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June 16, 2017

• Dr. Gary Teare, CEO,

Health Quality Council

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Today’s session:

Health System Modelling for Strategic Planning to Reduce Emergency Department Wait Times Adrienne Danyliw & Yuan Tian

The Presenters

Adrienne Danyliw

Project and Policy Consultant, ED Waits and Patient Flow Initiative, Health Quality Council

Yuan Tian

Researcher, Health Quality Council

What is simulation modelling?

Real-world applications in modelling and simulation

Flight Simulator Life Simulation Games Rocket Launcher Simulator Spread of a Zombie Disease Outbreak

What is Simulation Modelling?

• 1. Simulation modelling is NOT breaking news.
• 2. There are well-established methodologies to analyze

inefficiencies in health care system or processes.

• A. Discrete-event Simulation
• B. Agent-based Simulation
• C. System Dynamics
• 3. You can develop and use simulation modelling to design and

evaluate solutions that will improve quality of care, patient flow, patient safety and cost-effectiveness in health care.

Why we use computer simulation modelling?

System Experimentation Health Care System Experiment with the actual health care system Experiment with a system simulation model

Risky Disruptive Costly Time-consuming Using “Virtual Pilots” to better inform actions

Case Study: Using Simulation Modelling for Strategic Planning to Reduce Emergency Department Wait Times

Current State of Emergency Department(ED) Waits

• 1. What is emergency department crowding?
• 2. Why should we care?
• 3. How to measure crowding in emergency?
• 4. What are the causes of crowding in emergency?
• 5. How we used modelling to help set strategies?

Emergency Department Crowding Emergency department overcrowding is a situation in which demand for service exceeds the ability to provide care within a reasonable time, causing physicians and nurses to be unable to provide quality care.

Canadian Association of Emergency Physicians

Negative Impacts of Long Wait Times in Emergency Department Increase in mortality, costs and length of stay. Increase in adverse

• utcomes for time-

sensitive conditions. Decrease in patient satisfaction.

Emergency Department Waits and Patient Flow Initiative

Emergency Department (ED) Wait Time Measures

ED Registration / Triage Physician Initial Assessment Decision to Admit (or Discharge) Leave ED (Move to Inpatient Ward)

Waiting Time for Physician Initial Assessment (WPIA) Time Waiting for an Inpatient Bed (TWIB)

Total ED Length of Stay (admitted) Total ED Length of Stay (non-admitted)

Areas for Improvement to Decrease Emergency Department Wait Times Input

• ED Visits with Family

Practice Sensitive Conditions

• Hospitalization for

Ambulatory Care Sensitive Conditions

• Continuity of Care

With Family Medicine Physicians

Throughput

• Staff scheduling
• ED resources and

capacity

Output

• Inability to discharge

Alternate Level of Care (ALC) patients to appropriate setting.

• Lack of coordinated

care in the care transition from hospital to home.

What are the root causes of long wait times in SK hospitals? Where should we act, given limited resources?

Cross-Functional Planning

Emergency department waits is a system issue

Framework for Cross-functional Planning

What can we adapt? What do we already do well? Current state, identifies gaps/opportunities. Advisory Group and

• ther stakeholders

Recommendations

Health System Modelling for Patient Flow in Saskatchewan

Emergency Department Acute Care Post-acute Care and Community SK Population By Age and Gender Demo of ED in Royal University Hospital

Model Structure

Patient Flow in ED and Acute Care were simulated for 6 hospitals:

• Regina General Hospital
• Pasqua Hospital
• Saskatoon City Hospital
• St. Paul’s Hospital
• Royal University Hospital
• Victoria Hospital

Model Structure

Model Calibration and Validation

Internal Validation

Model Calibration and Validation

External Validation

Areas for Improvement to Decrease Emergency Department Wait Times Input

• ED Visits with Family

Practice Sensitive Conditions

• Hospitalization for

Ambulatory Care Sensitive Conditions

• Continuity of Care

With Family Medicine Physicians

Throughput

• Staff scheduling
• ED resources and

capacity

Output

• Inability to discharge

Alternate Level of Care (ALC) patients to appropriate setting.

• Lack of coordinated

care in the care transition from hospital to home.

What are the root causes of long wait times in SK hospitals? Where should we act, given limited resources?

What if…

What if we can reduce potentially avoidable ED visits for FPSCs during evening hours by 50%? What will be the impact on ED wait times?

Developed by Alberta Health Quality Council, FPSCs are “Emergency department or urgent care centre visits for health conditions that may be appropriately managed at a family physician's office.” – Alberta Health

What if…

What if we implement “High Quality Care Transition” for medical patients? What impact would this have on ED wait times?

What if…

What if we have more physician coverage in ED for busy hours (e.g. 9am to 12pm). How would this impact ED wait times?

Component Intervention/Factor Description Effect Size Current Level of Care Relevant Reference Input Reducing Potentially Avoidable ED Visits for FPSCs 50% Reduction for ED visits for FPSCs (Mon-Fri 9am to 7pm) 9%-19% (with variation across EDs)

• CIHI. 2014. Sources of Potentially

Avoidable Emergency Department Visits.

Improve Continuity of Care (measured as UPC Index) Shift 10% in the "low" and "moderate" categories to "high" category respectively. Reduce ED visits for FPSCs and hospitalization for ACSCs. 60.7%-71.68% (with variations across regions)

• CIHI. 2014. Continuity of Care With

Family Medicine Physicians: Why It Matters.

Reducing Potentially Avoidable Hospitalizations for ACSCs 10% reduction in avoidable ACSC hospitalization. % varies across hospitals.

• CIHI. 2014. Sources of Potentially

Avoidable Emergency Department Visits.

Reducing Potentially Avoidable ED Visits for FPSCs via extending hours in primary care 50% Reduction for ED visits for FPSCs (Mon-Fri 7pm-12am) 9%-19% (with variation across EDs)

Whittaker, W., et al., 2016. Associations between extending access to primary care and emergency department visits: a difference-in- differences analysis. PLoS Med, 13(9), p.e1002113.

Throughput Extra Physician Coverage in EDs 6-7 additional hours of physician coverage daily with variation across ED Output Reduce ALC hospital days 100% reduction in ALC hospital days 3.5% of hospital days (with variation across hospitals)

Sutherland, J.M. and Crump, R.T., 2013. Alternative Level of Care: Canada's Hospital Beds, the Evidence and

• Options. Healthcare Policy, 9(1), p.26.

Shift time of inpatient discharge by 2 hours earlier on average (on a daily basis) Safely discharge patients by 2 hours earlier on average 33%-69% of admitted patients discharged before 1pm (with variation across hospitals)

El-Eid, G.R., Kaddoum, R., Tamim, H. and Hitti, E.A., 2015. Improving hospital discharge time: a successful Implementation of Six Sigma

• methodology. Medicine, 94(12),

p.e633.

High quality care transition (or discharge planning) reduction in readmission rate (RR=0.82) and LOS (0.91 days) for medical patients LOS for medical patients: 8-35 days (with variation across hospitals)

Shepperd S et al. 2013. Discharge planning from hospital to home. Cochrane Database Syst Rev.

What ifs…

Modelling Results: Royal University Hospital

No Intervention (current state) High Quality Care Transition

Better (less wait times for an inpatient bed) Better (less wait times for physician initial assessment)

Reduce ED visits for FPSCs during evening hours Reduce ALC hospital days Add physician coverage in ED

Lessons Learned & Next Steps

Lessons:

• Use the right tools for strategic planning
• Work tirelessly to ensure collective wisdom

Next steps:

• Connected team based care
• Create space for sharing and learning
• Align with existing provincial work

Other Applications & Future Opportunities in Health Care

• Hospital scheduling and organization
• Infection and communicable disease
• Screening programs
• Costs of illness and economic evaluation

Questions?

About modelling: Ytian@hqc.sk.ca About Patient Flow: Adanyliw@hqc.sk.ca

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