Emergency Room Operation free essay sample

In other words, the ER’s primary target group of patients is those with a sudden and unexpected need for medical services and attentions at any given time. In general, the ER must be able to provide initial diagnosis and treatment for a broad range of illnesses and injuries, some of which are more crucial than others and may require greater and immediate care. Hence, ER patients can be generally classified into two categories, which we define to be ‘light’ patients and ‘emergency’ patients. There is the issue that emergency patients should be placed under a greater priority to medical services and attention as compared to ordinary patients, who are less severely injured or ill. Given that patient arrivals follow a Poisson distribution (randomly), in order to cater to irregular service demand, the ER generally operates 24 hours around the clock comprising of both day-shift duties and night-shift duties, usually with a variable staffing level to mirror general patient volume. Therefore, due to the critical nature of the ER’s services whereby timeliness and efficiency are of utmost importance, there are various service protocols such as effective situational queuing models that the department must follow to fairly determine and allocate service priorities to each different patient to ensure that they receive the necessary timely medical attention. 2. 0 Problem Recognition The Revision of Emergency Duty Law 2. 1 Rationale for the revision of Emergency Duty Law In August 5th 2012, the Ministry of Health and Welfare had revised the Emergency Duty Law governing emergency rooms in the hospitals. Before the revision, the emergency room generally employed the help of residents. However, the main intent of the revision of the revision of the law is to ensure that every emergency room should have at least 1 specialist and 5 nurses on night duty. After the revision, on-duty residents now first assesses the patients, and if the patients are unable to be treated properly by the residents, they are subsequently assessed by the on-duty specialist, taking over what was usually the job of a senior resident before the law revision. It is a requirement that the names of the on-duty specialist must be posted publicly. In addition, it is also required that even the specialists who are not on night duty must assume duty if the on-duty resident requests for it (on-call). Potential suspension of license or penalty will be imposed under violation of this law. 2. 2 The Problem Two bottlenecks have been identified to appear after the emergency duty law revision. The first bottleneck appeared at the stage of assessment by duty residents because of the publicly posted name list of the on-duty specialist. Many light patients have a tendency to visit emergency room during the night because they don’t want to use their day hours. As previously mentioned, light patients require less urgent medical attention, so they are able to spend time to consider and be selective of the on-duty specialists when they go to the emergency room. This behavior reflects the patients’ preference of choice of doctors. This resulted in an excess number of light patients seeking medical treatments on particular days, causing the first bottleneck. The second bottleneck is caused by a shortage of specialists. On-duty residents who take first examination may have a tendency to avoid difficult patients. Therefore, on-duty residents impute a heavier responsibility to on-duty specialists. Before the revision, there were three stages for treatment, but now, there are only two stages. In this case, night duty specialists who take second examinations will have to assess a large amount of patients. It is difficult to meet the required the number of duty specialists in small hospital. In Korea, most of the big main hospitals are located in the big city. In small cities or towns, there are only small hospitals. It is an issue that small hospitals often do not have enough on-duty specialists, so they have to close their emergency room. This results in the emergency patients who are in need of immediate medical attention from the small cities or towns seeking treatment from big city hospitals. This poses a critical problem whereby it takes a certain amount of precious time to shift to a big city hospital. In the case of very urgent emergency patients in small cities, it can be life threatening. 2. 3 Example In ‘ ’ which is very famous in Korea, they broadcasted an accident which was caused by the revision of the emergency duty law. Because of the new law, in Eusung in Kyong-buk, there was no emergency room. If there are emergency patients, they had to move to Andong or Sangju, which takes about 30 minutes to an hour. Evidently, Eusung covers a very large area, two times bigger than that of Seoul. In this traffic accident in Eusung, there was an old married couple that was severely hurt, but was unable to obtain medical treatment in Eusung, hence proceded to seek treatment in Andong. The journey to Andong took about 30 minutes itself, and after they finally arrived at emergency room, the woman had unfortunately passed away. 3. 0 Analysis for a Service Blueprint of ER When a patient first enters the ER, a triage is performed, whereby priorities for action in an emergency are determined. After the patient is categorized according to the seriousness of his or her illness or injury, he or she sees a doctor for the first time. Because it is mandatory for all patients to undergo registration for treatment, the patient goes to reception area and pays a fee for the medical examination. Then the patient goes through the necessary X-ray, CT, or blood tests for proper inspection. After the whole test inspection is finished, an on-duty resident in charge of diagnosis in the ER diagnoses the patient’s case. Since the resident is a non-specialist doctor, he or she sometimes meets difficulty in accurate medical diagnosis. Before the revision of emergency duty law, the on-duty resident hands over the case to more experienced senior residents. When the patient is still unable to be adequately treated by the senior residents, the on-duty specialist then has a responsibility to treat the patient. However, as the revision of emergency duty law came into effect, the on-duty resident now hands over the case directly to an on-duty specialist. The on-duty specialist resolves the problem and promptly sends the patient to the nurses for allocation of a hospital room. The patient will then be hospitalized for a few days. After the emergency duty law revision, the on-duty specialist suffers an increased amount of workload because there is no involvement of senior residents in ER process. What is depicted is a condensed case of ER process. The chart below records the waiting time and lead-time of each ER process as well as net average of those processes. Process| Average Waiting Headcount| Average Waiting Time| Net Average Waiting Time| Net Average Lead Time| Triage| 0. 3| 6. 25| 3. 837| 5. 254| Exam| 1. 06| 8. 46| | | Reg/Pay| 4. 02| 14. 37| | | X-ray| 6. 13| 77. 07| | | CT| 0. 98| 31. 91| | | Blood test| 0. 87| 11. 69| | | Diagnosis| 5. 61| 32. 40| | | Cooperative treatment| 2. 26| 60. 11| | | Room allocation| 4. 19| 86. 82| | | Preparation for Hospitalization| 3. 29| 77. 01| | | Reference: (2010, ) 3. 1 Blueprint of ER- Before the Revision Figure I: Blueprint of ER- Before the Revision This is a blueprint of ER before the emergency duty law revision. As you can see in the case above, the maximum number of assessment stages a patient can go through is three. They are a series of assessments done by on-duty residents, senior residents and on-duty specialists. 3. 2 Blueprint of ER- After the Revision B B A A Patients come Assessed by duty residents Triage X-ray CT Blood check Assessed by duty specialist Being treated and prescribing medicine Go home or hospitalization Diagnosis assistance Diagnosis Procedure Untreatable Treatable Patients come Assessed by duty residents Triage X-ray CT Blood check Assessed by duty specialist Being treated and prescribing medicine Go home or hospitalization Diagnosis assistance Diagnosis Procedure Untreatable Treatable Figure II: Blueprint of ER- After the Revision This is a modified blueprint after the revision. Out of the three assessment stages, second assessment by senior residents was eliminated. When an on-duty resident is unable to treat his or her patients, the on-duty specialist in then directly in charge of the treatment. For that reason, the responsibility of a duty specialist is greatly increased in ER process. Postponement of his or her performance also means that the residual processes will be also delayed. 3. 3 Bottleneck Analysis As you can see on the blueprint, after the law revision, two bottlenecks had appeared. Under the revised law, the most remarkable transition of ER system is the elimination of the senior residents’ examinations, which was a stage that had existed between that of the on-duty residents and specialists. Source: Healthcare Process Patterns with Triage in the Emergency Department (2009, KORMS) The first bottleneck spot is shown at point ‘A’ on ‘Figure II: Blueprint of ER- After the Revision’. At this stage, many lightly injured/sick people are coming to the ER in the night. Even though these patients are lightly injured, on-duty residents have the duty to medically examine them no matter the varying degree of medical need. This is the first step of the ER rule. However, in comparison to the unrevised law, patients then could be sent to senior residents directly. However, there are now no senior residents on duty anymore under the revised law. Thus, duty residents have the responsibility to attend to all of patients that enter the ER at the same time. Moreover, the theory of FIFO (First In, First Out) is not applicable in the ER because different patients have varying degree of medical attention needs, whereby the emergency patients should be given priority treatment. This results in a more complex queuing situation whereby there can be no confirmed estimated queue time for that of light patients. The second bottleneck occurs at the on-duty specialists’ medical examinations. This is also due to the elimination of senior residents. The bottleneck is shown as point ‘B’ in Figure II. After the first examination, should the on-duty resident be unable to treat the patients, they are sent to the on-duty specialist under the revised law. It has been identified that the service quality can also pose a problem. Certain departments, such as obstetrics, often do not have enough specialists even during the day shifts. Because at least one specialist of each department should be on night duty, these departmental specialists’ night shift duty are of higher frequency as compared to that of specialists of other bigger departments. In small institutions, there are less than 2 specialists, which suggests high difficulty in allocating night duty shifts. It results in crowding of patients whereby the service demand outweighs that of service supply. This scheduling problem also leads to low quality of medical examinations during both day shifts and night shifts. In addition, it was previously mentioned that on-duty residents have strong tendency to transfer the patients to on-duty specialists. This is because the on-duty residents are generally unwilling to assume full responsibility should diagnosis go wrong with patients should they do not seek assistance from the more experienced specialists on duty. What is worse is that it is very difficult for small hospitals to hire more specialists who are willing to take night duty shifts. . 0 Solution Since the new duty law on ER has changed the service operation model dramatically, we need to find out the queuing duration for the previous service operations, current service operations under the new duty law and a few of our further suggestions. It is straightforward to develop a queuing model based on the equations such as M/M/1 of M/M/S. However since the basic characteristic of ER d oesn’t allow usage of the theory FIFO (First In, First Out) because of varying degrees of patient need and priority, we cannot apply a basic equation queuing model. Instead, we would use a simulation model (Extend ver. 4) FIFO that has a priority consideration function. 4. 1 Past Service Operation (Before the Emergency Duty Law Revision) Suppose each patient arrives every 4 minutes. (360 person / day) Given that the patient arrival follows an exponential distribution. Patients are categorized into 5 categories. Category 1 refers to very urgent patients, and category 5 to very light patients. Probability of each category is shown on the left picture. On-duty residents and senior residents take 5 minutes to examine the patients. And on-duty specialists take 10 minutes to examine one. We assume that all the patients just go through the duty residents to the more experienced specialists. The reason for this assumption is that many of the Korean patients do want to seek further medical treatment from the on-duty residents to that from the on-duty specialists because residents are often perceived to be less experienced and capable in comparison to the senior residents and specialists. In addition, on-duty residents have strong tendency to transfer patients to senior residents to lessen responsibility and burden. Furthermore, we assume that only 20% of the patients are sent to on-duty specialists because there are many senior residents who are sufficiently skilled. In reality, most examination processes end with medical assessment and treatment from the senior residents. Overall result of this modeling is shown below. Y axis = number of served patients X axis = time (1440 minutes = 1 day) 4. 2 Current Service Operation (After the Emergency Duty Law Revision) After the revision of the night duty law, on-duty specialists must take the second examination. There is no role for the senior residents in the examination process. All the patients go through on-duty residents and specialist to exit. Every input data in the model is same as previous one. Overall result is shown below. We can see that number of served patients had decreased dramatically after the law revision. Also, the overall queue duration had becomes longer compared to the prior one. 4. 3 Solution 1- Increasing the Number of Servers To overcome the illustrated situation after the law revision, we simply double the number of on-duty specialists. The rest of the input data still remains unchanged. Evident from the results, as a result of doubling the specialists, the number of served patients has recovered up to that of first model. Also, queue duration and volatility have improved. 4. 4 Solution 2 Adopting CP (Clinical Pathway) Before explaining the model, let us explain what the ‘CP’ is. The definition of CP is shown below. â€Å"Clinical pathways, also known as care pathways, critical pathways, integrated care pathways, or care maps, are one of the main tools used to manage the quality in healthcare concerning the standardization of care processes. It has been shown that their implementation reduces the variability in clinical practice and improves outcomes. Clinical pathways promote organized and efficient patient care based on evidence-based practice. Clinical pathways optimize outcomes in the acute care and home care settings. † (Source: Wikipedia) The table above is the example of CP for acute stroke. According to the research from Korean society of nursing science, examination time was reduced from average 74. 07 minutes to 19. 27 minutes. It is more than a 73% decrease. However, this figure is specific to the example of acute stroke, so we cannot be sure that other illnesses apply the same effect when adopting CP. Therefore, we adjust the examination time by only 20%. Now, duty residents and specialists only need 4 minutes and 8 minutes respectively. Previously, they needed 5 and 10 minutes each. The result is shown below. After adopting CP, the number of served patients was increased by 25%. Also, queue duration had dramatically reduced. 5. 0 Conclusion We had established that there were bottleneck problems because of the new law imposed in the ER. To handle this problem we suggested 2 possible solutions. The result of each situation is summarized in the table below. | Mean Number of Patients Being Served | Mean Maximum Queue Duration| Before Law Revision| 287| 68. 4| After Law Revision| 143| 76. 9| Doubling The Number of Specialists| 280| 68. 5| Adopting CP (reducing examination time by 20%)| 179| 21. 6| To generate the mean of each variable, we ran the simulation for 10 times each. There were clear improvements after implementing the solutions. Both the number of served patients and the maximum queue length had improved significantly. In terms of number of patients, doubling the specialists is the best way to enhance efficiency. However in reality, hiring more specialists is sometimes impossible for many hospitals. There is shortage of specialists as well as financial distress in hospital management. Therefore, adopting the solution of CP might be a better option. Although developing CP may need a lot of time and effort, once it is developed, it does not incur more costs. In addition, hospitals are able to co-operate with each other, so they can reduce initial cost for developing specific CP. Moreover, CP could bring greater impact than increasing the number of staffs in the long run. For example, as we mentioned above, the effect of CP for acute stroke is 73% decrease in examination time. To summarize, increasing the number of doctors is the simplest and most effective solution. Adopting the CP will be the second best solution. And the most desirable action to take is adopting CP and hiring more doctors at the same time. If it is not feasible, each hospital should consider its own situation and select its own appropriate solution.