Waiting times, patient flow, and occupancy density in South African primary health care clinics: implications for infection prevention and control

Background Transmission of respiratory pathogens, such as Mycobacterium tuberculosis and severe acute respiratory syndrome coronavirus 2, is more likely during close, prolonged contact and when sharing a poorly ventilated space. In clinics in KwaZulu-Natal (KZN) and Western Cape (WC) provinces, South Africa, we estimated clinic visit duration, time spent indoors and outdoors, and occupancy density of waiting rooms. Methods We used unique barcodes to track attendees' movements in 11 clinics in two provinces, multiple imputation to estimate missing arrival and departure times, and mixed-effects linear regression to examine associations with visit duration. Results 2,903 attendees were included. Median visit duration was 2 hours 36 minutes (interquartile range [IQR] 01:36–3:43). Longer mean visit times were associated with being female (13.5 minutes longer; p<0.001) and attending with a baby (18.8 minutes longer; p<0.01), and shorter mean times with later arrival (14.9 minutes shorter per hour after 0700; p<0.001) and attendance for tuberculosis or ante/postnatal care (24.8 and 32.6 minutes shorter, respectively, than HIV/acute care; p<0.01). Overall, attendees spent more of their time indoors (median 95.6% [IQR 46–100]) than outdoors (2.5% [IQR 0–35]). Attendees at clinics with outdoor waiting areas spent a greater proportion (median 13.7% [IQR 1–75]) of their time outdoors. In two clinics in KZN (no appointment system), occupancy densities of ~2.0 persons/m2 were observed in smaller waiting rooms during busy periods. In one clinic in WC (appointment system), occupancy density did not exceed 1.0 persons/m2 despite higher overall attendance. Conclusions Longer waiting times were associated with early arrival, being female, and attending with a young child. Attendees generally waited where they were asked to. Regular estimation of occupancy density (as patient flow proxy) may help staff assess for risk of infection transmission and guide intervention to reduce time spent in risky spaces.

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Principles of capacity management, applied in the mental health context

Australian Health Review ◽

10.1071/ah17007 ◽

2018 ◽

Vol 42 (4) ◽

pp. 438

Author(s):

Kathryn Zeitz ◽

Darryl Watson

Keyword(s):

Mental Health ◽

Mental Health Problems ◽

Average Length ◽

Patient Flow ◽

Waiting Times ◽

Capacity Management ◽

Mental Health Setting ◽

Mental Health Consumer ◽

Mental Health Consumers ◽

Flow Improvement

Objective The aim of the paper was to describe a suite of capacity management principles that have been applied in the mental health setting that resulted in a significant reduction in time spent in two emergency departments (ED) and improved throughput. Methods The project consisted of a multifocal change approach over three phases that included: (1) the implementation of a suite of fundamental capacity management activities led by the service and clinical director; (2) a targeted Winter Demand Plan supported by McKinsey and Co.; and (3) a sustainability of change phase. Descriptive statistics was used to analyse the performance data that was collected through-out the project. Results This capacity management project has resulted in sustained patient flow improvement. There was a reduction in the average length of stay (LOS) in the ED for consumers with mental health presentations to the ED. At the commencement of the project, in July 2014, the average LOS was 20.5 h compared with 8.5 h in December 2015 post the sustainability phase. In July 2014, the percentage of consumers staying longer than 24 h was 26% (n = 112); in November and December 2015, this had reduced to 6% and 7 5% respectively (less than one consumer per day). Conclusion Improving patient flow is multifactorial. Increased attendances in public EDs by people with mental health problems and the lengthening boarding in the ED affect the overall ED throughput. Key strategies to improve mental health consumer flow need to focus on engagement, leadership, embedding fundamentals, managing and target setting. What is known about the topic? Improving patient flow in the acute sector is an emerging topic in the health literature in response to increasing pressures of access block in EDs. What does this paper add? This paper describes the application of a suite of patient flow improvement principles that were applied in the mental health setting that significantly reduced the waiting time for consumers in two EDs. What are the implications for practitioners? No single improvement will reduce access block in the ED for mental health consumers. Reductions in waiting times require a concerted, multifocal approach across all components of the acute mental health journey.

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Risk Factors for Occupational Transmission of Tuberculosis among Healthcare Workers in Zambia

International Journal of TROPICAL DISEASE & Health ◽

10.9734/ijtdh/2020/v41i1130335 ◽

2020 ◽

pp. 59-65

Author(s):

Namaunga Kasumu Chisompola ◽

Kapambwe Mwape Kamanga ◽

Pipina Vlahakis Matafwali

Keyword(s):

Diabetes Mellitus ◽

Risk Factors ◽

Healthcare Workers ◽

Critical Role ◽

Nosocomial Transmission ◽

Infection Prevention And Control ◽

Original Research ◽

Healthcare Facilities ◽

Prolonged Contact ◽

And Control

Healthcare workers (HCWs) play a critical role in the management and control of nosocomial transmission of tuberculosis (TB). At the same time, working in TB healthcare facilities such as hospital wards, diagnostic and treatment facilities increases the risk of acquiring TB due to occupational exposure in HCWs. The risk is further heightened in high TB prevalence populations, such as Zambia, as HCWs are exposed both occupationally and in the community. This review aims to provide a better understanding of the risk factors associated with occupational transmission of TB in HCWs in Zambia, by synthesising available data on TB in HCWs in Zambia and the surrounding region. A search of peer reviewed original research on the transmission of TB among HCWs in Zambia was conducted in PubMed and Google Scholar. Studies were eligible for inclusion in the analysis if they described TB amongst HCWs in Zambia, risk factors for TB in HCWs, and nosocomial transmission of TB in Zambia and the surrounding region. The prevalence of TB in HCWs has been demonstrated to be higher than that of the general population. Transmission of TB in healthcare facilities is driven by several factors centred on the lack of adherence to TB infection prevention and control (IPC) practices. Nosocomial transmission of TB in HCWs is further driven by the HIV epidemic and the rise in lifestyle diseases such as diabetes mellitus. However, there is very scarce data on the association of diabetes mellitus and TB among HCWs in Zambia. Prolonged contact with TB patients on wards has been demonstrated to play a vital role in occupational transmission of TB amongst nurses in Zambia. To curb the transmission of TB in HCWs several measures will require implementation such as; administrative support, IPC training and annual TB and HIV screening for all HCWs.

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Robust capacity planning for accident and emergency services

RAIRO - Operations Research ◽

10.1051/ro/2019112 ◽

2020 ◽

Vol 54 (6) ◽

pp. 1757-1773

Author(s):

Elvan Gökalp

Keyword(s):

Capacity Planning ◽

Emergency Services ◽

Simulation Optimization ◽

Patient Flow ◽

Waiting Times ◽

Model Parameters ◽

Planning Problem ◽

Accident And Emergency ◽

Number Of Patients ◽

The Impact

Accident and emergency departments (A&E) are the first place of contact for urgent and complex patients. These departments are subject to uncertainties due to the unplanned patient arrivals. After arrival to an A&E, patients are categorized by a triage nurse based on the urgency. The performance of an A&E is measured based on the number of patients waiting for more than a certain time to be treated. Due to the uncertainties affecting the patient flow, finding the optimum staff capacities while ensuring the performance targets is a complex problem. This paper proposes a robust-optimization based approximation for the patient waiting times in an A&E. We also develop a simulation optimization heuristic to solve this capacity planning problem. The performance of the approximation approach is then compared with that of the simulation optimization heuristic. Finally, the impact of model parameters on the performances of two approaches is investigated. The experiments show that the proposed approximation results in good enough solutions.

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Enhancing patient flow in emergency department (ED) using lean strategies–an integrated voice of customer and voice of process perspective

Business Process Management Journal ◽

10.1108/bpmj-11-2019-0457 ◽

2020 ◽

Vol ahead-of-print (ahead-of-print) ◽

Author(s):

Ali Alowad ◽

Premaratne Samaranayake ◽

Kazi Ahsan ◽

Hisham Alidrisi ◽

Azharul Karim

Keyword(s):

Waiting Time ◽

Emergency Services ◽

Single Case ◽

Patient Flow ◽

Waiting Times ◽

Small Sample ◽

Content Type ◽

Lean Tools ◽

And Performance ◽

Voice Of Customer

PurposeThe purpose of this paper is to systematically investigate the patient flow and waiting time problems in hospital emergency departments (EDs) from an integrated voice of customer (VOC) and voice of process (VOP) perspective and to propose a new lean framework for ED process.Design/methodology/approachA survey was conducted to better understand patients' perceptions of ED services, lean tools such as process mapping and A3 problem-solving sheets were used to identify hidden process wastes and root-cause analysis was performed to determine the reasons of long waiting time in ED.FindingsThe results indicate that long waiting times in ED are major concerns for patients and affect the quality of ED services. It was revealed that limited bed capacity, unavailability of necessary staff, layout of ED, lack of understanding among patients about the nature of emergency services are main causes of delay. Addressing these issues using lean tools, integrated with the VOC and VOP perspectives can lead to improved patient flow, higher patient satisfaction and improvement in ED capacity. A future value stream map is proposed to streamline the ED activities and minimize waiting times.Research limitations/implicationsThe research involves a relatively small sample from a single case study. The proposed approach will enable the ED administrators to avoid the ED overcrowding and streamline the entire ED process.Originality/valueThis research identified ED quality issues from the integration of VOC and VOP perspective and suggested appropriate lean tools to overcome these problems. This process improvement approach will enable the ED administrators to improve productivity and performance of hospitals.

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Waiting times in emergency departments: exploring the factors associated with longer patient waits for emergency care in England using routinely collected daily data

Emergency Medicine Journal ◽

10.1136/emermed-2019-208849 ◽

2020 ◽

pp. emermed-2019-208849

Author(s):

Steven Paling ◽

Jennifer Lambert ◽

Jasper Clouting ◽

Júlia González-Esquerré ◽

Toby Auterson

Keyword(s):

Emergency Departments ◽

Fixed Effects ◽

Patient Flow ◽

Waiting Times ◽

Healthcare Providers ◽

Ordinary Least Squares ◽

Hospital Length Of Stay ◽

Bed Occupancy ◽

Point Change ◽

Factors Associated

BackgroundLong lengths of stay (also called waiting times) in emergency departments (EDs) are associated with higher patient mortality and worse outcomes.ObjectiveTo add to the literature using high-frequency data from a large number of hospitals to analyse factors associated with long waiting times, including exploring non-linearities for 'tipping points'.MethodsMultivariate ordinary least squares regressions with fixed effects were used to analyse factors associated with the proportion of patients in EDs in England waiting more than 4 hours to be seen, treated and admitted or discharged. Daily situation reports (Sitrep), hospital episode statistics and electronic staffing records data over 90 days between December 2016 and February 2017 were used for all 138 English NHS healthcare providers with a major ED.ResultsHigher inpatient bed occupancy was correlated with longer ED waiting times, with a non-linear association. In a full hospital, with 100% bed occupancy, the proportion of patients who remained in the ED for more than 4 hours was 9 percentage points higher (95% CI 7.5% to 11.1%) than with an 85% occupancy level. For each percentage point change in the following factors, the proportion of ED stays over 4 hours also increased: more inpatients with hospital length of stay over 21 days (0.07%, 95% CI 0.008% to 0.13%); higher emergency admissions (0.08%, 95% CI 0.06% to 0.10%); and lower discharges relative to admissions on the same day (0.04%, 95% CI 0.02% to 0.06%), the following day (0.05%, 95% CI 0.03% to 0.06%) and at 2 days (0.05%, 95% CI 0.04% to 0.07%).ConclusionsThese results suggest that tackling patient flow and capacity in the wider hospital, particularly very high bed occupancy levels and patient discharge, is important to reduce ED waiting times and improve patient outcomes.

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(A181) Process Improvement in Disaster Relief: Implementation of a Fast Track in a Haitian Tent Hospital

Prehospital and Disaster Medicine ◽

10.1017/s1049023x11001774 ◽

2011 ◽

Vol 26 (S1) ◽

pp. s51-s51 ◽

Cited By ~ 1

Author(s):

C. Bloem ◽

R. Gore ◽

B. Arquilla ◽

T. Naik ◽

J. Schechter

Keyword(s):

Fast Track ◽

Disaster Relief ◽

Medical Center ◽

Patient Flow ◽

Waiting Times ◽

Time Of Arrival ◽

Study Objective ◽

Use Of Resources ◽

Number Of Patients ◽

Track Area

Study ObjectiveTo determine if instituting an Emergency Department (ED) fast-track area would increase efficiency in patient flow, improve utilization of limited resources, and identify critical versus non-critical patients during disaster relief in Port au Prince, Haiti.MethodsA survey was conducted at L'Hôpital de l'Université d'Etat d'Haïti (HUEH) in Port au Prince, Haiti by Emergency physicians and nurses from SUNY Downstate Medical Center on a disaster relief mission following the 2010 earthquake. The following variables were obtained to assess ED effectiveness: number of patients, acuity level, chief complaints, critical interventions, waiting times, length of stay, specialty service coverage and physical plant space. Additionally, existing practitioners were surveyed regarding existing ED practices. ED operation flow maps were created.ResultsThe assessment revealed a large volume of low-acuity patients mixed with high-acuity patients without identification of acuity level, time of arrival, or designated area for treatment. Although literature reports routine use of START triage, this was not being implemented in this setting. Results of implementing a fast track area included: (1) Improved identification of patients needing immediate treatment. (2) Increased flow of low acuity patients in designated fast track areas. (3) Improved triage protocols maximized appropriate use of resources, and expedited subspecialty consultation.ConclusionBy instituting well-accepted, validated patient flow systems and reinforcing communication regarding resources available and the use of geographic space, better management of incoming emergency patients was achieved.

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Development of a physiotherapy-led balance clinic: the Aintree model

The Journal of Laryngology & Otology ◽

10.1017/s0022215114002060 ◽

2014 ◽

Vol 128 (11) ◽

pp. 966-971 ◽

Cited By ~ 11

Author(s):

A V Kasbekar ◽

N Mullin ◽

C Morrow ◽

A M Youssef ◽

T Kay ◽

...

Keyword(s):

Patient Satisfaction ◽

Benign Paroxysmal Positional Vertigo ◽

Waiting Times ◽

Clinic Visit ◽

Positional Vertigo ◽

One Stop ◽

Set Up ◽

High Level ◽

Referral Letters ◽

Paroxysmal Positional Vertigo

AbstractObjective:To create a ‘one-stop’ clinic in which assessment, diagnosis, treatment and therapies for most patients presenting with balance and dizziness disorders are delivered simultaneously.Methods:Patients triaged via referral letters were selected to attend the balance clinic, which is led by specialist balance physiotherapists. Patients were seen by an audiologist, and a ‘balance’ ENT consultant was available for joint consultations when required. Further details of the clinic set up are discussed.Results:Over an 18-month period, 200 new ‘dizzy’ patients attended the clinic. Benign paroxysmal positional vertigo and labyrinthitis were the commonest diagnoses. Fifty per cent of all patients were discharged after a single clinic visit. Questionnaires showed that patient satisfaction was high.Conclusion:The physiotherapy-led balance clinic has reduced patient waiting times to be seen, has a high level of patient satisfaction and is economically beneficial.

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POCT in Emergency Rooms: One Key Factor for Process Streamlining with Lean Management

Conference Papers in Medicine ◽

10.1155/2013/143985 ◽

2013 ◽

Vol 2013 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Verena Lindenau-Stockfisch ◽

Julia Searle ◽

Martin Möckel

Keyword(s):

Negative Impact ◽

Patient Flow ◽

Waiting Times ◽

Care Hospital ◽

Lean Management ◽

Emergency Rooms ◽

Flow Process ◽

Value Stream ◽

Current State ◽

Key Factor

Overcrowding is a common problem in Emergency Departments (ED) worldwide and has a negative impact on patient satisfaction and, more importantly, patient safety. So, the Emergency Department of the secondary-care hospital Paul Gerhardt Stift in Wittenberg, Germany, was faced with increasing numbers of patients. Lean management was introduced to analyse, optimise, and standardise ED processes. Consequently, a project group concentrated on “cycling muda” which is to identify waste and cost drivers along a representative patient path using one suitable Lean tool: mapping the current state in a value stream. As a result, it became clear that both patients and staff suffered from immense waiting times that lead to risky patient care and employee frustration. By subsequently eliminating the waste drivers and designing a high-quality patient flow process creating standards supported by state-of-the-art technology, the hospital’s ED turned into a streamlined department with reduced waiting times offering employees a satisfactory and modern workplace where patients benefit from first-class care.

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Perspectives on waiting times in an antenatal clinic: A case study in the Western Cape

Health SA Gesondheid ◽

10.4102/hsag.v26i0.1513 ◽

2021 ◽

Vol 26 ◽

Author(s):

Justine C. Baron ◽

Doreen Kaura

Keyword(s):

Qualitative Methodology ◽

Single Case ◽

Waiting Times ◽

Skilled Birth Attendant ◽

Neonatal Morbidity ◽

Research Participant ◽

Antenatal Clinic ◽

Western Cape ◽

Structured Interviews

Background: Antenatal care (ANC) is vital in reducing maternal and neonatal morbidity and mortality. Globally, 85% of women had one ANC visit with a skilled birth attendant and only 58% received the recommended four ANC visits. Long waiting times (LWTs) in the antenatal clinic affects the utilisation of the service. Long waiting times are viewed as a significant barrier to ANC utilisation and needs further investigation.Aim: The aim of this study was to explore and describe the contextual realities within the antenatal clinic that influenced waiting times (WTs).Setting: This study was conducted in an antenatal clinic, within a Midwife Obstetric Unit (MOU), Western Cape, South Africa.Methods: This study utilised a qualitative methodology with a single case study design with three embedded units of analysis. Purposive sampling was used to recruit the participants. Data were collected through unstructured observation and semi-structured interviews with pregnant women and midwives. Interviews were audio recorded, transcribed and analysed using the framework method.Results: The antenatal clinics had LWTs. The barriers to WTs were related to staff factors, patient factors, operational factors, communication, equipment and infrastructure and other research participant recruitment.Conclusion: The factors that influenced WTs are multifaceted and interrelated. Many of the factors influencing the WTs could be remedied by implementing appropriate workflow strategies, improving communication and increasing equipment availability. The findings can be used to develop waiting time guidelines and improve WTs in the antenatal clinic.

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Discharge against medical advice and premature leave of neurological patients from an interdisciplinary emergency department: a retrospective observational study.

10.21203/rs.2.9965/v1 ◽

2019 ◽

Author(s):

Carolin Hoyer ◽

Patrick Stein ◽

Angelika Alonso ◽

Michael Platten ◽

Kristina Szabo

Keyword(s):

Emergency Department ◽

Observational Study ◽

Patient Flow ◽

Waiting Times ◽

Medical Advice ◽

Retrospective Observational Study ◽

Against Medical Advice ◽

Presenting Symptoms ◽

Neurological Patients ◽

Discharge Against Medical Advice

Abstract Background: Discharge against medical advice (DAMA) or premature leave (PL) from the emergency department represent relevant medical problems with impact on patient safety and potential medicolegal consequences. They may also indicate structural or procedural problems in the ED. To date, no dedicated analysis of DAMA/PL exists for neurological patients presenting to the ED. Methods: A retrospective observational study was performed of all patients with neurological complaints presenting to a German interdisciplinary emergency department between January and December 2017. DAMA/PL patients were compared to the total of patients who were admitted or discharged regularly (non-DAMA/PL). Results: Of all neurological cases, 3% left against medical advice and 2.2% left prematurely. DAMA/PL patients were younger (p<.001), and their presentation was more frequently self-motivated (p<0.001. Waiting times did not differ between DAMA/PL and non-DAMA/PL patients (p=.166) but treatment duration was significantly shorter in the former (p<.001) Headaches, seizures and sensory deficits were the most frequent presenting symptoms in DAMA/PL patients, and in 56.1% of those presenting with a seizure had a history of epilepsy. The most common documented reason for leaving was the length of waiting time. Conclusions: Both individual and structural/systemic reasons contribute to DAMA/PL in neurological patients. Optimization of pre-hospital assessment and the development of alternative models of care for patients with non-urgent conditions appear to be promising targets for future improvements regarding demand management and the direction of patient flow.

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