Simulating a Medical Observation Unit for a Pediatric Emergency Department. Mark Grum July 29 th, 2015
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1 Simulating a Medical Observation Unit for a Pediatric Emergency Department Mark Grum July 29 th, 2015
2 Acknowledgements Amy Cohn, Ph.D Gabriel Zayas-Caban, Ph.D Michelle Macy, MD Allison Cator, MD Hassan Abbas Valerie Washington Luke Stumpos Eli Sherman Paige Mollison Molly Laux Andrea Bouwhuis Henry Ballout Anna Munaco 2
3 Agenda Background Goals Methods Results Future Work 3
4 What is an Observation Unit? Dedicated area for Emergency Department (ED) Patients need extended time period (<24 hours) Evaluation Monitoring Treatments and patients response Too sick to leave, not sick enough to be admitted 4
5 Why Observation? Benefits: Improved quality of care Decreased ED revisits Decreased readmission rates Shorter lengths of stay Reduced health care costs 5
6 C.S. Mott Children s Hospital Children s Emergency Services 28 ED beds Over 25,000 visits per year No observation unit Use observation protocol 6
7 How Observation can be Structured Location Unit Scattered Beds Process of Care Observation Protocol Gold Standard Current State 7
8 Goals Determine how an observation unit would benefit the Mott ED How many beds? What policies should be implemented? 8
9 How Many Beds? Little s Law Determine occupancy rate Formula: L = λw L : average number of patients in the ED λ : arrival rate of patients W : time spent in the system; length of stay (LOS); throughput 9
10 How Many Beds? To determine the observation unit size N 0, we had to tweak Little s Law a bit λ = entire throughput of patients/day (63.16) Solution: multiply λ by f 0 f 0 = the fraction of patients/day who are put on observation status (.06) Final Formulation Used: N 0 = (f 0 λlos 0 ) / (Utilization Rate) 10
11 How Many Beds? Need to define Length of Stay (LOS) Input LOS obs Definition Time between the start of protocol and hospital discharge Value (Average) 0.47 days LOS total Time from ED arrival to ED exit (discharge or admit to inpatient) 0.85 days 11
12 How Many Beds? Assume utilization rate of.9 Input Definition Value Results LOS obs Time between the start of observation protocol and leaving ED 0.47 days N 0 = 2.3 beds ~3 beds LOS total Time from ED arrival to ED departure (discharge or admit) 0.85 days N 0 = 3.8 beds ~4 beds N 0 = (f 0 λlos 0 ) / (Utilization Rate) 12
13 How to Use the Observation Unit? Designed for observation patients Allows for boarding patients Patient taking up ED bed Time to First Treatment vs. Wait Time to Enter Observation Unit How do certain policies affect patients? 13
14 ED Observation Unit Entrance Blue = ED Patient Yellow = Observation Patient Red = Boarding Patient 14
15 ED Observation Unit Entrance Blue = ED Patient Yellow = Observation Patient Red = Boarding Patient 15
16 Simulation Model Tradeoffs Time to first treatment in ED Wait time to enter observation unit Arrival times for patients By hour of day By day of week Treatment Time (ED and observation) Boarding Time Based on time of day 16
17 Simulation Model Parameters Number of ED beds Number of observation beds Threshold of ED patients for boarding Number of observation beds for boarding patients 17
18 Simulation Model Baseline ED beds: 20 Observation beds: 2 ED Boarding Threshold: 18 Observation Beds for Boarding Patients: 0 18
19 Hour of Day Hour of Day Baseline Results ED Beds: 20 Observation Beds: 2 ED Threshold: 18 Beds for Boarding: 0 Time to First Treatment (mins) Wait Time to Enter Observation Unit (mins) S M Tu W Th F S S M Tu W Th F S
20 Hour of Day Hour of Day Scenario 1: More Observation Beds ED Beds: 20 Observation Beds: 4 ED Threshold: 18 Beds for Boarding: 0 Time to First Treatment (mins) Time to First Treatment (mins) S M Tu W Th F S S M Tu W Th F S
21 Hour of Day Hour of Day Scenario 1: More Observation Beds ED Beds: 20 Observation Beds: 4 ED Threshold: 18 Beds for Boarding: 0 Wait Time to Enter Observation Unit (mins) S M Tu W Th F S Wait Time to Enter Observation Unit (mins) S M Tu W Th F S
22 Hour of Day Hour of Day Scenario 2: Adding Flexibility ED Beds: 20 Observation Beds: 4 ED Threshold: 18 Beds for Boarding: 4 Time to First Treatment (mins) Time to First Treatment (mins) S M Tu W Th F S S M Tu W Th F S
23 Hour of Day Hour of Day Scenario 2: Adding Flexibility ED Beds: 20 Observation Beds: 4 ED Threshold: 18 Beds for Boarding: 4 Wait Time to Enter Observation Unit (mins) S M Tu W Th F S Wait Time to Enter Observation Unit (mins) S M Tu W Th F S
24 Summary of Scenarios Flexibility Allows for short first treatment time Increases time to get into observation unit Small observation units need restricted beds 24
25 Future Work Change parameters Capacities and thresholds Modify observation patients Other methods to determine how many beds 25
26 Acknowledgements Center for Healthcare Engineering and Patient Safety (CHEPS) C.S. Mott Children s Hospital The Seth Bonder Foundation The U of M Center for Research on Learning and Teaching (CRLT) The TDC Foundation 26
27 Thank You! Questions? Mark Grum
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