Resilient healthcare theory as a lens to research emergency department operations: a protocol for a scoping review

IntroductionEmergency departments (EDs) are complex systems that have constant fluctuations in demand, creating mismatches with planned capacity. Despite the complexity of ED operations, quality and safety improvement are often approached in a reactive, linear and reductionist manner. There is increasing interest in adopting Resilient Healthcare (RHC) techniques based on complex systems thinking as a method for quality improvement and research in EDs. However, the evidence for this approach is still developing and it is not clear what techniques have been used so far and which are most effective. This scoping review will be conducted between March 2022 until May 2022. It seeks to examine the international literature for available reports that have adopted RHC theory to study ED operations and identify approaches used and proposed benefits.Methods and analysisThe methodology for scoping reviews outlined by Arksey and O’Malley (2005) will be followed, acknowledging refinements made to the scoping review process by Levac et al (2010). The methodology consists of five steps: (1) identifying the research question; (2) identifying the relevant literature; (3) study selection; (4) charting the data; and (5) collating, summarising and reporting the results. A two-stage approach will be undertaken to synthesise and report results: (1) numerical analysis of the nature and distribution of studies (the overall number of studies, country of origin, the most studied core function of ED, type of research design); and (2) a thematic mapping of the literature.Ethics and disseminationScoping review methodology synthesises published data and, therefore, does not require ethical approval. An article formatted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses forScoping Reviews reporting guidance will be submitted for publication to a scientific journal. Findings will also be presented at relevant advanced practice conferences and disseminated within clinical and academic groups.

Changes in Emergency Department Performance during Strike of Junior Physicians in Korea

Objective. A nationwide strike that took place from August 21 to September 7, 2020, which was led by young doctors represented by residents and interns, resulted in shortages of manpower at almost all university and training hospitals. This study aimed to identify differences in the process and outcomes of emergency department (ED) patient care by comparing the performance over about 2 weeks of the strike with that during the usual ED operations. Methods. This retrospective observational study evaluated ED flow and performance during the junior doctors’ strike and compared it with the usual period in a single tertiary-care academic hospital. The outcome variables were defined as ED length of stay, crude mortality, and hospital mortality and adjusted for demographic and clinical parameters. The effect of the doctors’ strike on hospital mortality adjusted for demographic and clinical variables was investigated using logistic regression. Results. A total of 1,121 and 1,496 patients visited the ED during the strike and control periods (both 17 days), respectively. The care usually provided by four or six physicians, including one specialist, was replaced with that by one or two specialists at any one time. During the trainee doctors’ strike, EM specialists managed patients with fewer consultations. However, the proportion of patients who underwent laboratory and radiologic tests did not change significantly. The median ED length of stay significantly decreased from 359 minutes (interquartile range, IQR: 147–391) in the control period to 326 minutes (IQR: 123–318) during the strike period P < 0.001 . The doctors’ strike was not found to have a significant effect on mortality after adjustments with other variables. Conclusion. During the junior doctors’ strike in 2020 in Korea, EM specialists efficiently managed the care of emergency patients with higher levels of acuity without compromising the survival rate, through fewer consultations and faster disposition.

Increasing consultant-level staffing as a proportion of overall physician coverage improves emergency department length of stay targets

Objectives One goal of Emergency Department (ED) operations is achieving an overall length of stay (LOS) that is less than four hours. The goal of the current study was to assess for association between increasing number of on-duty EM Consultants and LOS, while adjusting for overall (all-grade) on-duty emergency doctors’ numbers and other operational factors. Methods This was a retrospective analysis of three years (2016–2019) of data, employing a unit of analysis of 3276 eight-hour ED shifts. The study was conducted using a prospectively populated ED database in a busy (annual census 420,000) Middle Eastern ED with staffing by Consultants and multiple non-Consultant grades (Specialists, fellows, and residents). Using logistic regression, the main predictor variable of “on-duty Consultant n” was assessed for association with the study’s primary (dichotomous) endpoint: whether a shift’s median LOS met the target of < 240 min. Linear regression was used to assess for association between on-duty Consultant n and the study’s secondary (continuous) endpoint: median LOS for the ED shift. Results Multivariate logistic regression adjusting for a number of operations factors (including total EP on-duty complement) identified an association between increasing n of on-duty Consultants and the likelihood of a shift’s meeting the 4-h ED LOS target (OR 1.27, 95% CI 1.20 to 1.34, p < .0001). Multiple linear regression, which also adjusted for total on-duty EP n and other operational factors, also indicated LOS benefit from more on-duty Consultants: each additional on-duty Consultant was associated with a shift’s median LOS improving by 5.4 min (95% CI 4.3 to 6.5, p < .0001). Conclusions At the study site, in models that adjusted for overall on-duty EP numbers as well as myriad other operational factors, increasing numbers of on-duty Consultants was associated with a statistically and operationally significant reduction in ED LOS.

Unnecessary wait hours: a novel ED system-level metric

BackgroundEmergency department (ED) operations leaders are under increasing pressure to make care delivery more efficient. Publicly reported ED efficiency metrics are traditionally patient centred and do not show situational or facility-based improvement opportunities. We propose the consideration of a novel metric, the ‘Number of Unnecessary Waits (NUW)’ and the corresponding ‘Unnecessary Wait Hours (UWH)’, to measure space efficiency, and we describe how we used NUW to evaluate operational changes in our ED.MethodsUWH summarises the relationship between the number of available rooms and the number of patients waiting by returning a value equal to the number of unnecessary patient waits. We used this metric to evaluate reassigning a clinical technician assistant (CTA) to the new role of flow CTA.ResultsWe retrospectively analysed 3.5 months of data from before and after creation of the flow CTA. NUW metric analysis suggested that the flow CTA decreased the amount of unnecessary wait hours, while higher patient volumes had the opposite effect.ConclusionsSituational system-level metrics may provide a new dimension to evaluating ED operational efficiencies. Studies focussed on system-level metrics to evaluate an ED practice are needed to understand the role these metrics play in evaluation of a department’s operations.

Analyzing Main and Interaction Effects of Length of Stay Determinants in Emergency Departments

Background: Measuring and understanding main determinants of length of stay (LOS) in emergency departments (EDs) is critical from an operations perspective, since LOS is one of the main performance indicators of ED operations. Therefore, this study analyzes both the main and interaction effects of four widely-used independent determinants of ED-LOS. Methods: The analysis was conducted using secondary data from an ED of a large urban hospital in Izmir, Turkey. Between-subject factorial analysis of variance (ANOVA) was used to test the main and interaction effects of the corresponding factors. P values <.05 were considered statistically significant. Results: While the main effect of gender was insignificant, age, mode of arrival, and clinical acuity had significant effects, whereby ED-LOS was significantly higher for the elderly, those arriving by ambulance, and clinically-categorized high-acuity patients. Additionally, there was an interaction between the age and clinical acuity in that, while ED-LOS increased with age for high acuity patients, the opposite trend occurred for low acuity patients. When ED-LOS was modeled using gender, age, and mode of arrival, there was a significant interaction between age and mode of arrival. However, this interaction was not significant when the model included age, mode of arrival, and clinical acuity. Conclusion: Significant interactions exist between commonly used ED-LOS determinants. Therefore, interaction effects should be considered in analyzing and modelling ED-LOS.

Modeling the Patients Flow Behavior in Hilla Emergency Departments

Emergency department (ED) represents a crucial and suitable for most patients' emergency cases at any time. It is extremely associated health services dedicated mostly to treat the arriving patient's with uncertain illnesses and without previousappointment.Patient flow sequences representa very complex processdue to the different uncertain requirements and different possible paths that patients may guide to complete their treatment. An Agent Based Modeling (ABM) approach is implemented and appliedin an emergency department in Hilla hospital as a case studyin this paper.Thisstudy combinesABM with queuing and discrete events simulationas an evaluation process for the patients flow behavior and staff utilization in an emergency department. ABM is a flexible tool that can be created to imitatecertain complex environment. It can offer certain level of supports for managers to consider the relative influence of current or suggested strategies. It provides a suitablesituation in studying andpredicting the interactions and behavior's in ED operations. This study aims to maximize the patient's throughput, minimize their waitingtimesand optimize the resources utilization. The methodology that followed in this study is to estimate the optimal required number of ED staff's, which involves doctors, triage nurses, and receptionist, lab and x-raytechnician. Patients were modeled as agents having an ability to interact with others and with staffs and to select whether to wait and stay in the system or to leave at any stage of treatment. The simulation results is implemented according to the real collected data and the managers experiences about the averages of arrival and service rates with flow sequence probabilities. Waiting and idle times for the patients and staffs showed a good indication about the quality of services.

Are Emergency Departments in Istanbul Ready for the Earthquakes? Past Experience and Suggestions for Future Preparedness from Employees’ Viewpoint and the Literature

This paper aims to review what is known about the preparedness of hospital emergency departments (EDs) for a possible major earthquake expected in the near future in Istanbul and reveal the past experience and future plans from employees’ viewpoints and, as well as from the related literature. For this purpose, potential effects of the earthquakes on ED operations, patient flow, and performance are discussed considering the statistical data of recent earthquakes in Turkey, a comprehensive report on the disaster preparedness of Istanbul and, one to one interviews with the earthquake experienced ED medical staff. In particular, issues on patient surge, triage and registration, communication, patient flow and transportation and, lack of enough resources and space to treat are presented as the main challenges. According to the viewpoints obtained from various sources, EDs in Istanbul are not ready to meet the needs caused by a major earthquake. It is proposed that operational research (OR) techniques can be useful to overcome these issues such as simulation modeling.

Conceptualizing Emergency Department Scenarios

To handle problems and trends in emergency department (ED) operations, designers and decision makers often simulate and evaluate various case-specific scenarios before testing them in a real-life environment. However, conceptualizing broad possible scenarios for ED operations prior to simulation operationalization is usually neglected. The authors developed a methodology that integrates design of simulation experiments (DSE) as follows: 1) From a literature survey, they culled generic factors whose varying levels determine possible scenarios; 2) the authors drew up a set of generic interactions among these generic factors; 3) a questionnaire was constructed to serve as an instrument to gather the relevant information from management staff about relevant factors, their levels and interactions for a specific ED. Questionnaire responses support a schematic conceptualization of scenarios that should be simulated for a specific ED. They illustrate the application of the authors' methodology for conceptualization of ED simulation scenarios in two different EDs.

Educating Emergency Medicine Residents in Emergency Department Administration and Operations: Needs and Current Practice

Background Emergency medicine (EM) residents are expected to develop competence in emergency department (ED) administration and operations. Objectives We assessed current needs and educational practices related to preparing EM residents for their role in ED operations, and explored whether there was an association between program characteristics and the presence of ED operations education in US EM residency programs. Methods We conducted a cross-sectional needs assessment, using a web-based survey sent to all US EM residency programs to assess program characteristics, provision of ED operations-related lectures, availability of an ED administrative fellowship, and presence of a formal ED operations curriculum. Logistic regression was used to determine if any program characteristics were associated with the presence of lectures and a formal operations curriculum. Results Of the 158 Accreditation Council for Graduate Medical Education–accredited EM programs, 117 (74%) responded. Of these, 109 (93%) respondents had at least 1 lecture on ED operational topics. Sixty programs (54%) measured resident productivity. Knowledge of Centers for Medicaid & Medicare Services reimbursement guidelines was significantly positively associated with presence of an ED operations curriculum (OR, 3.52, P = .009) and with lectures on patient satisfaction (OR, 3.99, P = .006). Measuring resident productivity was positively associated with having lectures on productivity (OR, 2.50, P = .02) and with ED throughput (OR, 2.32, P = .03). No 2 variables were simultaneously significant in the model. Conclusions Most EM programs had at least 1 lecture on ED operations topics. Roughly half of the programs measured resident productivity and half had a formal ED operations curriculum.