Emergency department (ED) overcrowding is a global concern. To help mitigate this issue, this thesis studies impediments to efficient patient flow in the ED caused by suboptimal worker behaviors and patient routing policies. I focus on three issues:
(i) admission batching, (ii) hallway placement and (iii) under-triage behavior, and empirically demonstrate their impact on patient flow and quality of care. These studies are summarized as follows.
Admissions batching: We study the behavior of admitting patients back-to-back (i.e., batching) by ED physicians. Using data from a large hospital, we show that the probability of batching admissions is increasing in the hour of an ED physician’s
shift, and that batched patients experience a longer delay from hospital admission to receiving an inpatient bed. We further show that this effect is partially due to the increase in the coefficient of variation of inpatient bed-requests caused by batching.
However, we also find that batching admissions is associated with a higher shift-level productivity. An important implication of our work is that workers may induce delays in downstream stages, caused by practices that increase their productivity.
Hallway utilization: A common practice in busy EDs is to admit patients from the waiting area to hallway beds as the regular beds fill up. Using data from a large ED, we first perform a causal analysis to quantify the impact of hallway placement on wait times and quality of care – as defined by disposition time, room-to-departure (R2D) time and likelihood of adverse outcomes. We find that patients admitted to the hallway experience a significantly lower door-to-doctor time at the cost of longer disposition and R2D times. Hallway patients are also substantially more likely to experience an adverse outcome. Next, using a counterfactual analysis we show that a pooling policy, where hallway beds are used only if all regular beds are full, significantly reduces wait times, albeit at the cost of a slightly higher hallway utilization. Also, too little or too much wait tolerance for rooming patients may result in under- or over-utilization of the hallway space, both of which are detrimental to
overall ED length of stay (LOS) and wait times.
Under-triage behavior: Triaging ED patients upon arrival to the ED and assessing their urgency for treatment is crucial for timely service to all patients. Despite the standard patient classification algorithm by which all nurses are trained, we hypothesize, and show, that the ED’s workload impacts the perceived patient urgency, and subsequently, patient severity scores. We first use a predictive model to predict a patient’s true triage level using information collected at triage and define under-triage, accordingly. We find that under-triage is decreasing up to a certain point of workload but increasing after (U-shape). We also quantify the impact of under-triage on disposition time, room-to-departure time and risk of readmission.
Collectively, this thesis demonstrates how patient-flow may be improved without the need to increase explicit physical capacity in the ED (e.g., beds). It offers practical solutions to managers and contributes to the operations management literature.
| Identifer | oai:union.ndltd.org:bu.edu/oai:open.bu.edu:2144/44422 |
| Date | 12 May 2022 |
| Creators | Feizi, Arshya |
| Contributors | Carson, Anita L. |
| Source Sets | Boston University |
| Language | en_US |
| Detected Language | English |
| Type | Thesis/Dissertation |
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