Análisis de los Principales Servicios Demandados

We place our conclusions upon the system with the configurations as described in scenario 2, as we believe these represent the reality best. We conclude that when blood tests are started by the triage nurse:

the average waiting time to triage increases with 1 minute and 25 seconds, from 7 minutes and 15 seconds to 8 minutes and 40 seconds, an increase that affects 72% of all patients6.

the number of patients of whom their triage is not started within the 10 minute norm (NVSHV, 2008; Prins, 2011) increases from 23.9% to 28.7%, an increase of 4.8%.

the number of patients treated in a hallway bed decrease with 13.1%.

the average length of stay of patients whose blood test is started by the triage nurse (D10-A) decreases by 9 minutes and 28 seconds, a decrease for 16% of all patients6. Further, due to the increased waiting time to triage the average length of stay of 42% of all patients increases with 1 minutes and 25 seconds, and 14% faces an average increase in patient LOS of 1 minute and 44 seconds. The remaining 28% of the patients faces no difference in their average patients LOS, as their treatment is always directly started at arrival (see Subsection 5.2.4). The results are shown in Table 5.14.

Patient group Difference in average patient LOS Fraction of all patients4 D1 to D8 0 28% D9 and D12 + 1m25s 42% D10-A - 9m25s 16% D10-B and D11 + 1m44s 14%

Table 5.14: Effect on patient LOS of patients when the triage nurse starts blood tests.

Now it is up to the management of the RVE acute care to decide whether they accept an increased waiting time to triage of 1m25s, to gain a decrease in patient LOS of 9m25s for 16% of all patients and a 13% decrease in the number of patients treated in hallway beds. We believe the increased patient LOS of 1m25s and 1m44s are significant small considering that the average patient LOS are 2 to 3 hours, and therefore do not have to be included in this decision.

Assessment

We recommend to adopt this intervention, as we believe that especially the benefits of a 13% reduction in hallway beds outweigh the disadvantage of an average 1m25s increase in waiting time to triage. In this decision, we also included that the intervention is easy to implement, no costs have to be made, and that the benefits of this intervention are the highest during the most critical

moments, namely the moments of crowding.

To clarify this last argument, note that the simulation results are overall averages. The 9m28s time saving found is the average of all times saved during both crowded and non crowded moments. Although also during non crowded moments the blood tests are requested some minutes earlier

101 compared to situation in which the patient is first taken to a treatment room, the advantage of the triage nurse starting the blood test is relative small. During crowded moments on the other hand, the advantage of the triage nurse starting blood tests is significant larger, as the waiting time between triage and placement in a treatment room is much longer. Therefore, especially during the most

critical moments the benefits of this intervention are the highest.

But what are the advantages and disadvantages of the triage nurse starting patient’s blood tests when the ED, a GP post and the new AADU are going to cooperate in the IEP? And what are the consequences when the ED Sportlaan is closed for adult emergency care?

Unfortunately we cannot determine the exact effects, as we lack information to run a reliable future scenario. For example, the probability distribution functions we used in our model to simulate the

time patients spend inside a treatment room likely become invalid. The cardiology is going to work

with two residents during the day instead of one (our capacity vs demand analysis contributed to this decision!); two additional treatment rooms become available on the medium/high care; and the number of patients send to the larger AADU increases (see Subsection 2.6.1). All these changes influence the time patients spend inside a treatment room, but we do not know how much.

Nevertheless, we expect that having the triage nurse starting blood tests also benefits in the future situations; when the ED becomes part of the IEP and when the number of patients attending the IEP

increase. Patients still need blood tests, and, also in the IEP it will be likely that many patients have to

wait after triage to be placed in a treatment room. Therefore, placing the times patients wait for

their blood test results and for placement in a room in parallel will save time, and, as these patients

occupy the rooms less long, the number of hallway beds needed decreases (see Subsection 5.1). But what is the effect on the waiting time to triage? We expect that the waiting time to triage increases, as more patients have to be triaged by the triage nurse. From Subsection 2.6.2 we know that when the ED Sportlaan is closed for adult emergency care the number of patients increases with an expected 4,770 patients a year, and this number might increase when also other EDs in the region are closed, closed during specific parts of the day or closed for specific patient groups on pressure of health insurers (Prins, 2012). In addition, we expect that the flow of indirect patients decreases. In the IEP the triage will also be used to divide the incoming flow of patients towards the GP post and the ED (see Section 2.6), and therefore it is assumable that less patients are taken out of the waiting room before being triaged. All these changes yield that more patients need to pass the triage room, and this likely results in an increase in waiting time to triage, as well as the number of patients of whom the triage is not started in the 10 minute norm increases (NVSHV, 2008; Prins, 2011).

To prevent that the triage nurse becomes a bottleneck of significance in the future, we recommend to investigate whether the accessibility of triage remains within acceptable limits, each time a significant change takes place in patient flows. And when the waiting time becomes unacceptable, we recommend to investigate alternative solutions, e.g. deployment of a second triage nurse, as we showed that starting blood tests earlier in the process clearly benefits.

Concluding, we recommend to adopt this intervention, but with the remark that additional research is needed to determine whether the triage nurse does not become a bottleneck of significance when patient flows change.

103