Process Improvement Approaches for Increasing the Response of Emergency Departments against the COVID-19 Pandemic: A Systematic Review

Abstract

The COVID-19 pandemic has strongly affected the dynamics of Emergency Departments (EDs) worldwide and has accentuated the need for tackling different operational inefficiencies that decrease the quality of care provided to infected patients. The EDs continue to struggle against this outbreak by implementing strategies maximizing their performance within an uncertain healthcare environment. The efforts, however, have remained insufficient in view of the growing number of admissions and increased severity of the coronavirus disease. Therefore, the primary aim of this paper is to review the literature on process improvement interventions focused on increasing the ED response to the current COVID-19 outbreak to delineate future research lines based on the gaps detected in the practical scenario. Therefore, we applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to perform a review containing the research papers published between December 2019 and April 2021 using ISI Web of Science, Scopus, PubMed, IEEE, Google Scholar, and Science Direct databases. The articles were further classified taking into account the research domain, primary aim, journal, and publication year. A total of 65 papers disseminated in 51 journals were concluded to satisfy the inclusion criteria. Our review found that most applications have been directed towards predicting the health outcomes in COVID-19 patients through machine learning and data analytics techniques. In the overarching pandemic, healthcare decision makers are strongly recommended to integrate artificial intelligence techniques with approaches from the operations research (OR) and quality management domains to upgrade the ED performance under social-economic restrictions.

Modelling Granular Process Flow Information to Reduce Bottlenecks in the Emergency Department

“…The specific factors driving ED crowding vary based on the local context of a hospital, and the success of any process improvement initiative is highly dependent on the process of identifying the causes and, subsequently, addressing them sustainably. Improvement approaches can only be successfully adopted if these are contextualised to a particular hospital [18]. This underscores the need to first develop accurate representations of an ED's processes by modelling information about these processes at the granular level.…”

“…To date, several approaches have been trialled to address ED bottlenecks [18,23,34,35,[56][57][58]. Some of these have involved real-world interventions such as doctor-led triage, rapid assessment, fast tracking, streaming, alternative admission options during periods of access block, expansion of nursing scope of practice, the co-location of a primary care clinician in the ED, and Point-of-Care Testing (POCT), which have yielded varying degrees of success [34,56,58].…”

“…Timely care is an important quality indicator (QI) in emergency departments (ED) [1][2][3][4][5][6][7][8]. At the same time, EDs are experiencing unprecedented rises in demand [5,[9][10][11][12][13][14][15][16][17][18]. Moreover, the case-mix of the demand is also changing since, in addition to the critically ill, EDs are seeing more cases with chronic illnesses [19], medical patients with complex symptoms [20], as well as non-urgent presentations [21], putting additional pressures on resources and clinician time.…”

Examining patient flow in a tertiary hospital’s emergency department at a low coronavirus prevalence region

“…The COVID-19 pandemic has posed a dramatic, unexpected, and unprecedented burden on many healthcare systems worldwide. Universally decreased numbers of ED visits by age, disease categories, and the characteristics and case severity of patients have been revealed by anecdotal reports [18][19][20][21][22][23][24][25][26][27][28][29][31][32][33][34][35][36]. Most studies originated from severe pandemic areas that analyzed the change in the early stage (4-8 weeks) of the COVID-19 outbreak and reported a significant decrease, ranging from 31.0 to 63.5%, in ED patient flow compared to a historical control period [18,19,21,23,27,31,34].…”

“…Identifying changes in the pattern of patient flow in the ED is important for preparedness and mitigation. During the early days of the COVID-19 pandemic, a characteristic change and significant decrease in the number of patients who came to the ED with complaints unrelated to COVID-19 was reported [18][19][20][21][22][23][24][25][26][27][28][29], mostly in devastated regions, limited sections, or only for a short period of observation. However, the impact of patient flow throughout the pandemic year on the ED of a tertiary hospital, in a low-prevalence region, has not been comprehensively examined, especially in a health system that from April to December 2020 (i.e., 253 days) had no locally transmitted cases reported [30].…”