Simulation-Based Design of ED Operations with Care Streams to Optimize Care Delivery and Reduce Length of Stay in the Emergency Department.

Faced with the opportunity to significantly deviate from classic operations, a new emergency department (ED) and novel strategy for patient care delivery were simultaneously initiated with the aid of model-based simulation. To answer the design and implementation questions, a traditional strategy for construction of discrete-eventmodel simulation was employed to define ED operations for a newly constructed facility in terms of workflow, variables, resources, structure, process logic and associated assumptions. Benefits were achieved before, during and after implementation of an unprecedented operations strategy-i.e., the organization of the ED care delivery around four care streams: Critical, Diagnostic, Therapeutic and Fast Track. Prior to opening, it shed light on the range of context variables where benefits might be anticipated, and it facilitated staff understanding and judgements of performance. Two years after opening, the operations data is compared to the simulation with encouraging results that shed light on where to continue pursuit of improvement.

A method for understanding some consequences of bringing patient-generated data into health care delivery.

OBJECTIVE: The consequences of personal health record (PHR) phenomena on the health care system are poorly understood. This research measures one aspect of the phenomena--the time-cost impact of patient-generated data (PGD) using discrete event model (DEM) simulation. BACKGROUND/SIGNIFICANCE: Little has been written about the temporal and cognitive burden associated with new workflows that include PGD. This pilot study reports the results for time-cost and resource utilization of a ''typical'' ambulatory clinic under varying conditions of PGD burden. METHODS: PGD effects are modeled with DEM simulation reflecting the sequential relationships, temporal coupling, and impact assumptions within a virtual clinic. Three simulation scenarios of ever-increasing PGD impact are compared to a baseline case of no PGD use. RESULTS: Introduction of PGD resulted in expected increases in cost and resource utilization along with a few key exceptions and unanticipated consequences. Direct and indirect impacts were observed with notable nonlinear, nonadditive, disproportionate, heterogeneous aspects and interactions among consequent labor cost, visit length, workday length, and resource utilization. The middle-impact simulations showed a 29% increase in daily labor costs and 28% shrinkage of the margin between revenues and labor costs. Lengths of both workday and patient visit were extended and less predictable with PGD use. Utilization rates of most staff positions rose. Nurse utilization rates showed greatest increases. Physicians' utilization rates paradoxically stayed relatively unchanged. CONCLUSION: This analysis contributes to an understanding of the effects of PGD on time and cognitive burdens of physicians, staff, and physical resources. It illustrates the usefulness of DEM simulation for the purpose. Avoidable consequences are exposed quantifiably for both the patient and the clinic. More realistic ways to respond to PGD impact are needed.

The role of simulation and modeling in disaster management.

The threat of pandemic disaster has motivated many collaborative exercises for the purpose of preparation and evaluation. The nature of these exercises depends upon the status of pre-existing expectations for system behavior and the aims of the exercise stakeholders. The contents of this article argue that these exercises may be developed using the same approach as simulation modeling to advantage. Four levels of maturity are outlined as a guide to understanding reasonable expectations for such activity.