1 Emergency Information Support System for Brazilian Public Hospitals. M. J. F. de Oliveira, and L. N. P. Toscano Federal University of Rio de Janeiro, Brazil Caixa Postal 68501 CEP 21945-970; Email: mario_jo@pep.ufrj.br Abstract The objective of this paper is to contribute towards the improvement of the admission system of a major emergency hospital in one of the planning areas in the municipality of Rio de Janeiro. The hospital has a problem of congestion and queues at reception, caused by the imbalance between the demand and supply of services. The emergency patients system is studied in two phases. The pre-hospital phase starts immediately after the emergency call, following the occurrence of an incident, demanding public services such as the fire brigade and the ambulance service and finishes when the patient arrives at the hospital. The hospital phase comprises of reception, triage and medical attention. We argue that lack of information causes problems in accessing the hospital services in both phases. Visual simulation is used to evaluate ways to improve the quality of the emergency admission system. Keywords: Emergency planning; Hospital admissions; Information systems; Visual Simulation; 1.0 Introduction The city of Rio de Janeiro has more than 300 hospitals and health facilities, providing a variety of public and private services to a population of about 12 million people. The accessibility to health services in the city is a big issue, and much remains to be done to improve the quality of the public health services. There are sixty public municipal hospitals, twenty state hospitals and a large number of private health institutions. Most of the public hospitals are not able to cope with the increasing demand. The private system is usually connected with health insurance, but the majority of people cannot afford to pay for health care. There is no organised information available and the consequence is that with this variety of services, for most people, it is not clear what to do in case of a medical emergency. Improvement in the quality of emergency admission systems is considered an important factor in controlling the social costs, and increasing the effectiveness of the medical care provided. The admission of emergency patients, however, is not isolated from what happens before the patient comes to the hospital. The response time in the rescue and treatment of the victim(s) is very important and, in many instances, means the difference between life and death. Therefore, in order to understand and evaluate the problem of emergency patients, one must consider the arrangements for dealing with emergencies from the moment the initial incident takes place until the request for hospital admission is made. To obtain the necessary background information, one must take into consideration a number of factors, which are directly or indirectly related to the admission of the patients, such as the normal patterns of seeking and receiving medical care and the factors affecting the urgency of need for such care [7].
2 The municipality of Rio de Janeiro has a population of six million people. There are fifteen emergency hospitals in ten planning areas. The Hospital Miguel Couto (HMC) specialises in emergency cases in one of the planning areas. The emergency rescue service on the public roads is formally provided by the Grupo de Socorro de Emergência (GSE), which is part of the military fire brigade. The GSE and the HMC have provided the data for the present research. From the available data, one is able to examine the flow of emergency patients from the moment the incident happens to the moment the patient is admitted to the hospital. The admission system is divided into two phases and separate models are described for each of the phases. It is argued that the emergency system will improve considerably if the services are connected with each other, and also with the ambulance service of the HMC, providing useful information to the hospital admission system. The number of daily emergency calls in the whole region is about 22,000. The current system is able to answer 72% of the calls, and 3.5% of the cases generate a police record. From an organisational point of view, emergency patients may be admitted to a hospital ward in one of two possible ways: through the Accident and Emergency department or by direct arrangement with the administration. Immediately after the occurrence of an incident resulting in some kind of medical problem judged to be serious, a decision has to be made in order to contact the health care system. The decision depends on factors such as: the location of the incident, the nature of the problem, the patient s condition, the local resources and the capacity of the private medical care available. One can see the possible schemes to access the hospital: Institutional schemes such as the fire brigade and the public ambulance service; Private schemes requiring previous payment and/or membership and Individual schemes, which are the most common initiative in Rio de Janeiro. Emergency patients are generated by two processes. The first is the natural onset of some disease or breakdown of some bodily function of its own accord. Typically, but not exclusively, such patients are medical rather than surgical patients. The second process is by accident. Such patients have had their state of health affected by some external factor and are typically, but not exclusively, surgical emergency patients, e.g., victims of road traffic accidents with broken limbs, lacerations, crushing and burns injuries. Here one defines accidents as the circumstances giving rise to all forms of injury, i.e., any condition that would be assigned to categories of the International Classification of diseases. Emergency services providers are facing new challenges after recent disasters happening at the beginning of the 21st century. Some are complex, either natural or caused by man, and our authorities will need a training device to be prepared to meet these challenges. There are a remarkable number of publications in the field of emergency management over the last two decades [2, 6]. Most of the earlier studies concentrate on management considerations and administrative issues such as the demand for services [4], evacuation planning [11], location of vehicles [2] and other interesting problems that arise from this broad subject. Emergency arrivals are normally regarded as an unknown process and very few studies take into consideration the value of the short-term prediction of the emergency demand and the value of this prediction to improve the admission system of most hospitals.
3 2.0 The Hospital The HMC is a 400-beds public emergency health unit, which receives about 400,000 patients/year. The services provided are: medical, triage, emergency (levels II and III), maternity, laboratory analyses, outpatient, clinical and surgical services. The administration of the HMC has produced a very interesting paper [10] with the desired new profile for the HMC. It includes a full description of the services provided by the hospital, the profiles of the hospital and of the clients, the goals of the administration and guidelines for further research. The profile of eligible clients is composed of: Patients (children and adults) showing a health condition requiring either an evaluation or prompt emergency care, whether or not they live in the planning area; Patients, living in the planning area, seeking any of the services provided by the hospital; Transfers from other public and private facilities and Patients transported by the GSE. The hospital compiles a reasonable amount of data on the management of its services. A sample of the available data is shown in Table 1. It can be seen for example, that the number of cases increases over the years. From the total cases, 74.4% are considered emergencies and 4.6% of emergencies are admitted to the hospital. 2000 1999 1998 1997 1996 1995 Emergencies 834 778 751 710 652 675 Total Cases 1,120 1,105 1,122 1,044 887 903 Admissions 39 41 40 39 25 33 External 51 53 14 18 15 17 Causes Discharges 37 39 36 37 19 27 Deaths 4,4 4,3 4,5 4,4 4 4,5 Table 1: Daily number of emergency admissions and discharges from 1995-2000. Source: Hospital Miguel Couto. Some of the problems are: Low level of communication with other health units; Long queues at reception and at the medical triage; Doctors are not updated with the timetable and work flow of other health units; The number of doctors at triage is insufficient to cope with the demand and A high percentage of adults are not real emergencies. The goal of the hospital is to improve its admission system. Therefore, it is necessary to examine both the supply and the demand. The flow of patients and the reception process should be studied in order to define, among other things, the configuration and number of staff required to improve the quality of the services.
4 3.0 The Pre-Hospital Activity In 1986, the GSE started researching the pre-hospital phase, on the streets and public places of the city of Rio de Janeiro. The corporation is part of the military Fire Brigade and its structure is similar to the North American and French paramedics [3]. All the staff involved with the operation are very well trained and protocol is strict. The medical staff has many doctors, senior nurses, assistant nurses and technicians, specialised in prompt attendance, rescue, life support and transportation to hospitals. The GSE provides services to several hospitals [1]. An incident causes the occurrence of a set of conditions in a public place creating a demand for one or more emergency units. Response time is the time interval from the receipt of a call until the dispatch of the first available unit(s) to the scene of the incident. The goal of the GSE is to decrease the elapsed time in response to an emergency call. The size of the fleet and the position of the ambulances within the service area are two factors that can be controlled [2]. The distribution of the rescue vehicles is made according to the placement of the headquarters, which are already placed strategically. The number of vehicles however, is a problem. Table 2 shows the daily total number of cases on public roads from 1995 to 1997 involving the GSE and the daily number of cases transferred to the HMC. 1995 1996 1997 Number of cases * 43800 54750 69715 Transfer to HMC ** 2190 2920 3650 Table 2: Cases on public roads - (Sources:* GSE; ** HMC) Figure 1 shows the daily flow of cases from the planning area AP2.1. The figures are taken from a sample of 22,685 recent calls received over a period of six months. It can be seen that 76.7% of the victims are taken to hospital and about 10% of the emergency patients arriving to the HMC are referred by the GSE. About 38% of the calls are refused. 127 Average Daily Calls Services 78 49 Refusals Hospitals 59 19 Discharges HMC 12 47 Other Hospitals Figure 1: The daily number of cases arriving to the HMC
5 The management of activities is centralised. There is a call centre, which co-ordinates not only the operations of the GSE, but also most operations of the Fire Brigade. Figure 2 shows a diagram of the usual procedures. Figure 2: Flow diagram of the usual routine of the Fire Brigade [3] The activities of the pre-hospital rescue operation of interest in the present study are: Call (user dials 193, radio, telex, fax); Reception (information, confirmation, data collection, warning, alarm); Displacement (settings, itinerary, traffic conditions, radio contacts); Scene (parking, recognition of situation, evaluation of risks, finding support); Primary care (evaluation of the victim(s), diagnosis, treatment, inspection, data, release); Removal (settings, contact hospital, itinerary, traffic conditions); Delivery (arrival, reception, acknowledge responsibility) and Return (transit, on call). The time measurements used as criteria for the health of the victim(s) involved are: Seven minutes for displacement; Eleven minutes for primary care; Eleven minutes for removal and Fourteen minutes waiting at the hospital before liberation of the rescue team.
6 4.0 The Visual Simulation Platform The essence of simulation and modelling within the framework of practical and experimental applications is the characterisation of real-life objects by a set of abstract entities, a relationship between these entities and a set of unique mappings that give the abstract entities a real-world interpretation. In this sense systems modelling is one of the basic knowledge-building processes and simulation is a knowledge-evaluation technique, which enables one to explore the possibility of knowledge and the limits of this possibility. Simulation modelling is a process described as follows: There is a real world problem, which. is formulated as a logical model (there are a variety of ways to represent the logic of a formulated problem). The next step is to convert the logical model into a computer model, which is then verified and tested to see if it is doing what the analyst wants it to do. The model is used as an operational model to produce some results, or some conclusions and is implemented after validation with the real world. Because the problem studied here is complex, formulation is a very difficult task. The construction of the logical model representing the formulation of the problem is, in many instances, the most difficult aspect of the modelling. In fact, understanding what the problem is may be the object of the whole exercise. One should be prepared to constantly undertake reformulation to obtain a common understanding of the problem as part of the modelling process. In many instances, the function that the computer model serves is to perform a medium of communication for the structuring of the problem for all participants in the decision-making process. The model proposed here is based on discrete event simulation (DES). The elements of DES are entities or group-entities such as patients, doctors and ambulances and the attributes are properties such as urgency level, skill and fuel tank capacity. The state of an entity can be thought of as the specific attribute, which represents the current situation. An activity is a system function in which an entity remains, either on its own or with other entities consuming simulation time. An event is a point in time when the status of the system changes. In this sense, a queue is an ordered list of entities, which are waiting to start an activity. The approach to modelling is patient-oriented [4], the patients being considered the main entity around which all the activities, events and processes are organised. Previous experiences with simulation [8], reveals that the approach to be adopted depends on the nature of the problem. The platform proposed here is flexible and consists of a suite of modules that provides the basic steps required to execute different experiments. A complete description of this platform has been published elsewhere [5]. The main modules are: Formulation- helps to understand the problem and to produce the computer model; Simulation- verifies the effect of different policies in the system s performance; Scenario Building- produces the scenario and analyses the physical space and 3D Visual Simulation- enables one to see the results.
7 5.0 The Rescue Operation The focus of this research was on the admission of emergency patients to the HMC. However, the GSE is formally responsible for the delivery of emergency patients to the hospital, following the occurrence of an incident in a public place. It is clear that changes in the level of delivery services affect the admission system of all hospitals in the area. The objective of this section was to understand how the changes in the rescue operation would affect the admission system of this hospital. Simulation was used to investigate several alternatives: 1. Evaluation of the existing system; 2. Reduction of the reception time at the hospital; 3. Increasing the number of rescue vehicles; 4. Reduction of the reception time and increasing the number of vehicles and 5. The above, plus a reduction of the displacement time. The simulation model allows the user to explore a number of other hypotheses of interest to all parties involved in the emergency admission system. A preliminary evaluation revealed some interesting ways of tackling this very complex problem. Figure 3 shows, for example, a progressive reduction in the patient s waiting time under the second alternative. Time (hrs) 0,5 0,4 0,3 0,2 0,1 0 Alt. 1. Alt. 2. Alt. 3. Alt. 4. Alt. 5. Figure 3: Patient waiting times The results showed that: It is necessary to increase the number of rescue units; The time wasted at the reception affects the whole operation; The patient waiting times are reduced under the second alternative; The waiting time starts to be acceptable under the fourth alternative; The total reduction of waiting time is significant under the fifth alternative and The resources are used completely in both the first and second alternatives. Most changes will, of course, create new demands on the admission systems and affect the operation of all hospitals. The proposed initiatives however, contribute to the understanding of the essential part of a number of current social problems. Some of these problems affect people s quality of life. The actions of increasing the number of ambulances and reducing the duration of operations are difficult, but not impossible. For example, eight new ambulances will be enough to enable the GSE to cope with all calls. It is clear that the GSE contributes only a low percentage of the emergency cases of the HMC however, the model is useful to partially understand the demand of the HMC.
8 6.0 The Ambulance Service The HMC have few ambulances, which provide transport and transfers, to and from other public and private health units. There is an average of 55 calls/day and the fleet is not able to cope with all calls. This section presents the results of a simulation study with the objective of analysing the response capacity of this fleet. Two alternatives are investigated: firstly, the present situation, with two vehicles; secondly, the impact of adding an extra ambulance. The focus was on patient waiting times, the utilisation of the ambulances and on the number of services provided. An available geographic information system [11] provided a series of very interesting official data about the planning area AP2.1, where the HMC is located. This system recorded information about the geography of the area, accurate distances and the access road to other health units, where most of the calls are made from. The generation of calls was distributed among 18 locations within the planning area. For each location a centre point is defined, according to the population density. A simple simulation model was used to analyse the operation of the ambulances for a 24-hour period. The calls were assumed to be random. The travelling time was a function of the distance and of the average speed of the ambulance. There was road traffic in the area and the average speed of the ambulances was 40km/h. The patient s delivery at the hospital was again a problem, because of congestion and long queues at the reception. Therefore, special time mechanisms were included in the model, to represent some delays that usually happen in the hospital, before the vehicle and the crew are free to cope with another call. The simulation provided a series of results about the performance of this service. The current utilisation of each of the vehicles is 76%. The addition of an extra ambulance would bring this rate down to 49.7%. Patient s waiting time at certain locations is about two hours. It can be seen, for example, that the addition of an extra vehicle would considerably reduce the waiting time at the critical locations 1,3,4,6 and 9. The simulation model is, therefore, a valuable tool to reflect the present situation. In social terms, the result of the present study shows that a more efficient service will certainly save peoples lives. However, a definite solution requires further studies. An animated simulation of the ambulance service is shown in Figure 4, below Figure 4: Movement of the ambulances in the planning area
9 7.0 The Inpatient Care This section sets out to describe the admission system of the special emergency hospital. The work was carried out in the following steps: Study of the reception and medical triage; Evaluation of the primary care; Modelling of the medical attention; Simulation; Team building and Quality achievement. 7.1 The Entry Door First, a field study was carried out. The flow of patients, the physical layout of both the reception and the medical triage were inspected. A series of interviews with patients, doctors and receptionists were carried out. A simulation model was designed in order to identify the major congestion points, and investigate different ways to tackle the problems found in the hospital s admission system. The layout of the emergency department was utilised and the main parameters of the simulation model were estimated by sampling procedures. The entry comprises of three sections: the reception, the information desk and the medical triage. Two basic activities are carried out at the reception desk: Form filling and appointments. There are sometimes two or three people working at reception. The information desk is not open all the time and is located near the building s entry door. A private security guard controls the patient s entry to the hospital. This person organises the waiting line and also provides information to most people, especially when the information desk is closed. The reception hall is clearly inadequate for an emergency unit. The area is not big enough to accommodate the large number of people who arrive at the hospital by their own means. That is, in our opinion, where most of the problems rise. The functioning of this system was studied at different times and four basic queues were identified: 1. The reception queue. This is the longest queue, where most patients have to go before any action is taken. The selection of cases is made from this queue. 2. The information queue. This is located near the entry door, causing congestion and making other patient s access to the building difficult. 3. Medical patients. This queue occurs next to the reception desk, where patients wait for a call after registration. The queue is not organised, contributing to the congestion. 4. Triage patients. Patients requiring triage wait in this queue. A sample of patients was interviewed and there were several complaints about the service. The main problems were: The number of staff ; The communication system ; The location of the information desk ;. The irregular workload on doctors; Manual data collection;
10 The inappropriate layout and Excessive waiting times. A visual simulation experiment was carried out. The objective was to reduce patient waiting times. A series of runs revealed the appropriate number of staff, and suggested changes in the layout. The result can be seen in Figure 5. Figure 5: The proposed layout for reception A series of other experiments were carried out and the results showed that actions have to be taken to change the existing situation. The recommendations of the exercise were: To define criteria to reduce the patient waiting times; To work on medical team building and To improve the quality of the services. 7.2 Modelling the medical attention. Efficient and productive actions are required to improve medical attention in the hospital. Medical attention, in this context, is the relationship between patient and the medical staff during and after triage. Triage is a brief and immediate evaluation of the case to establish priorities according to the gravity of the case and the medical procedures required. This section evaluates simulation models of the medical emergency attention. Three aspects are considered: patient waiting times, the required configuration of staff and the achievement of quality goals. Quality, however defined, is considered as an attribute of the attention. In order to attain quality, continuous and systematic observation and assessment of all activities involved in the patient s care is required [9]. A continuous evaluation of medical practice is necessary to measure how far the current practice is from pre-defined goals. The usual method of evaluating quality in public hospitals is quantity and costs however this may cause irreparable errors to the health status of a large number of patients.
% of Quality 11 The structure of the current emergency medical attention was studied and the attention process was examined in detail. Patients were classified in four emergency levels according to the gravity of the case. The staff required for each emergency level was defined, using a scoring system for the desired standard of the medical practice. The quality measures were: The correct sequence of medical procedures; Achievement of the desired medical team and The reduction of patient waiting times. The configuration of the staff was in terms of the number of doctors, nurses and assistants. The simulation evaluated, for each urgency level, the percentage of quality achieved. A series of experiments for surgical and medical specialties can be found elsewhere [12]. Figure 6 shows a sample of results from a 30-hour period simulation of a medical specialty. 120 100 80 Urgency 1 60 Urgency 2 Urgency 3 40 Urgency 4 20 0 1 2 3 4 5 6 3-7 doctors/1-3 nurses/1-10 assistants Figure 6: Percentage quality achieved by urgency level and staff configuration The results of the experiment show that it is possible to choose the right configuration of the staff according to attention level and/or reduction of the patient waiting times. For example, a minimum of three doctors, two nurses and five assistants are required to improve quality. 8.0 Conclusion A number of actions are required to improve the quality of the admission system in the majority of public hospitals in the city of Rio de Janeiro. The most important issue is the lack of valuable information on the right services to call when there is a need for it. Another important point is the accessibility to health services in the city. On the one hand, the private system offers a large number of services, which are expensive and seem not to be properly connected with the other services. On the other hand, there are difficulties in using the available public services. As a consequence, emergency patients have to wait for attention and the whole process of the prehospital phase and the hospital services are delayed because of the long waiting period. The HMC is a very good emergency hospital. However, the chronic problem of congestion is the key point for changes. The study of the pre-hospital system reveals that the structure of the services seems to be satisfactory, but the number of rescue units is insufficient to cope with the increasing demand.
12 The simulation experiment shows that the addition of a few rescue units and ambulances considerably improves the capacity to cope with demand. However, these changes do not necessarily improve the admission system of the HMC, which is critical. The visual simulation illuminates the way to improvement. It is expected that simple changes in the sector may cause a significant impact in the operation of the whole admission system. The GSE recently carried out a real simulation on a public road, using actors instead of patients: The performance of the rescue team was impressive. Quality will be reached if there is an initiative towards an integrated information support system, which grants access to anyone and improves the standard of services from the rescue operation to patient discharge. Preliminary contributions are proposed in this paper. However, there is more to do in this direction than meets the eye, for the implementation of such a system depends on social, technological and political measures that are beyond the scope of this study. Accessibility and quality of health services are the theme of the 28 th meeting of the Operational Research Applied to Health Services (ORAHS) Working Group. 9.0 Acknowledgements I am grateful to all the medical personnel and staff of the HMC, who provided the basic data used in this study; to the GSE for their interest and practical support, as well as other colleagues of ORAHS for their valuable suggestions and stimulating discussions; and last, but not least, to all of my research students for their help. 10.0 References [1] M.B. Carneiro, Normalização dos serviços de emergência no Estado do Rio De Janeiro: Reorganização do subsistema de emergência no Estado do Rio de Janeiro. CREMERJ, (1995). [2] J. Chaiken and R. Larson, Methods for allocating urban emergency units: a survey, Management Science, 19(1998) 110-130. [3] S. R.T.P. De Barros, Análise ergonômica da mitigação de acidentes em via pública: um estudo de caso no GSE, Msc Thesis, Federal University of Rio de Janeiro, (1988). [4] M.J.F De Oliveira, A patient-oriented modeling of the emergency admission systems of a brazilian hospital, Paper presented at EURO XIII, Glasgow, July 19-22, (1994). [5] M.J.F. De Oliveira, 3D Visual simulation platform for the project of a new hospital facility, in: V de Angelis, N.Ricciardi & G. Storchi (Eds.), Monitoring, Evaluating, Planning Health Services, World Scientific Publishing Co. Pte. Ltd., (1998) 39-52. [6] M. Lagergren, What is the role and contribution of models to management and research in the health services? European Journal of Operational Research, 105(2)(1998) 257-266. [7] D.C. Lane, C. Monefield and J.V. Rosenhead, Looking in the wrong place for health care improvements: a system dynamics study of an accident and emergency department, Journal of the Operational Research Society, 51 (2000) 518-531.
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