed an average of 12.7 and 14.4% decrease in total waiting time and number of patients who left without being seen, respectively. The results showed an average increase of 11.5% in total number of discharged patients from emergency department.

Improving emergency department patient flow

Emergency departments (ED) face significant challenges in delivering high quality and timely patient care on an ever-present background of increasing patient numbers and limited hospital resources. A mismatch between patient demand and the ED’s capacity to deliver care often leads to poor patient flow and departmental crowding. These are associated with reduction in the quality of the care delivered and poor patient outcomes. A literature review was performed to identify evidence-based strategies to reduce the amount of time patients spend in the ED in order to improve patient flow and reduce crowding in the ED. The use of doctor triage, rapid assessment, streaming and the co-location of a primary care clinician in the ED have all been shown to improve patient flow. In addition, when used effectively point of care testing has been shown to reduce patient time in the ED. Patient flow and departmental crowding can be improved by implementing new patterns of working and introducing new technologies such as point of care testing in the ED.

Impacts of health care alliance on the visiting rate of NRCMS patients within the county:Case study of Huangzhong county, Qinhai province / 中国卫生政策研究

Objective:After examining the changes in medical expenses and flows of hospitalized patients with-in and outside the county under the New Rural Cooperative Medical Scheme ( NRCMS ) before and after the imple-mentation of health care alliance reform, this paper analyzes the impacts of health care alliance reform on the visiting rate of NRCMS patients within the county and explores their causes and channels. Methods:This paper uses the hos-pitalization data of NRCMS patients in 2013 and 2014 collected from Huangzhong county Qinghai province and inter-views with key informants and analyzes the hospitalization expenses, visiting flows and other indicators of patients. Results:After starting health care alliance reform, the total number of hospitalized patients to seek treatment outside the county decreased by 6 . 38%, the total hospitalization expenses to seek treatment outside the county decreased by 22 . 13%, and the hospitalization expenses per inpatient day to seek treatment within and outside the county increased by 14. 41% and 20. 69% respectively. Conclusions: By improving service capabilities of township health centers and increasing synergies between county-township-village health institutions, the county health care alliance reform has suc-cessfully enhanced the service capabilities of health care systems in the whole county and reasonably helped patients with common diseases to be hospitalized outside the county and frequently hospitalized people to return back to the county.

Duración de la estancia hospitalaria. Metodologías para su intervención / Length of the Hospitalization. Methodologies for Intervention / Duraqáo da estancia hospitalar. Metodologias para sua intervengo

La estancia hospitalaria prolongada constituye una preocupación mundial, ya que genera efectos negativos en el sistema de salud como, por ejemplo: aumento en los costos, deficiente accesibilidad a los servicios de hospitalización, saturación de las urgencias y riesgos de eventos adversos. El presente trabajo presenta una investigación que enumera las causas más comunes encontradas en la prolongación de la estancia y las metodologías de logística hospitalaria más aplicadas para su estudio y mejoramiento. Resultados: los factores causales de estancias prolongadas más encontrados en la literatura son: demora en la realización de procedimientos quirúrgicos y diagnósticos, necesidad de atención en otro nivel de complejidad, situación sociofamiliar y edad del paciente. Se concluye que para analizar el problema de la estancia hospitalaria es conveniente realizar un "ajuste por riesgo", utilizando el método de grupo relacionado de diagnóstico (GRD) y que una metodología adecuada es la simulación, para la identificación de cuellos de botella.

Prolonged hospitalization constitutes a grave concern worldwide because it generates negative effects on the health system such as, for example: increase in costs, deficient accessibility to hospitalization services, overload of emergency services, and the risk of adverse effects. This work presents a research that lists the most common causes found in the extension of the hospitalizations and the most applied hospital logistic methodologies for its study and improvement. Results: The causal agents of extended hospitalizations found with higher frequency in literature are: delay in the performance of surgical and diagnostic procedures; need for attention in another complexity level; social-family situation, and the age of the patient. We conclude that to analyze the problem of hospitalizations it is convenient to perform an "adjustment for risk", using the method of the related diagnosis group (GRD), and simulations are an appropriate methodology to identify bottlenecks.

A estancia hospitalar prolongada constitui uma preocupacao mundial pois gera efeitos negativos no sistema de saúde como, por exemplo: aumento nos custos, deficiente acessibilidade aos servicos de hospitalizacao, saturacao das urgencias e risco de eventos adversos. O presente trabalho apresenta pesquisa que enumera as causas mais comuns encontradas na prolongacao da estancia e as metodologias de logística hospitalar mais aplicadas para o seu estudo e melhoramento. Resultados: os fatores causais de estancias prolongadas mais encontrados na literatura sao: demora na realizacao de procedimentos cirúrgicos e diagnósticos, necessidade de atendimento em outros níveis de complexidade, situacao sociofamiliar e idade do paciente. Conclui-se que para analisar o problema da estancia hospitalar é conveniente realizar um "ajuste por risco", utilizando o método de grupos de diagnósticos relacionados (drg) e que uma metodologia adequada é a simulacao, para a identificacao de engarrafamentos.

Research on patient flow tendency and guidance methods for elderly patients in Shanghai / 中华医院管理杂志

Objective To analyze the flow tendency of elderly patients,create a better mechanism to help guide elderly patients to form a good order in seeking medical care,and consequently improve the resource operational efficiency in medical service.Methods Analyzing the data by the descriptive,χ2 test and logistic regression of SPSS 20.0.Results Elderly patients prefer community health service centers and tertiary hospitals;of those visiting tertiary hospitals,nearly 30% seek medical advice for common chronic diseases.Main influencing factors for patient flow are medical insurance coverage and education. They tend not to embrace the two-way referral service,due to such factors of inconvenient process and defective mechanisms.Conclusion Transition from medical demand management to medical supply management.Such factors as quality cost,expense cost,time cost,and public opinion cost should be used to replace and weaken their mindset of the medical hierarchy,and embrace the concept of “seeking medical advice by grades”,thus improving the utilization of medical resources,and optimizing medical service accesibility.

A survey on massive number of patients overcrowded in the emergency department of tertiary hospital in a pattern of diurnal rhythm and holiday phenomenon / 中华急诊医学杂志

Objective To study the variation in numbers of patients attended in the Emergency Department (ER) of a large - scale teaching hospital during weekends or holidays and workdays in order to find out an objective criterion for the assessment of ER overcrowding and the regularity of ER overcrowding.Methods It was a prospective observational study of variation in number of.patient attended in ER during different periods of time round the clock observed from May 1 through October 31 in 2008 -2010 with 110000 emergency patients annually.The roles of diurnal rhythm,holiday phenomenon and medical coverage in the variation in numbers of patients were observed.The multiple logistic regression analysis was used to define the criterion of ED overcrowding.Results During workdays,the regularity of variation in number of critically ill patients seen to in ER was distinctive,the number of patients peaked in the period of 20:00 -22:00 and bottomed out in the period of 4:00 -6:00,while overcrowding scores of both peak and bottom were carried out 2 hours later.The number of emergency patients significantly increased at weekends and long holidays in a form of double peaks,from 10 am to 12 pm and 8 pm to 10 pm.The number of emergency patients was obviously determined by the provisions of medical coverage,but it was only true to non - critical patients,while the number of critical patients did not noticeably change during weekends or holydays.Multivariate regression analysis showed that the number of emergency patient attended in ER ( B =0.027,P ＜0.01 ) and the rate of emergency bed occupancy ( B =5.25,P ＜0.01 ) in the period of two hours significantly correlated with the ER overcrowding in the coming period of two hours (B =0.027,P ＜0.01,B =5.25,P ＜ 0.01,respectively).Conclusions The demand for critical care resources varies up and down all the time.The variation in volume of critical patients is quite regular during workdays and weekdays or holydays.It is important to separate critical patients from non - critical patients in order to divert non - critical patients quickly.Prediction of overcrowding in ER can be made with knowledge of the number of patient attended and the rate of bed occupancy,if the provisions of medical coverage unchanged.This regularity of variation in number of patients can be used as a practical guidance to rational allocation of critical care resources and improvement of patient throughput.

Layout Planning Model for Medical Service Rooms / 대한의료정보학회지

The layout problem involves finding the best arrangement of physical components of the service system possible within the time, cost, and technology constraints of the situation. And the layout problem can be a very complex system design problem requiring the most sophisticated lay system analysis and design tools in order to develope satisfactory layout solutions. The objective of this layout study is to reorganize service rooms for minimizing overall patient's moving distance. In solving the service room layout problem, there exist a number of constraints on the building facilities in current location. All other service rooms can be moved if layout analysis indicates it would be beneficial. The first step is to analyze records in order to determine the number of trips made by patients between departments in two months. And a number of layout cases developed as methods to a good service room layout. The result is shortened total patient's layout distance of 252,880 meters.

Discussion on rehearsal of field medical unit in NBC environment / 医疗卫生装备

Objective To discuss the treatment mode of mass NBC casualties by field medical unit in NBC environment.Method Field medical unit rehearsed in a simulated NBC environment.Result The procedure for the rehearsal and treatment of field medical unit in NBC environment was determined.The importance of high-tech medical equipment for the obstructed patient flow was made clear.Conclusion High-tech medical equipment should be emphasized on to enhance the treatment capability of field medical unit.