A discrete event simulation-based methodology for building a digital twin of patient pathways in the hospital for near real-time monitoring and predictive simulation

Background: Discrete Event Simulation (DES) is one of the many tools and methods used in the analysis and improvement of healthcare services. Indeed, DES provides perhaps the most powerful and intuitive method for analyzing, evaluating, and improving complex healthcare systems. This paper highlights the process of developing a Digital Twin (DT) framework based on online DES to run the DES model in parallel with the real world in real-time. Methods: This paper suggests a new methodology that uses DES connected to the Internet of Things (IoT) devices to build a DT platform of patient pathways in a hospital for near real-time monitoring and predictive simulation. An experimental platform that mimics the behavior of a hospital has been used to validate this methodology. Results: The application of the proposed methodology allowed us to test the monitoring functionality in the DT. Therefore, we noticed that the DT behaves exactly as the emulator does in near real-time, we also tested the prediction functionality and we noticed that the DT provides us with a proactive overview for the near future of the patient pathways. The predictive functionality of this DT must be improved depending on the various reasons mentioned in this article. Conclusions: This paper presents a new methodology called HospiT'Win that uses DES and IoT devices to develop a DT of patient pathways in hospitals. This DT consists of two real-time models, a DT for Monitoring (DTM) and a DT for Predicting (DTP). An experimental platform with an emulator of a real hospital was used to validate this methodology before connecting to the real hospital. In the DTP, "dynamic" empirical distributions were used to perform a predictive simulation for the near future. In future research, some additional features and machine learning algorithms will be used to improve the proposed DT models.

Merging existing practices with new ones: the adjustment of organizational routines to using cancer patient pathways in primary healthcare

Background The introduction of new tools can bring unintended consequences for organizational routines. Cancer Patient Pathways (CPP) were introduced into the Swedish healthcare system in 2015 to shorten time to diagnosis and treatment. Primary healthcare (PHC) plays a central role since cancer diagnosis often begins in PHC units. Our study aimed to understand how PHC units adjusted organizational routines to utilizing CPPs. Method Six PHC units of varied size from both urban and rural areas in northern Sweden were included. Grounded theory method was used to collect and analyse group interviews at each unit. Nine group interviews with nurses and physicians, for a total of 41 participants, were performed between March and November 2019. The interviews focused on CPPs as tools, the PHC units’ routines and providers’ experiences with using CPPs in their daily work. Results Our analysis captured how PHC units adjusted organizational routines to utilizing CPPs by fusing existing practices with new practices to offer better quality of care. Specifically, three overarching organizational routines within the PHC units were identified. First, Manoeuvring diverse patient needs with easier patient flow, the PHC units handled the diverse needs of the population while simultaneously drawing upon CPPs to ease the patient flow within the healthcare system. Second, (Dis) integrating internal know-how, the PHC units drew upon internal competence even when PHC know-how was not taken into account by those driving the CPP initiative. Third, Coping with unequal relationships toward secondary care, the PHC units dealt with being in an unequal position while adopting CPPs instead further decreased possibilities to influence decision-making between care-levels. Conclusion Adopting CPPs as a tool within PHC units brought various unintended consequences in organizational routines. Our study from northern Sweden illustrates that the PHC know-how needs to be integrated into the healthcare system to improve the use of new tools as CPP. Further, the relationships between different levels of care should be taken in account when introducing new tools for healthcare. Also, when adopting innovations, unintended consequences need to be further explored empirically in diverse healthcare contexts internationally in order to generate deeper knowledge in the research area.

Barriers to Accessing Health Care for People with Chronic Conditions: A Qualitative Study

Background: There is a growing interest in redesigning healthcare systems to increase access to and coordination across care settings for people with chronic conditions. We aim to promote patient-centredness by gaining a better understanding of the barriers faced by (1) children with chronic bronchial asthma, (2) adults with non-specific chronic back pain, and (3) older people with pre-existing mental illness/es while addressing the problem of fragmentation in Austria’s healthcare system.Methods: Using a qualitative design, we conducted semi-structured interviews face-to-face and by telephone with health service providers, researchers, experts by experience (e.g., patient advocates, family members/carers), and employees in public health administration between July and October 2019. The analysis and interpretation of data were guided by Levesque’s model of access, a conceptual framework used to evaluate access broadly according to five dimensions of accessibility to care: approachability, acceptability, availability and accommodation, affordability, and appropriateness.Results: The findings from the 25 expert interviews were organised within Levesque’s conceptual framework in four dimensions of barriers. They highlight the lack of coordination and defined patient pathways, particularly at the onset of the condition, when seeking a diagnosis, but also later on. Barriers related to issues such as geography (e.g., longer distances and travel times as well as fewer healthcare services in remote rural regions), coordination of care (e.g., structural barriers and inconsistent care pathways), socioeconomic status (e.g., the ability to pay for healthcare services but also basic health literacy), and comorbidity (e.g., consideration of the patients’ state of mental health and holistic therapy approaches).Conclusions: Barriers to healthcare access are of particular concern for patients with chronic conditions, resulting in an urgent need to improve health services according to patients’ specific needs. For health services to be properly accessible, timely and integrated care independent of social and economic resources, continuity of care, and significant improvements in patient-centred communication and coordination of care are paramount. This study has important implications for policy and practice as it highlights provider, expert, and researcher perspectives on access to the healthcare system in Austria and offers a broader look at the changes required by stakeholders in the future.

FORENSIC MENTAL HEALTH IN EUROPE: SHARED LEGAL HERITAGE AND CONTEMPORARY LANDSCAPE

This paper provides an overview of some of the key features of forensic mental health systems around Europe. Forensic mental health systems share in common the aim to assist in the rehabilitation of people diagnosed with a mental disorder and reduce reoffending or risk of harm. How these aims are pursued varies across the continent. We suggest that best practices can be learnt from observing different countries’ approaches. This paper has six foci: legal traditions in Europe, the concept of criminal responsibility, patient pathways through forensic systems, epidemiological studies of forensic patients, training programmes in forensic mental health, and recent developments in the field across Europe. Readers should reflect on these topics in the context of their own country and how these diverge/converge from the countries described in this paper.

Dispatch accuracy of physician-staffed emergency medical services in trauma care in south-east Norway: a retrospective observational study

Background Selection of incidents and accurate identification of patients that require assistance from physician-staffed emergency medical services (P-EMS) remain essential. We aimed to evaluate P-EMS availability, the underlying criteria for dispatch, and the corresponding dispatch accuracy of trauma care in south-east Norway in 2015, to identify areas for improvement. Methods Pre-hospital data from emergency medical coordination centres and P-EMS medical databases were linked with data from the Norwegian Trauma Registry (NTR). Based on a set of conditions (injury severity, interventions performed, level of consciousness, incident category), trauma incidents were defined as complex, warranting P-EMS assistance, or non-complex. Incident complexity and P-EMS involvement were the main determinants when assessing the triage accuracy. Undertriage was adjusted for P-EMS availability and response and transport times. Results Among 19,028 trauma incidents, P-EMS were involved in 2506 (13.2%). The range of overtriage was 74–80% and the range of undertriage was 20–32%. P-EMS readiness in the event of complex incidents ranged from 58 to 70%. The most frequent dispatch criterion was “Police/fire brigade request immediate response” recorded in 4321 (22.7%) of the incidents. Criteria from the groups “Accidents” and “Road traffic accidents” were recorded in 10,875 (57.2%) incidents, and criteria from the groups “Transport reservations” and “Unidentified problem” in 6025 (31,7%) incidents. Among 4916 patient pathways in the NTR, 681 (13.9%) could not be matched with pre-hospital data records. Conclusions Both P-EMS availability and dispatch accuracy remain suboptimal in trauma care in south-east Norway. Dispatch criteria are too vague to facilitate accurate P-EMS dispatch, and pre-hospital data is inconsistent and insufficient to provide basic data for scientific research. Future dispatch criteria should focus on the care aspect of P-EMS. Better tools for both dispatch and incident handling for the emergency medical coordination centres are essential. In general, coordination, standardisation, and integration of existing data systems should enhance the quality of trauma care and increase patient safety.

P-B01 First Inventory of Access and Quality of Metabolic Surgery across Europe

Background Europe consists of 51 independent countries. Variation in healthcare regulations results in differing challenges faced by patients and professionals. The obesity pandemic has multiple health, economic and social implications. However, metabolic surgery is not universally accessible, with significant variations in its provision. This study aimed to gain insight into compliance with international guidelines; the accessibility and barriers to surgery; patient pathways and qualitor indicators of both metabolic and body contouring surgery after weight loss in different European countries. Methods This study was initiated during the European Obesity Academy (EOA). Expert representatives in the metabolic field from all 51 European countries were sent a novel, 37-item, electronic self-administered online questionnaire on their data and experiences from the previous year exploring accessibility to and quality indicators for metabolic surgery and body contouring surgery after weight loss. The survey tool was peer-reviewed by experienced researchers and piloted by fifteen experienced researchers with a spread of seniority and specialty. Content and face validity were ensured by peer-review and the piloting process. 45 completed responses were collected. Results 68% of countries had eligibility criteria for metabolic surgery; 59% adhered to these. 46% had reimbursement criteria for metabolic surgery. 41% had eligibility criteria for plastic surgery and 31% reimbursement criteria. Average tariffs for a metabolic procedure varied (€800-€ 16000). MDTs were mandated in 78%, with team members varying significantly. Referral practises differed. In 45% metabolic surgery is performed by pure metabolic surgeons. 23% had a metabolic training program. Access to metabolic surgery was rated poor/ very poor in 33%. 35% had a bariatric registry. 24% required a minimum procedure number for metabolic centres; varying from 25 to 200 procedures. Conclusions This is the first study to describe accessibility and quality data on metabolic and body contouring surgery from most European countries. There are myriad differences between European countries in terms of accessibility to metabolic surgery. Lack of funding, education and structure fuels this disparity. We hope this study will impact standardisation of access and quality indicators for metabolic and body contouring surgery across European countries, as well as be a springboard for further evaluation of international metabolic surgery practices.

P-EGS29 Is an ambulatory emergency general surgery management pathway of biliary disease more cost effective than a traditional approach? A matched case series study

Background Patients presenting with biliary colic with or without deranged liver function tests (LFT’s) requiring surgery have traditionally been managed as inpatients or on an elective basis. Emergency surgery has previously been associated with higher costs in comparison to outpatient, elective management. Methods Thirteen patients presenting as an emergency with a diagnosis of cholecystitis, with or without deranged LFTs, who underwent different patient pathways resulting in laparoscopic cholecystectomy were identified randomly over 1 month period. They were then matched into groups to compare elective, inpatient and ambulatory care pathway management for patients with similar demographics and clinical picture. The costs of each patient’s journey, from acute presentation to discharge following laparoscopic cholecystectomy was calculated in conjunction with the patient level information costing team (PLICS). Results Three matched groups of patients were identified: 50-60M, 65-75F with normal LFTs, 60F with obstructive LFT’s. Each patient underwent an ultrasound scan of the upper abdomen, laparoscopic cholecystectomy with additional investigations dependent on the group and clinical picture. In each group, when elective, emergency inpatient or ambulatory care pathways were compared there was a consistent cost difference. The order from most expensive to cheapest was: inpatient management, elective management, ambulatory care. The difference in costs was primarily linked with emergency department assessment and inpatient bed stays with cost saving of up to £5000 in one group when comparing inpatient stay to ambulatory emergency care management. Conclusions The use of an ambulatory emergency general surgical pathway for patients with a variety of biliary colic presentations including those with deranged LFT’s is economically comparable and potentially advantageous to more traditional and established patient management pathway options in a number of patient demographics across age, gender and pathology. An ambulatory care pathway, when developed and used correctly can provide significant cost savings to a wide range of patients.

P-O15 “Knife to Skin” time: The invariable variable

Background The Covid-19 pandemic has affected all aspects of healthcare globally. Theatre utilisation assumes a substantial proportion of hospital resources, creating a streamlined pathway increases efficiency and productivity. With concerns regarding aerosol generating procedures, viral transmission to health care workers in theatre and patient pathways through the hospitals the covid-19 pandemic has added another dimension to the theatre pathway. The aim of this study was to quantify the impact of Covid-19 on the “knife to skin” (KTS) time and compare it to previous historical data (HD). Methods Retrospective analysis of real time theatre data was analysed for the first 12 months of the pandemic from 11th March 2020 to 11th March 2021. To try and minimise variability between different specialities and operations we picked one operation to study: Laparoscopic cholecystectomy (LC). Historical data was also gathered from the same time frame over the last 5 years (2015-2020) for comparison. Data collected included emergency or elective, time sent for patient, anaesthetic start time, knife to skin time and duration of operation. Comparison of means were analysed by One-way ANOVA tests and Student’s T-Test. Results 399 laparoscopic cholecystectomies were performed during the first year of the pandemic. KTS time was calculated as operation start time minus time sent for patient. Average time during the pandemic for emergency LC KTS was 56 minutes and 35 minutes for elective LC. Comparison of these times to HD revealed no statistical difference (Emergency LC 56 mins vs 58 mins p > 0.05, Elective LC 35 mins vs 35 mins p > 0.05). The anaesthetic time for emergency LC during the pandemic vs HD was 10 mins vs 14 mins (p < 0.05), no statistical difference was found in the elective group, 16mins vs 14mins (p > 0.05) Conclusions The Covid-19 pandemic has had no detectable effect on Knife to skin time as compared to our previous historical data. It seems the extra Covid 19 precautions involving PPE, pathways etc. have not affected theatre efficiency or utilisation. In fact, there was very little variance in KTS time over the six years studied (2015-2021) with very consistent levels for both elective and emergency procedures. The shorter anaesthetic time for emergency LC during the pandemic needs to be further investigated but one hypothesis is the unconscious or conscious decision to decrease the amount of preoxygenation to minimise aerosolisation.

Equitable access to cancer patient pathways in Norway – a national registry-based study

Background In 2015, cancer patient pathways (CPP) were implemented in Norway to reduce unnecessary non-medical delay in the diagnostic process and start of treatment. The main aim of this study was to investigate the equality in access to CPPs for patients with either lung, colorectal, breast or prostate cancer in Norway. Methods National population-based data on individual level from 2015 to 2017 were used to study two proportions; i) patients in CPPs without the cancer diagnosis, and ii) cancer patients included in CPPs. Logistic regression was applied to examine the associations between these proportions and place of residence (hospital referral area), age, education, income, comorbidity and travel time to hospital. Results Age and place of residence were the two most important factors for describing the variation in proportions. For the CPP patients, inconsistent differences were found for income and education, while for the cancer patients the probability of being included in a CPP increased with income. Conclusions The age effect can be related to both the increasing risk of cancer and increasing number of GP and hospital contacts with age. The non-systematic results for CPP patients according to income and education can be interpreted as equitable access, as opposed to the systematic differences found among cancer patients in different income groups. The inequalities between income groups among cancer patients and the inequalities based on the patients’ place of residence, for both CPP and cancer patients, are unwarranted and need to be addressed.