Development of an observational instrument to determine variations in the patient care process and patient flow among emergency physicians and internists at the emergency department

Abstract

BackgroundThe increasing demand for acute care and restructuring of hospitals resulting in emergency department (ED) closures and fewer inpatient beds are reasons to improve ED efficiency. The approach towards the patient care process varies among doctors. The objective of this study was to determine variations in the patient care process and patient flow among emergency physicians (EP’s) and internists at the ED of Leiden University Medical Centre (LUMC), the Netherlands.MethodsAn observational instrument was developed during a pilot study at the LUMC ED, following observations of activities performed by EP’s and internists. The instrument divides all different types of activities a clinician can perform on the ED into eight categories. Using the observational instrument, their activities were observed and registered for 10 separate days. Primary outcomes were defined as the time spend on the eight separate activity categories, the total length of stay (LOS) and the number of patients seen during an interval. Secondary outcomes were general observations of working routine features that determine patient flow at the ED. The obtained data were analyzed into SPSS.ResultsTen doctors were observed during a total of ± 36 hours in which 42 patients were seen. Although EP’s were observed for a shorter period of time than internists (13:48 vs. 22:10 hrs, -38%), they saw more patients (26 vs. 16, +62%). EP’s tended to spend a higher proportion of their time on patient contact than internists (27.2% vs. 17.3%, p = 0.06). Both groups dedicated the highest proportion of their time to documentation (31.5% and 33.4%, p = 0.75) and had little communication with ED nurses (3.7% and 2.4% p = 0.57). The average LOS of internal patients was higher than that of EP’s patients (5.25 ± sd 1:33 and 2.26 ± sd 1:32 hours). Internists occupied more treatment rooms at the same time (2.41 vs. 2.08, p < 0.00) and followed a more sequential working routine.ConclusionsThis paper describes the determination of variations in the ED care process and patient flow among EP’s and internists by an observational instrument. A pilot study with the instrument showed variations in the patient care process and patient flow among the two groups at the LUMC ED.

Assigning treatment rooms at the Emergency Department

“…5, which is a typical result for a non-optimal policy. For the (4,2) policy, the norm will be exceeded for type 1 patients arriving in a system with 12 patients of their type present. For both policies, type 2 patients will never have an expected sojourn time exceeding the norm, but as the conditional expected sojourn time depends more on the number of type 2 patients in the system, it may exceed the norm for other values of (n 2 , r 2 , i 2 ).…”

“…Policies (δ 1 , δ 2 ) 1 (6, 6) * , (6,5), (6,4), (5, 6) * , (4, 6) * , (3,6), (2, 6) 2 (6, 6) * , (6, 5) * , (6, 4) * , (6, 3), (6, 2), (5, 6) * , (4, 6), (3, 6) * , (2, 6) 3 (6, 6) * , (6, 5) * , (6,4), (5,6), (4, 6) 4 (6, 6) * , (6,5), (6,4), (5,6), (4, 6) * , (3, 6) * , (2, 6) * RPC is also efficient according to simulation results.…”

“…In our study, since we only consider 66% of the patients, we assume that there are only five treatment rooms. For five treatment rooms, there exist 19 allowed room assignment policies: (5, 5), (5, 4), (5, 3), (5, 2), (5, 1), (4,5), (4,4), (4, 3), (4, 2), (4, 1), (3,5), (3,4), (3,3), (3,2), (2,5), (2,4), (2,3), (1,5), (1,4). There are two possible working routines for each doctor, thus the total number of RPCs investigated is 19 × 4 = 76.…”

“…Typically at an ED, one doctor occupies multiple rooms in parallel; when a patient requires diagnostic tests, the doctor visits other patients. Each specialty/doctor has a different working routine: Emergency Physicians are for example specially trained for only providing urgent care, while other doctors tend to provide care more like they are used to outside the ED [4]. As a consequence, sojourn and waiting times of different patient types differ significantly, and the room utilization can be unbalanced over the doctor types.…”

“…Therefore, governments have set legal norms on the waiting and sojourn times of patients visiting the ED. Meeting these norms is often difficult due to an increasing demand for acute care and the closure of many EDs and hospital beds [4].…”