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Building an efficient facility for advanced bronchoscopic procedures involves many considerations. This review places particular emphasis on anesthesiology services, based on experience at a tertiary/quaternary care referral academic medical center. Topics include equipment requirements, applicable clinical standards and multidisciplinary collaboration. Patient flow arrangements for both outpatients and inpatients, from pre-operative care to discharge/disposition are highlighted. The importance of effective business planning, personnel training, leadership, communication, teambuilding, quality of care and patient safety are also discussed.

Objective & Hypothesis Assess the impact of universal mental health screening with MyHEARTSMAP on emergency department (ED) flow, an important aspect of feasibility. We hypothesized that the difference in departmental level ED length of stay (LOS) for screening and matched non-screening days is less than 30 minutes. Methods We conducted a two-center, retrospective cohort study between December 2017 and June 2019. At each center, random mental health screening days were assigned over the course of 15 consecutive months. We matched each 24-hour screening day to a unique non-screening day based on: location (Center 1 or Center 2); day type (weekday: Monday-Thursday or weekend: Friday-Sunday); date (+/- 28 days); and 24-hour volume (+/- 15 patients). We collected retrospective patient flow data, including LOS, across all ED visits to determine the difference in departmental level median LOS between matched screening and non-screening days. Results There was not a statistically significant difference in departmental LOS between screening and non-screening days. Overall, the difference in departmental LOS was -4.0 minutes (95% CI: -9.8, 1.8) for screening days compared to non-screening days, with a difference of -2.0 minutes (-9.0, 4.9) at Center 1 and -6.0 minutes (-15.4, 3.4) at Center 2. Conclusion Our findings show that universal mental health screening with MyHEARTSMAP can be implemented without a significant impact of ED LOS.

Background The SARS-CoV-2 pandemic caused severe disruption to scheduled surgery in Ireland but its impact on emergency abdominal surgery (EAS) is unknown. Aims The primary objective was to identify changes in volume, length of stay (LOS), and survival outcomes following EAS during the pandemic. A secondary objective was to evaluate differences in EAS patient flow including admission source, ITU utilisation, discharge destination, and readmission rates. Methods Using a national administrative dataset, demographic, comorbidity, and patient flow data on 5611 patients admitted for EAS between 2018 and 2020 were extracted. Pre-pandemic and pandemic timeframes were compared using graphic and regression analyses, and bivariate logistic regression, adjusting for demographics and case-mix. Results There was a 19.9% decrease in EAS during the 2020 COVID-19 pandemic with no difference in comorbidity, nor in the commonest procedures. Most patients (92.4%) were admitted from home. In-hospital post-operative mortality was unchanged (7.6%). Patients over 80 comprised 16.3% of EAS pre-COVID, but 17.9% during COVID. Average total LOS reduced significantly by 4.9 days and 3.5 days during COVID-19 waves 1 (29 Feb 2020–30 June 2020) and 2 (1 July 2020–30 Nov 2020), respectively. During wave 1, pre-operative LOS reduced (1 day) and ICU LOS was significantly shorter (0.8 days), but similar change was not observed during wave 2. Conclusions Significant improvements in patient flow following admission for EAS during the pandemic were observed. These changes were not associated with greater mortality nor increased readmission rates and offer important insights into optimal delivery of EAS services.

Patient flow analysis was used to assess the waiting time of patients referred to a large paediatric outpatient department, and also the lengths of the consultations of the paediatricians and interns. The average waiting times to see the paediatricians and interns were 77 minutes and 7.8 minutes, respectively. The average lengths of consultation for the paediatricians and interns were 3.4 minutes, and 7.7 minutes, respectively

The demand for renal replacement therapy (RRT) from the growing number of patients suffering from chronic kidney disease (CKD) and end stage renal disease (ESRD) in Nigeria is reported to be on the rise. However, dialysis clinics are few with limited facilities to meet the increasing demand leading to congestion, long waiting time and increased length of stay (LOS) in dialysis clinics. This paper presents an optimisation model for scheduling patient flow in an outpatient haemodialysis clinic. The objective is to minimize patient LOS using Genetic Algorithm (GA), implemented in Python programming language with Spyder Integrated Development Environment (IDE). The model was tested using data obtained from a haemodialysis clinic, in Lagos, Nigeria. The model generated optimum LOS values (193.01, 275.02 and 390.01) minutes compared to the mean LOS values at the haemodialysis clinic (235.50, 296.62 and 424.50) minutes for the 3-hour, 4-hour and 6-hour dialysis sessions. Furthermore, a simulation experiment of patient flow in a typical haemodialysis clinic was performed by gradual variations in patient arrival rates, λ. Simulation results at (λ=0.1,0.2,0.3,0.4) revealed mean LOS (minutes) as (312.85 ± 73.45, 348.18 ± 84.89, 342.18 ± 81.30, 305, 28 ± 63.67) respectively. The optimisation model was effective in reducing patient LOS.

Aim To measure the influence of rotatory pediatrics postings for dental residents on the outpatient census of the pediatric dentistry department. The secondary aims were to assess the change in trend toward the number of preschool children visiting the department before and after the initiation of pediatrics posting and also to find the percentage of children affected with caries among children visiting the pediatricians. Materials and methods Retrospectively, the census of the pediatric dentistry department was calculated from 2010 to 2016. The number of preschool children who visited the pediatric dentistry department during this period was determined. From the pediatrics posting records, the dental status of the children, the number screened, the number referred, and the number reported to dentistry following referral were tabulated. Descriptive statistics and Chi-square tests were performed. Results After the initiation of pediatrics postings for residents, the outpatient census has increased by 26%. There was a significant increase in the number of preschool children visiting the pediatric dentist. About 57.09% of children screened in the pediatrics department had dental disease. Conclusion There is an increase in the patient flow of the pediatric dentistry department with a greater number of preschool children visiting the pediatric dentist after initiation of the pediatrics postings for residents. More than half the children visiting pediatricians had dental disease requiring professional care. Clinical significance Pediatrics postings for residents can be used in teaching centers as an opportunity to spread awareness and increase the number of preschool children visiting pediatric dentists, thereby increasing prevention and early intervention of early childhood caries. How to cite this article Mohan A, Muthu MS, Ramachandran P, et al. Impact of Pediatric Dentistry Residents Posted in Pediatrics Department: A Retrospective Assessment of 6 Years. Int J Clin Pediatr Dent 2021;14(1):84–87.

Good patient flow in an acute hospital is concerned with ensuring patients experience minimal delays throughout the hospital journey, from the emergency department to the wards, outpatients and to a suitable discharge destination. Good flow requires effective processes, staff buy-in and staff education. This study aimed to explore ways in which this topic is currently taught in an Irish acute hospital group. Participants were recruited to engage in semi-structured interviews about their experience of teaching patient flow. Following qualitative data analysis using a structured analysis guide, five main themes were identified: current methods, unstructured nature of teaching, frustration with frequency, dissemination of teaching/learning and opportunities for improvement. Recommendations from this study could be used to support a formalised approach to teaching this topic in the future. The use of the Teaching for Understanding framework and Universal Design for Learning principles are strongly advocated to support the development of a nationwide module, to structure the topics to be taught and provide guidance on how to effectively and efficiently teach this topic in Ireland.

BACKGROUND Patient satisfaction is a focus for emergency department (ED) and hospital administrators. ED patient satisfaction studies have tended to be single site and focused on patient and clinician factors. Inclusion of satisfaction scores in a large, national operations database provided an opportunity to conduct an investigation that included diverse operational factors. METHODS We performed a retrospective analysis of the 2019 Academy of Administrators in Academic Emergency Medicine/Association of Academic Chairs of Emergency Medicine (AAAEM/AACEM) benchmarking survey to identify associations between operational factors and patient satisfaction. We identified 59 database variables as potential predictors of Press Ganey likelihood-to-recommend and physician overall scores. Using random forest modeling, we identified the top eight predictors in the models and described their associations. RESULTS Forty-three (57.3%) academic departments responding to the AAAEM/AACEM survey reported patient satisfaction scores for 78 EDs. Likelihood to recommend ranged from 30.0 to 93.0 (median = 74.8) and was associated with ED length of stay, boarding, use of hallway spaces, hospital annual admissions, faculty base clinical hours, proportion of patients leaving before treatment complete (LBTC), and provider in triage hours per day. Physician overall score ranged from 53.3 to 93.4 (median = 81.9) and was associated with faculty base clinical hours, x-ray utilization, annual ED arrivals, LBTC, use of hallway spaces, arrivals per attending hour, and CT utilization. CONCLUSIONS ED patient satisfaction was associated with intrinsic and extrinsic factors, some being potentially manageable within the ED but others being relatively fixed or outside the control of ED operations. For likelihood to recommend, patient flow was dominant, with erosion of satisfaction observed with increased boarding and longer LOS. Factors associated with physician overall score were more varied. The use of hallway spaces and base clinical hours greater than 1,500 per year were associated with both lower likelihood-to-recommend and lower physician overall scores.

Background COVID-19, a highly contagious respiratory virus, presents unique challenges to ophthalmology practice as a high-volume, office-based specialty. In response to the COVID-19 pandemic, many operational changes were adopted in our ophthalmology clinic to enhance patient and provider safety while maintaining necessary clinical operations. The aim of this study was to evaluate how measures adopted during the pandemic period affected retina clinic performance and patient satisfaction, and to model future clinic flow to predict operational performance under conditions of increasing patient and provider volumes. Methods Clinic event timestamps and demographics were extracted from the electronic medical records of in-person retina encounters from March 15 to May 15, 2020 and compared with the same period in 2019 to assess patient flow through the clinical encounter. Patient satisfaction was evaluated by Press Ganey patient experience surveys obtained from randomly selected outpatient encounters. A discrete-events simulation was designed to model the clinic with COVID-era restrictions to assess operational performance under conditions of increasing patient and provider volumes. Results Retina clinic volume declined by 62 % during the COVID-19 health emergency. Average check-in-to-technician time declined 79 %, total visit length declined by 46 %, and time in the provider phase of care declined 53 %. Patient satisfaction regarding access nearly doubled during the COVID-period compared with the prior year (p p Conclusions Clinic throughput was optimized in response to the COVID-19 health emergency. Modeling these clinic changes can help plan for eventual volume increases in the setting of limits imposed in the COVID-era.

Infective endocarditis (IE) is a rare but serious condition with a dismal prognosis. One of the keys to improving outcomes is the prompt identification of high-risk patients who have intracardiac and extracardiac (systemic and neurologic) complications. However, as cardiac and extracardiac complications indicating surgery add to the surgical risk for active IE, controversies surround the optimal indication and timing for surgery, especially in patients presenting neurologic complications. This article reviews the necessary evaluation for patients with suspected IE and proposes a state-of-the-art patient flow chart for evaluation of suspected IE.

Summary Background The Acute Medical Unit (AMU) provides care for unscheduled hospital admissions. Seven-day consultant presence and morning AMU discharges have been advocated to improve hospital bed management. Aims To determine whether a later time of daily peak AMU occupancy correlates with measures of hospital stress; whether 7-day consultant presence, for COVID-19, abolished weekly periodicity of discharges. Design Retrospective cohort analysis. Methods : Anonymised AMU admission and discharge times were retrieved from the Profile Information Management System (PIMS), at a large, urban hospital from 14 April 2014 to 31 December 2018 and 20 March to 2 May 2020 (COVID-19 peak). Minute-by-minute admission and discharge times were combined to construct a running total of AMU bed occupancy. Fourier transforms were used to determine periodicity. We tested association between (i) average AMU occupancy and (ii) time of peak AMU occupancy, with measures of hospital stress (total medical bed occupancy and ‘medical outliers’ on non-medical wards). Results : Daily, weekly and seasonal patterns of AMU bed occupancy were evident. Timing of AMU peak occupancy was unrelated to each measure of hospital stress: total medical inpatients (Spearman’s rho, rs = 0.04, P = 0.24); number of medical outliers (rs = −0.06, P = 0.05). During COVID-19, daily bed occupancy was similar, with continuation of greater Friday and Monday discharges than the weekend. Conclusions : Timing of peak AMU occupancy did not alter with hospital stress. Efforts to increase morning AMU discharges are likely to have little effect on hospital performance. Seven-day consultant presence did not abolish weekly periodicity of discharges—other factors influence weekend discharges.

BackgroundPatient flow directly affects quality of care, access and financial performance for hospitals. Multidisciplinary discharge-focused rounds have proven to minimise avoidable delays experienced by patients near discharge. The study objective was to support discharge-focused rounds by implementing a machine-learning-based discharge prediction model using real-time electronic health record (EHR) data. We aimed to evaluate model predictive performance and impact on hospital length-of-stay.MethodsDischarge prediction models were developed from hospitalised patients on four inpatient units between April 2016 and September 2018. Unit-specific models were implemented to make individual patient predictions viewable with the EHR patient track board. Predictive performance was measured prospectively for 12 470 patients (120 780 patient-predictions) across all units. A pre/poststudy design applying interrupted time series methods was used to assess the impact of the discharge prediction model on hospital length-of-stay.ResultsProspective discharge prediction performance ranged in area under the receiver operating characteristic curve from 0.70 to 0.80 for same-day and next-day predictions; sensitivity was between 0.63 and 0.83 and specificity between 0.48 and 0.80. Elapsed length-of-stay, counts of labs and medications, mobility assessments and measures of acute kidney injury were model features providing the most predictive value. Implementing the discharge predictions resulted in a reduction in hospital length-of-stay of over 12 hours on a medicine unit (pConclusionsIncorporating automated patient discharge predictions into multidisciplinary rounds can support decreases in hospital length-of-stay. Variation in execution and impact across inpatient units existed.

Pediatric head injury is a common presenting complaint in the emergency department (ED), often requiring neuroimaging or ED observation for diagnosis. However, the traditional diagnostic neuroimaging modality, head computed tomography (CT), is associated with radiation exposure while prolonged ED observation impacts patient flow and resource utilization. Recent scientific literature supports abbreviated, or focused and shorter, brain magnetic resonance imaging (MRI) as a feasible and accurate diagnostic alternative to CT for traumatic brain injury. However, this is a relatively new application and its use is not widespread. The aims of this review are to describe the science and applications of abbreviated brain MRI and report a model protocol's development and ED implementation in the evaluation of children with head injury for replication in other institutions.

Objective: To review the literature on common issues impacting psychiatric patient flow in emergency departments (EDs) and to explore evidence-based solutions proposed to improve patient flow. Methods: The review was divided into three parts and a broad array of keywords were chosen to achieve greater depth in the review. Administrative data and organisational publications were included along with peer-reviewed articles in various databases. Results: Psychiatric patients have increased ED length of stay (EDLOS) and the proportion of psychiatric presentations in ED has increased significantly.1 Several factors contributed to increased EDLOS. Introduction of psychiatric short stay units,2 improving patient flow3 and appropriate increase in beds were identified as some of the possible solutions to improve patient flow. Conclusion: Psychiatric patient flow in ED is a complex issue and needs a coordinated approach to improve access. Future studies should focus on understanding the effectiveness of some of the proposed strategies.

This article describes the authors' experiences of a specialist pathway for low-risk patients with chest pain admitted to the emergency department. This pathway uses a modified HEART score and highly sensitive troponin I testing to categorise patients. This was introduced to facilitate safe and speedy discharge of these patients within the 4-hour target. The aim was to demonstrate a reduction in length of stay and a reduction in overcrowding in the emergency department. This also included the introduction of a new nurse-led chest pain hot clinic to provide a specialist cardiology review within 72 hours of discharge. This clinic enabled more appropriate targeted investigation and treatment for patients. As a new initiative, it was important to ensure patient safety with a

Background Centralization has improved the outcome of complex operations including cancer surgery. Moreover, the implementation of multidisciplinary team conferences (MDT) has ameliorated the decision making, but the impact on patient outcome is controversial. The aim of the study was to investigate the outcome of pancreatic surgery in the setting of centralization and upfront multidisciplinary decision making. Method The decisions of MDT from 2010 to 2016 and the outcome of operations were compared with operations from 2003 to 2009 before centralization of pancreatic surgery and implementation of MDT. Data were drawn from the department's database and from hospital's electronic patient files. Results From 2010 to 2016, 7.015 patients were evaluated at the MDT. In 72.6% of patients a treatment plan followed the first evaluation, the referral diagnosis was changed in 12.4% of cases. Of 3.362 solid neoplasms, 1.680 (50.0%) were evaluated as resectable and 1.080 (32.1%) patients were operated. The annual resection rate of operated patients was78.3%–88.5% (median 80.0%) compared to 21.4% to 80.% (median 68.6%, p = 0.0001) from 2003 to 2009 with 279 operated patients. The post-operative 30 – and 90-days mortality from 2003 to 2009 and 2010 to 2016 was 3.4% vs. 1.8% (NS) and 5.0% vs 3.6% (NS). In the same periods explorative laparotomies and palliative resections decreased from 18.3% to 3.6% (p = 0.0001) and 18.6%–10.2% (p = 0.0002). The median survival of radically resected pancreatic adenocarcinoma (PAC) from 2003 to 2009 and from 2010 to 2016 was 20.2 and 21.9 months, respectively (p = 0.687). Conclusion The MDT increased patient flow, improved quality of decision-making and offered more patients surgical treatment without increasing morbidity or mortality. But an impact on the long-term survival of patients with PAC was not found.

Perianal fistulizing Crohn's disease (PFCD) is a common, disabling and aggressive phenotype that negatively impacts on the quality of life of affected patients. Its successful treatment is still a struggle for both physicians and patients. Significant advances in the management of this condition have occurred in the last two decades holding promise for a better future. This culminated into the concept of a collaborative multidisciplinary approach using the latest medical therapies combined with modern surgical and endoscopic techniques. Despite this, PFCD management and treatment have not been standardized yet. Thus the gastroenterologist and surgeon have to be familiar with several approaches and/or techniques. The positioning of each therapeutic option will certainly evolve with new data, but for the time being it should be driven by patient's characteristics, physician's preference and/or experience, costs and availability in local practice. Additionally, patient's perception of benefits and risks of treatment may differ from those of physicians and recognition of this difference is a starting point for difficult clinical decision-making. In this paper, a multidisciplinary group of Italian IBD experts explore and discuss current medical and surgical therapeutic options, highlighting areas of unmet needs in PFCD, with particular focus on the optimal patient flow within the Italian clinical reality.

The emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has posed great challenges for both public health and medical clinical practice since the first cases reported in Wuhan, China Coronavirus disease (CoVID-19) is a zoonotic disease caused by an RNA virus SARS-CoV-2 is transmitted through respiratory droplets and fomites, and it has a lethality estimated at 4% In the pediatric population it mainly produces mild cases, but it also can cause severe cases with hypoxemia, respiratory distress, and multiple organ failure Children have been recognized as an important disease vector than can spread disease to higher risk groups It is fundamental to rearrange emergency department functioning, in order to achieve an adequate patient flow that reduces the risk of disease transmission In the following, we lay out the recommendations for patient care in the emergency room La emergencia mundial del virus SARS-CoV-2 (CoV2) ha producido grandes desafios para la salud publica y para la atencion clinica, desde la aparicion de los primeros casos en Wuhan, China La enfermedad, CoVID-19, es una infeccion zoonotica producida por un virus RNA (1) Se transmite a traves de gotitas y fomites con una letalidad estimada en 4% En pediatria, provoca cuadros respiratorios en su mayoria leves, pero tambien cuadros severos con hipoxemia y distres respiratorio (2) Se ha reconocido al nino como un vector importante que aumenta los contagios en personas que tendran probablemente cuadros de gravedad La organizacion adecuada de los servicios de urgencias es fundamental para lograr un flujo y areas especiales para los pacientes sospechosos de CoVID-19 y asi evitar nuevos contagios A continuacion, se detallan las principales recomendaciones para la atencion de estos pacientes en un servicio de urgencias

ABSTRACT FOR SERVICE SPOTLIGHT

Objective Intermediate care units provide a high level of care to complex patients and are becoming increasingly popular in North America. Despite the growing popularity of Intermediate care units, very little is known about them. This study explored a typical Intermediate care unit, identifying patient characteristics including demographics, comorbidities, length of stay, as well as primary and secondary diagnosis and mortality. Results A total of 200 patients chart were reviewed, of which, 102 were male, and 89 patients were younger than 65 years old. Diabetes, hypertension, and chronic obstructive pulmonary disease were common among patients with a prevalence of 33.5%, 56%, and 32.5%, respectively. Alcohol use disorder, asthma, liver disease and IV drug abuse were much more common in patients younger than 65 years. The average length of stay was 5.31 days regardless of age. Almost two-thirds of the patients in the Intermediate care unit were admitted directly from the emergency room. The mortality rate among the patients studied was 9.5%. The most common admitting diagnosis was respiratory diseases such as chronic obstructive pulmonary disease or Pneumonia (38.0%), followed by cardiac disorders which were predominantly arrhythmias and congestive heart failure (27.0%).

Introduction Emergency Department (ED) crowding negatively impacts patient outcomes, patient satisfaction, and patient safety. One solution involves introducing a Concierge Physician (CP) whose sole purpose is to provide a brief initial assessment (BIA) and aid patient navigation through the ED. The goal of this study was to quantify the impact of a CP on patient flow dynamics in an urban ED setting. Methods We performed a retrospective observational cohort study in an urban academic ED over a 6-month period. Initially, the CP was present in the treatment area during weekdays; during the last half of the observation period, an additional CP was added to the waiting room on weekends. We identified four major milestones in the ED visit with regards to patient throughput. Adult patients presenting to the ED with a triage level of Urgent (ESI 3) were analyzed for this study. Data were stratified based on the patient's ultimate disposition (admitted or discharged) and presented as means with predictive analysis. Results Between August 2016 and January 2017, the ED evaluated 42,397 adult patients. Of those, 26,976 (64%) were triage level Urgent (3). Of the level 3 patients, 10,279 (38%) received a BIA from a CP. Patients evaluated by a CP were seen approximately 30 mins faster (40% reduction in Door to Doctor time), but stayed 30 mins longer in the ED on average, because the medical decision-making process took >1 hr longer when the patient was initially evaluated by a CP. Conclusion Adapting a concierge medicine model to rapidly evaluate patients resulted in a dramatically reduced Door to Doctor time, but an increase in overall time spent in the ED. This discrepancy was a direct result of the delay in physician disposition.

BACKGROUND Inefficient emergency department to inpatient handoff processes can contribute to delayed care. LOCAL PROBLEM The average emergency department length of stay for admitted patients and admission wait times at this institution were well above national averages, and a standard handoff process was lacking. METHODS Lean methodology was used to evaluate flow and identify opportunities for improvement. INTERVENTIONS Two tools were developed to standardize handoff. RESULTS Emergency department length of stay and admission wait times were not significantly improved following intervention implementation. However, patient transfer time decreased significantly (P < .01, F = 29.02) from 30.5 minutes (SD = 18.2) to 21.7 minutes (SD = 7.4). The length of time to give/receive report also decreased significantly (P = .04, F = 2.2) from 3.8 (SD = 1.6) minutes to 2.8 (SD = 1.2) minutes. CONCLUSIONS Although length of stay and admission wait times did not decline significantly, implementation of standard work and tools can potentially improve patient flow.

ObjectiveWe developed a discrete event simulation model to evaluate the impact on system flow of a quality improvement (QI) initiative that included a time-specific protocol to decrease the time to antibiotic delivery for children with cancer and central venous catheters who present to a paediatric ED with fever.MethodsThe model was based on prospective observations and retrospective review of ED processes during the maintenance phase of the QI initiative between January 2016 and June 2017 in a large, urban, academic children’s hospital in New York City, USA. We compared waiting time for full evaluation (WT) and length of stay (LOS) between a model with and a model without the protocol. We then gradually increased the proportion of patients receiving the protocol in the model and recorded changes in WT and LOS.ResultsWe validated model outputs against administrative data from 2016, with no statistically significant differences in average WT or LOS for any emergency severity index (ESI). There were no statistically significant differences in these flow metrics between the model with and the model without the protocol. By increasing the proportion of total patients receiving this protocol, from 0.2% to 1.3%, the WT increased by 2.8 min (95% CI: 0.6 to 5.0) and 7.6 min (95% CI: 2.0 to 13.2) for ESI 2 and ESI 3 patients, respectively. This represents a 14.0% increase in WT for ESI 3 patients.ConclusionsSimulation modelling facilitated the testing of system effects for a time-specific protocol implemented in a large, urban, academic paediatric ED, showing no significant impact on patient flow. The model suggests system resilience, demonstrating no detrimental effect on WT until there is a 7-fold increase in the proportion of patients receiving the protocol.

Introduction Patient flow is the process by which movement of patients and clinical productivity is achieved. The objectives of this study were to implement and evaluate the NHS Improvement SAFER patient flow bundle, evaluate the impact of the Red2Green initiative, and assess the impact of frailty on patient flow. Materials and methods All patients admitted to a neurosurgery unit from 1 September to 30 November 2017 were included. Using guidance set out by NHS, data were prospectively collected from daily ward lists and patient notes, including demographics, admission and discharge details, length of stay, anticipated discharge date, red days with reasons and frailty (Rockwood Clinical Frailty Scale). NHS reference costs were used for cost analyses. Results A total of 420 patients (55% elective) were included, totalling 3909 bed days. All patients received daily senior reviews before midday, and anticipated discharge dates were set at daily multidisciplinary team meetings. Ten per cent of patients were discharged before midday. There were 21% (837) red days, significantly more (76%) for emergency patients (639 vs 198 elective; P < 0.001); 63% red days were attributed to awaiting a bed in a local hospital; 25% (106) patients were classed as frail (50 elective), which was associated with a significantly longer length of stay (17.3 vs 6; P < 0.01), and more red days (615 vs 222; pConclusions SAFER has identified areas for improvement in patient flow, with obvious cost implications. It has created a platform for discussion within the referral network and identified a role for a geriatric liaison service.

To describe the unevenness in daily patient flow (quiet, optimal and busy days) in different sized delivery hospitals.Population based register-study of 610 227 hospital deliveries. Data were collected from the Finnish Medical Birth Register from 2006 to 2016. Delivery hospitals (N = 26) were stratified into four categories by annual delivery volume: C1 1000, C2 1000-1999, C3 2000-2999, C4 ≥3000. Uneven daily patient flow was defined based on the mean of daily delivery volume for each hospital category: quiet day (≤50% of the mean), optimal day (50% of the mean to two times the mean) and busy day (≥two times the mean or more).The mean of daily delivery volume varied from 2.0 to 12.6 between the smallest and the largest hospital, respectively in hospital categories C1 and C4. The daily delivery volume was optimal in 41.2%, 68.3%, 84.0%, and 91.0% of the days in hospital categories C1, C2, C3, and C4, respectively. In the smallest hospitals (C1) almost half of the days appeared to be quiet (42.9%) whereas in the larger hospitals approximately one in four (25.4%), one in seven (13.6%), and less than one in ten of the days were quiet, in the categories C2, C3, and C4 respectively. Busy days were most common in the smallest hospitals (C1) where one in six of the day (15.9%) had daily delivery volume ≥two times the mean or more. In the other hospital categories busy days were rare, and the lowest in the largest hospitals.Unevenness in daily patient flow was more prominent in the smaller delivery units compared to larger ones. Quiet and busy days both caused challenges to delivery unit organisations. During quiet days, fully over-resourcing of staffing occurred whereas during busy days there was a risk of under-resourcing. It is possible to optimise the size of delivery units to minimise the variation of the daily patient flow to decrease the number of quiet and busy days.

OBJECTIVES Hospital mergers and acquisitions are increasingly used as a strategy to facilitate value-based care. However, no studies have assessed health care utilization (HCU) and patient flow across merged institutions. We aim to evaluate patient population distribution, HCU, and patient flow across a recent hospital merger of an academic medical center (AMC), a primary and specialty care alliance (PSC), and a community-based medical center (CMC). STUDY DESIGN This was a retrospective observational study. METHODS The study used 2018 adult demographic and encounter data from electronic health records. Patients' parent health care institution was determined by the most frequently visited site of face-to-face visits. Differences in patient demographics and HCU (ie, emergency department [ED] visits, hospitalizations, primary care visits) were compared. Independent factors associated with utilization were identified using adjusted logistic regression models. RESULTS A total of 406,303 adult patients were identified in the cohort. The PSC setting, compared with the AMC and the CMC, had significantly more female (62.7% vs 54.4% and 58.5%, respectively), older (mean [SD] age, 52.0 [18.1] vs 51.1 [17.8] and 49.2 [17.8] years), and privately insured (63.6% vs 51.3% and 56.0%) patients. A higher proportion of patients at the CMC (27.5%) visited the ED compared with patients at the AMC (10.8%). Approximately 1645 primary care patients (7%) at the CMC setting went to the AMC for specialized care such as oncology, surgery, and neurology. CONCLUSIONS Hospital mergers are increasing across the United States, allowing AMCs to expand their reach. These findings suggest that patients mainly sought care at their parent health care institution, yet appropriately received specialized care at the AMC. These results provide insights for future mergers and guide resource allocation and opportunities for improving care delivery.

Australia is rapidly moving towards 'living with COVID-19', with relaxation of some public health measures. The number of severe cases of COVID-19 may be mitigated by vaccination, but 'living with COVID-19' will be associated with higher number of patients seeking emergency care. This impending impact on the emergency care system requires recognition, monitoring and co-ordinated management. Current challenges include a lack of emergency care monitoring systems, staff shortages and patient flow processes that are quickly overwhelmed by large numbers, particularly in a system already operating at capacity. Effective monitoring systems are required for health systems to proactively detect and respond to stresses. Additional solutions include public health messaging and clinical innovation to facilitate care of the right patient in the right place at the right time. Optimising staff numbers and morale, and efficient patient flow, are integral steps to increasing capacity within the emergency care system.

Aim A full-cycle audit was conducted at our plastic surgery unit, assessing adherence to hand trauma standards by the British Society for Surgery of the Hand. These stipulate that time from referral to clinic for open injuries and closed fractures should be within 24 hours and 72 hours respectively and time to theatre from date of injury (DOI) within 4 and 7 days, respectively. Method Data for the initial audit was collected from Nov 2019-Feb 2020 and for the re-audit from Aug-Dec 2020. Lists were generated of 50 patients with open injuries including flexor tendon, extensor tendon and nerve injuries and 50 hand fractures in both cycles. Data was collected on DOI, date of referral, clinic review and surgery. Results The initial audit results showed poor DOI documentation (open injuries 30%, fractures 54%). For open injuries, 44% met standards for clinical review within 24 hours and 94% for time to theatre. For fractures, 94% met the standard for time to clinic and 90% for time to theatre. The interventions included adding the standards to the clinic booking form and creating a mandatory DOI field on the referral system. The re-audit showed improvement of DOI documentation (open injuries 95%, fractures 100%) and the proportion of open injuries seen within 24 hours to 60%. Conclusions The interventions had a positive impact on our hand trauma pathway. Areas for improvement include reducing the number of patient visits to the service and encouraging early decision-making, particularly for patients reviewed in the emergency department.

Purpose of review Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) impacted every facet of hematopoietic cell transplantation. This article reviews the adjustments to recipient and donor care that occurred in response to this unprecedented event. Recent findings Transplant centers modified algorithms, patient flow, education, and how we provided care. Our donor center partners reworked how donors were evaluated and products delivered to the transplant center. Our professional societies provided guidelines for patient and donor care and rapidly modified these based upon the never-ending stream of new data learned about SARS-CoV-2. Our research organizations provided rapid analyses to ensure the care modifications necessitated did not have a profound negative impact on our patients or donors. Summary The efforts of transplant providers and donor centers worldwide allowed patients to receive the transplant needed with assurances that they were receiving the best care available despite the worldwide challenge.

Transitions between care settings are common in the last weeks of life, particularly between the home and hospital. This chapter explores patient journeys using the model of integrated palliative care: content of care, patient flow, information logistics, and availability of resources. It emphasises the importance of good communication and effective targeting of resources. Institutions such as hospitals operate with an acute care or “rescue” ideology that emphasises medical interventions and may make it more difficult to manage dying as a natural process. Services need to be configured in ways that respond to the changing needs of the dying patient. The chapter explores recent innovative projects that aim to simplify and streamline the patient journey.

Outpatient parenteral administration of medications and blood transfusions using an outpatient parenteral antibiotic therapy (OPAT) unit has gradually become a standard of care. We report a continuous quality improvement project that was conducted on an OPAT unit of a tertiary care cancer hospital in Lahore, Pakistan. Prior to the initiation of the project, it was identified that 52% of the patient encounters in the OPAT unit were being delayed by a median of 63.5 minutes. A cause-and-effect analysis was performed, using a fishbone diagram, to identify the reasons for the delay in appointments. Based on the findings, several modifications were made to the processes of the OPAT unit including, but not limited to, a computerised physician order entry (CPOE) system module for prescribing, dispensing, reviewing and dispensing medications, changes in the nursing and staffing roster, and assignment of additional duties to the ward clerks. These changes resulted in improvement of waiting time to a median of 24.5 minutes and percentage delay in patient meetings decreased to 18%. Likewise, in 2019, 5,399 (27%) more patient meetings took place compared with 2018, which would have otherwise costed the hospital between 21.28 to 45.85 million Pakistani rupees. The use of continuous quality improvement techniques in the OPAT unit can result in substantial and appropriate changes in the process of patient flow, leading to measurable and significant reductions in the variability of care, and optimisation of service.

We report the case of an asymptomatic (no fever, no cough, no dyspnea) 80-year-old woman who had an F-FDG PET/CT scan for initial staging of Lieberkuhnian adenocarcinoma located on anal canal. Chest analysis incidentally revealed bilateral diffuse patchy ground-glass opacity with mild increasing F-FDG uptake, consistent with incidental COVID-19 infection finding during the March 2020 pandemic. The infection was confirmed by reverse transcription-polymerase chain reaction. It led us to improve patient flow and to undertake broader measures to avoid patient clinical issues and potential disease spreading.

Biographies Adam Harvey-Sullivan MB BS MA is a junior doctor living and working in East London. Currently whilst continuing clinical work he is studying for a Masters in Public Health at the London School of Hygiene and Tropical Medicine. He gained a degree in Natural Sciences from the University of Cambridge before going on to qualify in Medicine from Imperial College, London. This August he will start an Academic Clinical Fellowship in General Practice at Queen Mary’s University in East London. He has an interest in medical education, health inequalities and the wider social, political and ecological determinants of health. Tom Sullivan MB BS MA MRCS studied medicine at the University of Cambridge and Imperial College London, qualifying in 2017. He is a Clinical Fellow in general and trauma surgery at a London teaching hospital. Adam : I would say the key messages are for colleagues to be patient and kind with each other. We are going through an extraordinary event at the moment and the NHS is having to adapt faster than ever in its existence. On the ground, this means significant and evolving changes to our behaviours ranging from interactions with patients and relatives to donning/doffing of PPE and coordinating patient flow. We are all learning as we go and there will be mistakes and disagreements. When these happen we need to support each other. Tom : Leaders are not expected to have all the answers right away. We all know that this is a situation with no precedent in most of our lifetimes. We know that it is fast moving and that trying to respond and plan (whether day by day, or looking months and years ahead) has myriad unknowns and challenges. Plans will have to change and strong leadership will involve admitting when something is not working. …

Objective: To show how interrupted time series can be used to isolate and measure the impact of process improvement while accounting for confounders often present in complex hospital operations. Me...

Background Patient flow, the movement of patients is an integral part of the patient care pathway. With the goal of improving overall patient care and discharge planning, a hospital wide, multidisciplinary team based, patient discharge meeting or ‘HUDDLE’ was devised with the goal of facilitating onward care planning for all inpatients especially those with complex discharge needs in a city centre teaching hospital. Methods The patient flow huddle has evolved to include a Patient Flow Clinical Nurse Manager, Bed Manager, Medicine for Older Persons Clinical Nurse Specialist, Physiotherapist/Occupational Therapist, Consultant Geriatrician and Geriatric Medicine Registrar. Each team in the hospital are requested to attend at least twice a week. Predicted discharge dates are established. Teams discuss patients who have a requirement for rehabilitation, either short-term or complex rehabilitation and patients over 65 years who may need review from Older Persons Services .We sought to optimise issues including housing, home care packages, interim home supports, community intervention team referrals, integrated care and Nursing Home Support Scheme applications. Results There were 3918 Emergency Department presentations by adults over 75 in 2018 and 2113 admissions (3704, 2081 respectively in 2017). Accuracy for discharge within one day of PDD ranged from 52.5% (Jan) to 72.6 % (Nov). The average length of stay was 6.2days (SD 0.47). 172 patients (84 female, 88 male) were admitted for slow stream rehabilitation (median length of stay 30 days). Conclusion Rather than using a negative view of older adults as potential ‘bed blockers’, the discharge huddle allowed a pro-active approach to assist medical and surgical teams in the management and re-enablement of patients with complex care needs. Early identification of such patients with complex care and discharge needs allowed greater focus on appropriate planning earlier in the patient’s hospital journey.

Objective: The objective of this study is to assess the impact of a multimodal intervention on emergency department (ED) crowding and patient flow in a Dutch level 1 trauma center. Methods: In this cross-sectional study, we compare ED crowding and patient flow between a 9-month pre-intervention period and a 9-month intervention period, during peak hours and overall (24/7). The multimodal intervention included (1) adding an emergency nurse practitioner (ENP) and (2) five medical specialists during peak hours to the 24/7 available emergency physicians (EPs), (3) a Lean programme to improve radiology turnaround times, and (4) extending the admission offices' openings hours. Crowding is measured with the modified National ED OverCrowding Score (mNEDOCS). Furthermore, radiology turnaround times, patients' length of stay (LOS), proportion of patients leaving without being seen (LWBS) by a medical provider, and unscheduled representations are assessed. Results: The number of ED visits were grossly similar in the two periods during peak hours (15,558 ED visits in the pre-intervention period and 15,550 in the intervention period) and overall (31,891 ED visits in the pre-intervention period vs. 32,121 in the intervention period). During peak hours, ED crowding fell from 18.6% (pre-intervention period) to 3.5% (intervention period), radiology turnaround times decreased from an average of 91 min (interquartile range 45-256 min) to 50 min (IQR 30-106 min., p < 0.001) and LOS reduced with 13 min per patient from 167 to 154 min (p < 0.001). For surgery, neurology and cardiology patients, LOS reduced significantly (with 17 min, 25 min, and 8 min. respectively), while not changing for internal medicine patients. Overall, crowding, radiology turnaround times and LOS also decreased. Less patients LWBS in the intervention period (270 patients vs. 348 patients, p < 0.001) and less patients represented unscheduled within 1 week after the initial ED visit: 864 (2.7%) in the pre-intervention period vs. 645 (2.0%) patients in the intervention period, p < 0.001. Conclusions: In this hospital, a multimodal intervention successfully reduces crowding, radiology turnaround times, patients' LOS, number of patients LWBS and the number of unscheduled return visits, suggesting improved ED processes. Further research is required on total costs of care and long-term effects.

Effective communication between nurses and physician teams on the internal medicine unit is crucial for high quality, safe, and efficient patient care. In our hospital of interest, a large academic...

Objective To describe the numbers and length of stay (LOS) of patients with mental health (MH) problems at a Dutch emergency department (ED) and the effect of a psychiatric intervention team (PIT) on patient flow. Methods A longitudinal design was used to assess number of MH presentations and LOS during a 3-year period (2014–2016). In 2017, we introduced a PIT during ED peak hours, to reduce LOS for patients with MH problems. We evaluate the effects of the PIT on patients’ LOS with an 18-month before and after intervention study (2017–2018). Results Total number of ED presentations increased with 4%. Total number of MH presentations increased with 23% from 2014 to 2016. LOS increased by 28 min (95 min vs. 123 min) for all presentations, while not changing for MH presentations (2014: 195 min, interquartile range (IQR) 120–293 and 2016: 190 min, IQR 116–296). In the before and after intervention study, number of MH presentations increased with 36% while LOS decreased with 46 min (p Conclusions The number of MH presentations increased over the three years while LOS remained similar. In the before and after intervention study, number of presentations increased even more while LOS decreased significantly. Specialist psychiatric input reduces ED LOS.

PURPOSE: The National Comprehensive Cancer Network (NCCN) formed an Infusion Efficiency Workgroup to determine best practices for operating efficient and effective infusion centers. METHODS: The Workgroup conducted three surveys that were distributed to NCCN member institutions regarding average patient wait time, chemotherapy premixing practices, infusion chair use, and premedication protocols. To assess chair use, the Workgroup identified and defined five components of chair time. RESULTS: The average patient wait time in infusion centers ranged from 25 to 102 minutes (n = 23; mean, 58 minutes). Five of 26 cancer centers (19%) routinely mix chemotherapy drugs before patient arrival for patients meeting specified criteria. Total planned chair time for subsequent doses of the same drug regimens for the same diseases varied greatly among centers, as follows: Administration of doxorubicin and cyclophosphamide ranged from 85 to 240 minutes (n = 22); of FOLFIRINOX (folinic acid, fluorouracil, irinotecan hydrochloride, and oxaliplation) ranged from 270 to 420 minutes (n = 22); of rituximab ranged from 120 to 350 minutes (n = 21); of paclitaxel plus carboplatin ranged from 255 to 380 minutes (n = 21); and of zoledronic acid ranged from 30 to 150 minutes (n = 22) for planned total chair time. Cancer centers were found to use different premedication regimens with varying administration routes that ranged in administration times from zero to 60 minutes. CONCLUSION: There is a high degree of variation among cancer centers in regard to planned chair time for the same chemotherapy regimens, providing opportunities for improved efficiency, increased revenue, and more standardization across centers. The NCCN Workgroup demonstrates potential revenue impact and provides recommendations for cancer centers to move toward more efficient and more standard practices.

The article is devoted to the mechanisms and epidemiological aspects and diseases arriving in emergency department patients. On the basis of the conducted analysis, identified promising group to increase patient flow in the emergency department. The problems identified in the course of work and ways of their solution.

Background We seek to determine if experienced emergency medicine physicians can accurately predict the likelihood of admission for patients at the time of triage. Such predictions, if proven to be accurate, could decrease the time spent in the ED for patients who will ultimately be admitted by hastening downstream workflow. Methods This is a prospective cohort study of experienced physicians at a large urban hospital. Physicians were asked to predict the likelihood of admission for patients based only on information available in the EMR at the time of triage. Physicians also predicted the service to which the patients would be admitted. Physicians provided a confidence level of their prediction. Measures of predictive accuracy were calculated, including sensitivity, specificity, and area under the receiver operating characteristic curve. Results 35 physicians evaluated 398 patient charts and made predictions. Sensitivity of determining admission for the entire cohort was 51.8%. The specificity was 89.1%. For those predictions made with a confidence level of >90%, sensitivity was 61.5% and specificity was 95.7%. Among physicians correctly predicting admission, the admitting service was predicted accurately 88.6% of the time. Conclusion Physicians performed poorly at predicting which patients would be admitted at the time of triage, even when they were confident in their predictions. Conversely, physicians accurately predicted who would be discharged. Physicians predicted with reasonable accuracy the service to which patients were ultimately admitted. More research and operational assessment needs to be performed to determine if these predictions can help improve ED efficiency.

Objective.To perform comparative assessment and identification of determinants of efficiency of the centralized system for delivery of specialized medical care to victims with acute spinal cord injury in the modern metropolis.Material and Methods.The results of specialized medical care delivered to 2283 victims with acute spinal cord injuries were studied. The comparison group (decentralized system: treatment in several multidisciplinary hospitals in St. Petersburg) included 306 patients, and study group (centralized system: treatment in a specialized urban center for emergency spinal surgery) – 1977. Comparative analysis of the results of surgical treatment included 44 patients from comparison group and 223 patients from the study group (p> 0.05). The methods of non-parametric statistics were used.Results.The centralized treatment system is characterized by a statistically significant increase in the rate of surgical activity, a manifold increase in the proportion of emergency spinal surgery (p < 0.01) and the mandatory use of modern technologies for surgical stabilization of the spine, shortening the hospital stay, as well as higher values of all indicators characterizing the results of treatment (p < 0.01).Conclusion.In a large city, the centralized system of treating victims with spinal cord injury is characterized by more efficient use of urban health resources and better treatment outcomes. The key to its successful creation and subsequent operation, in addition to the centralization of medical care with the reasonable formation and distribution of the incoming patient flow, adequate logistic support for the treatment process and the presence of highly qualified medical personnel, is the availability of modern surgical technologies in delivering specialized emergency care.

Purpose: The aim was to find the ideal time for the patients to know all the necessary information about their health from the doctor in the clinic and increase the performance of clinics in a better way. Methods: Observational study was conducted at the General Surgery and Cardiology clinics in general outpatient department of a tertiary care hospital in Riyadh, from Feb 2016 to Mar 2017. The time points of 202 randomly selected patients—Arrival time, Appointment time, Entry time & Exit time were recorded using a standardized questionnaire and analyzed using SPSS 21. Results: From Cardiology department, 60 (58.8%) from the forenoon clinic, 42 (41.2%) post noon clinics and that of General surgery department, 76 (76.0%) were from the forenoon and 24 (24.0%) post noon clinics. The overall median waiting time was 29 mts with interquartile range from (11 - 51) mts and a 95% confidence interval for mean between (29 - 41) mts for cardiology and for general surgery, it was 24 mts with interquartile range from 6 mts to 1 hr and 4 mts. The median utilization time was 8 mts with an interquartile range (5 - 11) mts for cardiology and 10 mts with an interquartile range (10 - 15) mts for general surgery respectively. The Pearson’s coefficient of correlation between entry time & exit time was r = 0.96 (P < 0.001) for Cardiology and r = 0.66 (P < 0.001) for general surgery. Conclusions: This study was useful in assessing clinic efficiency and patient flow. A significant relationship was detected between allocated time and actual time spent by the patient in the clinic. This data helped in designing interventions that increase efficient use of resources and improve scheduling patterns.

During the COVID-19 pandemic, the number of visits in emergency departments (ED) worldwide decreased significantly based on several studies. This study aims to compare the patient flow in the emergency surgery department during the COVID-19 pandemic and a control period in the emergency department of a public tertiary care hospital in Greece. The overall patient flow reduction regarding the ED visits between the two examined periods was 49.07%. The emergency surgery department’s corresponding visits were 235 and 552, respectively, which indicated an overall patient flow decrease of 57.43%. Chi-square analysis showed that age groups and ambulance use had statistically significant associations with the periods examined. An independent samples t-test was applied and deduced that the average patient’s age was statistically significantly higher in the COVID-19 pandemic than in the non-pandemic period. By analyzing hospital information system data, useful conclusions can be drawn to prepare a surgical emergency unit better and optimize resource allocation in a healthcare facility in similar critical situations.

Background Overcrowding of the Emergency Department is rapidly becoming a global challenge and a major source of concern for emergency physicians. The desire to improve Emergency Department throughput requires novel approaches to patient flow. Materials and methods We conducted a prospective and cluster-randomized study, to evaluate the impact in patient outcomes of a new patient flow based on Point-of-Care Testing (POCT). A total of 380 Emergency Severity Level-3 patients were enrolled and studied in two different groups, interventional arm (laboratory analyses performed on POCT analyzers implemented in the Emergency Department) or control arm (central laboratory). The primary outcome was the Emergency Department length of stay. Secondary outcome included the time to first medical intervention, the laboratory turnaround time and the time to disposition decision. Readmission within the 7 days after discharge was also calculated. Results Length of stay significantly decreased by 88.50 min (from 247.00 to 158.50), time to disposition decision by 89.00 min (from 192.00 to 103.00) and laboratory turnaround time by 67.11 min (from 89.84 to 22.73) in the POCT group. No increase in readmission was found. Conclusion Our strategy based on POCT represents a good approach to optimize patient flow in the Emergency Department and it should be seen as a starting point for further studies focusing on improving throughput.

Introduction The COVID-19 pandemic has seen fundamental organisational changes to emergency departments internationally. Specialties throughout the hospital setting have been asked to change their working practice, often with the aim of adapting to new processes in emergency departments. Early in the pandemic, the orthopaedic team at one district general hospital were required to provide 24/7 onsite cover in a multi-specialty area. Confusion over the referral pathways of two specialties (orthopaedics and plastic surgery) led to increase waiting times, constrained patient flow and poor patient and staff satisfaction. Method This quality improvement project occurred over three cycles of data collection and intervention over a two-month period. A novel referral pathway was developed and implemented after discussion with consultants in orthopaedics, plastics, and emergency medicine. Interventions included staff teaching, clarifying of roles at morning meetings and the deployment of posters. Results In cycle 1, 39% of orthopaedic referrals were inappropriately referred. By cycle 3, 0% of orthopaedic patients were inappropriately referred. Average time in department for patients referred to orthopaedics improved from 124 minutes to 88 minutes. Staff reported increased satisfaction, with appreciation for the clarification on referral criteria. Conclusions This QUIP demonstrates how simple interventions during times of crisis can solve complex organisational issues.