Systems Engineering for the ED

Simulation Session

Part 1: The View from the ED

Eric Goldlust, M.D., Ph.D., FACEP

Clinical Professor of Emergency Medicine, Stanford University School of Medicine

Emergency Physician, TPMG, Kaiser Permanente – Santa Clara, CA

January 31, 2016 – Healthcare Working Group, INCOSE International Workshop; Torrance, CA

What to expect for the next 30 minutes:

• My background

• Perspectives on SE / M&S from the healthcare industry

– Clinicians

– Medical administrators

– Medical researchers

• The disconnect

• The reconnect

Consider the source:

My view on MBSE

How does our

healthcare system

actually WORK?

What am I

DOING?

How do we do

it BETTER? How do we

STUDY these

questions?

St. Louis (John Cochrane) VA Medical Center

• Quality

Improvement

Project

– Objective:

Decrease % of

ED patients with

length of stay

(LOS) > 6 hrs

– Compared real

vs simulated

results

And here’s what I’ve done with it:

VA: Throughput Metrics

Mean Daily LOS:

– Simulation: 249’ ± 39.7’

– Real World: 247’ ± 39.8’

% Patients with LOS > 6h:

– Simulation: 19.0%

– Real World: 19.9%

200’ ± 19.0’

210’ ± 16.6’

13.1%

14.3%

37 minutes (p

Rhode Island Hospital

AEC: Process Flow Map (2010)

• Yikes. “”Standard Triage”

“Team Triage” (Rapid Initiation of Care)

Security Transport

“Pivot”

“Rapid Disposition”

“Pull ‘til Full” (Rapid Bed Placement)

Pivot Nurse:

2. Greets patient; Gets name, DOB, chief complaint;

Enters into MedHost

A. Does patient look ill or have a critical chief complaint?

YES

Triage Nurse ± PCT:

4. Transports patient to CC room

NO

PCT / ?Security:

17. Transports patient to Urgent Pod room

Triage Nurse returns

Quick-Reg, followed by Full Reg, in CC Room

Pivot Nurse:

3. Performs brief screening (“LOOK TEST”)

DONE

Pivot Nurse:

16. Assigns room in MedHost; arranges transport with PCT / TN

DONE

How to notify?

Provider (Midlevel?):

27. Completes T-sheet; informs TN of Rapid Dispo; Discharges pt in MedHost

Patient:

1. Arrives in department

Pivot Nurse:

5. Escorts patient to Vital Signs are; determines if pt needs ECG, glu Notifies PCT

B. PCT TN:

Do VS / Glu warrant CC room?

PCT [1]:

6. Completes vital signs, Glumeter, BAL

Enters into MedHost

PCT [1]:

7. Escorts patient to Triage Room 1

C. Does Pivot / TN / PCT assessment warrant EKG?

NO

Y

ES

Consult Pivot, Provider as deemed necessary

PCT [1 or 2]

9. Finds attending or PGY-4 to read ECG; returns to triage.

D. Does ECG warrant Critical Care room?

Pct [1 or 2]:

8. Gown patient, Perform ECG

NO

PCT [1 or 2]:

21. Directs patient to triage room; Moves pt to “Pub Triage” in MedHost

NO

YES

H. PCT TN:

Is a triage room available/warranted for this patient?

Pivot / PCT?:

19. Polls triage rooms between patients

Family Asst:

18A. Approaches patient for needs; invokes Triage Nurse when indicated.

PCT:

18. Returns patient to waiting area; Moves pt to “Main Waiting” in MedHost

Registrar:

19A. Performs Full Registration; assembles chart for GK; places in rack

Where does chart go?

YE

S

NO

G. Do available treatment rooms exceed # of pts waiting?

NO

YES

E. Does patient require Constant Obs (EtOH, SI/HI)?

NO

Transfer to Ambulance Waiting / Treatment Room

Pivot / Security:

11. Calls Security Dispatch for patient transport

Pivot Nurse:

10. Notifies Triage staff; moves patient to Triage Room; Moves pt to “Pub Triage” in MedHost

Amb

Triage

called>

?

Requires Secruity?

YES

PCT / Security:

15. Transports patient to Ambulance Triage (or A/B Pod, or D Pod)

DONE

Security?:

12. Calls Security Dispatch

Security Dispatch

13. Nextel to Campus Security: Call off-site guard

Security:

14. Arrives in Public Triage

NO

YES F. Sec Dispatch:

Nextel to D-Pod: Security available?

Pivot / PCT?:

20. Calls and escorts patient (in group to back hallway

No Medhost action?

Family Asst:

2A. Greets patient

TN:

28. Discharges patient; Directs to Discharge Desk

DONE

Bed Placement (during “Team Triage”)

Triage Nurse / Pod Nurse:

36. Escorts pt & chart to tx room; Assigns room in MedHost

DONE

TN:

35. Flags for “Public” as appropriate, ?calls Pod

VA

VA

BVA VA

BVA VA

VA VA

VA

VA ?

VA

BVA

BVA

How to coordinate?

TN?:

34. Polls MedHost for available tx room

Patient:

33A. Approaches TN / Provider as needs arise

TN / Provider:

34A. Address patient needs as indicated

VA

PCT / TN / Prov:

33. Returns pt to Diagnostic Transition Area; Moves pt to “Pub Waiting” in MedHost

Main Waiting

Diagnostic Waiting

Vital Signs

ECG

No Medhost action?

Registrar:

22A. Performs Full Registration

Triage Nurse:

22B. Performs full Triage Assessment

Triage Nurse

23B. Enters initial assessment into MedHost; Assigns initial ESI

• J1. Does patient warrant a Critical Care room?

Registrar:

23A. Assembles chart (with ECG) & places in rack

BVA BVA

BVA VA ? VA

H1. Is the full Triage Team (inc. Provider) available?

YES

NO

Registrar:

22A. Performs Full Registration

Provider:

24C. Places initial orders:

ECG, labs, meds, imaging (no IV)

YE

S

TN / PCT:

25A. Draws and sends blood work; Instructs patient re urine collection

Patient:

26A Provides urine sample if / when able

Provider:

22C. Performs “Focused Assessment” with TN

Provider (Midlevel?):

25C. Establishes follow-up plan as needed (e.g., for meds)

K. Does patient have a condition which can be treated immediately?

N

O

N

O

PCT

25D. Addresses comfort needs

PCT / TN?:

29. Places pt in queue for imaging

PCT:

30. Takes patient to imaging; requests X-ray to return pt to triage

X-RAY TECH?:

32. Returns patient from imaging

[X-ray]:

31. Performs imaging

Clarify how patient enters imaging queues

No Medhost action?

• J2. Does patient warrant a Critical Care room?

Triage Nurse:

25B. Provides meds and conveys plan for reassessment

Registrar:

23A. Assembles chart (with ECG) & places in rack

BVA BVA

BVA ? VA VA

VA

BVA

VA

VA BVA

VA

BVA

No Medhost action?

N

O

Triage Nurse:

22B. Performs “Focused Assessment” with Provider

Triage Nurse

23B. Enters initial assessment into MedHost; Assigns initial ESI

• J1. Does patient warrant a Critical Care room?

BVA VA ? VA

AEC: Process Flow Map (2010)

• Yikes. “”Standard Triage”

“Team Triage” (Rapid Initiation of Care)

Security Transport

“Pivot”

“Rapid Disposition”

“Pull ‘til Full” (Rapid Bed Placement)

Pivot Nurse:

2. Greets patient; Gets name, DOB, chief complaint;

Enters into MedHost

A. Does patient look ill or have a critical chief complaint?

YES

Triage Nurse ± PCT:

4. Transports patient to CC room

NO

PCT / ?Security:

17. Transports patient to Urgent Pod room

Triage Nurse returns

Quick-Reg, followed by Full Reg, in CC Room

Pivot Nurse:

3. Performs brief screening (“LOOK TEST”)

DONE

Pivot Nurse:

16. Assigns room in MedHost; arranges transport with PCT / TN

DONE

How to notify?

Provider (Midlevel?):

27. Completes T-sheet; informs TN of Rapid Dispo; Discharges pt in MedHost

Patient:

1. Arrives in department

Pivot Nurse:

5. Escorts patient to Vital Signs are; determines if pt needs ECG, glu Notifies PCT

B. PCT TN:

Do VS / Glu warrant CC room?

PCT [1]:

6. Completes vital signs, Glumeter, BAL

Enters into MedHost

PCT [1]:

7. Escorts patient to Triage Room 1

C. Does Pivot / TN / PCT assessment warrant EKG?

NO

Y

ES

Consult Pivot, Provider as deemed necessary

PCT [1 or 2]

9. Finds attending or PGY-4 to read ECG; returns to triage.

D. Does ECG warrant Critical Care room?

Pct [1 or 2]:

8. Gown patient, Perform ECG

NO

PCT [1 or 2]:

21. Directs patient to triage room; Moves pt to “Pub Triage” in MedHost

NO

YES

H. PCT TN:

Is a triage room available/warranted for this patient?

Pivot / PCT?:

19. Polls triage rooms between patients

Family Asst:

18A. Approaches patient for needs; invokes Triage Nurse when indicated.

PCT:

18. Returns patient to waiting area; Moves pt to “Main Waiting” in MedHost

Registrar:

19A. Performs Full Registration; assembles chart for GK; places in rack

Where does chart go?

YE

S

NO

G. Do available treatment rooms exceed # of pts waiting?

NO

YES

E. Does patient require Constant Obs (EtOH, SI/HI)?

NO

Transfer to Ambulance Waiting / Treatment Room

Pivot / Security:

11. Calls Security Dispatch for patient transport

Pivot Nurse:

10. Notifies Triage staff; moves patient to Triage Room; Moves pt to “Pub Triage” in MedHost

Amb

Triage

called>

?

Requires Secruity?

YES

PCT / Security:

15. Transports patient to Ambulance Triage (or A/B Pod, or D Pod)

DONE

Security?:

12. Calls Security Dispatch

Security Dispatch

13. Nextel to Campus Security: Call off-site guard

Security:

14. Arrives in Public Triage

NO

YES F. Sec Dispatch:

Nextel to D-Pod: Security available?

Pivot / PCT?:

20. Calls and escorts patient (in group to back hallway

No Medhost action?

Family Asst:

2A. Greets patient

TN:

28. Discharges patient; Directs to Discharge Desk

DONE

Bed Placement (during “Team Triage”)

Triage Nurse / Pod Nurse:

36. Escorts pt & chart to tx room; Assigns room in MedHost

DONE

TN:

35. Flags for “Public” as appropriate, ?calls Pod

VA

VA

BVA VA

BVA VA

VA VA

VA

VA ?

VA

BVA

BVA

How to coordinate?

TN?:

34. Polls MedHost for available tx room

Patient:

33A. Approaches TN / Provider as needs arise

TN / Provider:

34A. Address patient needs as indicated

VA

PCT / TN / Prov:

33. Returns pt to Diagnostic Transition Area; Moves pt to “Pub Waiting” in MedHost

Main Waiting

Diagnostic Waiting

Vital Signs

ECG

No Medhost action?

Registrar:

22A. Performs Full Registration

Triage Nurse:

22B. Performs full Triage Assessment

Triage Nurse

23B. Enters initial assessment into MedHost; Assigns initial ESI

• J1. Does patient warrant a Critical Care room?

Registrar:

23A. Assembles chart (with ECG) & places in rack

BVA BVA

BVA VA ? VA

H1. Is the full Triage Team (inc. Provider) available?

YES

NO

Registrar:

22A. Performs Full Registration

Provider:

24C. Places initial orders:

ECG, labs, meds, imaging (no IV)

YE

S

TN / PCT:

25A. Draws and sends blood work; Instructs patient re urine collection

Patient:

26A Provides urine sample if / when able

Provider:

22C. Performs “Focused Assessment” with TN

Provider (Midlevel?):

25C. Establishes follow-up plan as needed (e.g., for meds)

K. Does patient have a condition which can be treated immediately?

N

O

N

O

PCT

25D. Addresses comfort needs

PCT / TN?:

29. Places pt in queue for imaging

PCT:

30. Takes patient to imaging; requests X-ray to return pt to triage

X-RAY TECH?:

32. Returns patient from imaging

[X-ray]:

31. Performs imaging

Clarify how patient enters imaging queues

No Medhost action?

• J2. Does patient warrant a Critical Care room?

Triage Nurse:

25B. Provides meds and conveys plan for reassessment

Registrar:

23A. Assembles chart (with ECG) & places in rack

BVA BVA

BVA ? VA VA

VA

BVA

VA

VA BVA

VA

BVA

No Medhost action?

N

O

Triage Nurse:

22B. Performs “Focused Assessment” with Provider

Triage Nurse

23B. Enters initial assessment into MedHost; Assigns initial ESI

• J1. Does patient warrant a Critical Care room?

BVA VA ? VA

• OBJECTIVE:

• Develop a model which accurately

predicts patient queue lengths

by hour of day.

– Waiting for triage room

– * Waiting for main treatment bed

– Waiting for X-ray, CT, ultrasound

– Waiting for a hospital bed (if admitted)

Census: “A” Pod

-10

0

10

20

30

40

50

60

70

0 5 10 15 20 25 30

Mean Census, REAL

Mean Census, SIM

Error

# o

f p

atie

nts

in q

ueu

e

Queue for Service: “Main Waiting” Area #

of

pat

ien

ts in

qu

eue

-10

0

10

20

30

40

50

60

70

0 5 10 15 20 25 30

Mean Census, REAL

Mean Census, SIM

Error

RIH: Throughput Metrics

Mean Length of Stay:

• Arrival to Discharge / Transfer:

– Simulated (N = 91,174): Mean 345’, SD 285’

– Actual (N = 7,904): Mean 339’, SD 195’

• Arrival to Admission:

– Simulated (N = 169,468): Mean 485’, SD 324’

– Actual (N = 18,170): Mean 558’, SD 444’

My colleagues’ view on SE:

Administrators

Operations

Researchers Clinicians

Although there are some good examples…

2001 – 2015: Discrete Event Simulation to: • Optimize physician and staff scheduling

Hung ‘07, Brenner '10*, Day ’15

• Analyze & visualize patient flow Codrington-Virtue ’05, *Mes ‘12, Batarseh ‘’

• Optimize unit bed capacity Zhu ’12, Santos ‘13

• Forecast near-future operating status

Hoot ‘08, Hoot ‘09

• Assist in ancillary service design (e.g., pharmacy)

Reynolds ‘11

• Compare alternative triage processes Connelly ‘04, Day ’13, Ward ’14

• Assist in pharmaceutical allocation and

trial design Barrett ‘12

• Decrease inpatient boarding Levin ‘08, Hung ‘09, Khare ‘09

• Evaluate ED/EMS interventions

Stahl ‘03, Chase ‘06 • Study interactions between providers

Genuis ‘13, Lim ‘13

• Identify bottlenecks in a continuum of care * Noonan ’09, Santos ‘13

1975: First proposed… in the economics literature (Hannan 1975)

1989: First published simulation of ED flow (Saunders 1989)

2001: Second article, proof-of-concept model (Coats 2001)

Although there are some good examples…

2001 – 2015: Discrete Event Simulation to: • Optimize physician and staff scheduling

Hung ‘07, Brenner '10*, Day ’15

• Analyze & visualize patient flow Codrington-Virtue ’05, *Mes ‘12, Batarseh ‘’

• Optimize unit bed capacity Zhu ’12, Santos ‘13

• Forecast near-future operating status

Hoot ‘08, Hoot ‘09

• Assist in ancillary service design (e.g., pharmacy)

Reynolds ‘11

• Compare alternative triage processes Connelly ‘04, Day ’13, Ward ’14

• Assist in pharmaceutical allocation and

trial design Barrett ‘12

• Decrease inpatient boarding Levin ‘08, Hung ‘09, Khare ‘09

• Evaluate ED/EMS interventions

Stahl ‘03, Chase ‘06 • Study interactions between providers

Genuis ‘13, Lim ‘13

• Identify bottlenecks in a continuum of care * Noonan ’09, Santos ‘13

1975: First proposed… in the economics literature (Hannan 1975)

1989: First published simulation of ED flow (Saunders 1989)

2001: Second article, proof-of-concept model (Coats 2001)

Although there are some good examples…

2001 – 2015: Discrete Event Simulation to: • Optimize physician and staff scheduling

Hung ‘07, Brenner '10*, Day ’15

• Analyze & visualize patient flow Codrington-Virtue ’05, *Mes ‘12, Batarseh ‘’

• Optimize unit bed capacity Zhu ’12, Santos ‘13

• Forecast near-future operating status

Hoot ‘08, Hoot ‘09

• Assist in ancillary service design (e.g., pharmacy)

Reynolds ‘11

• Compare alternative triage processes Connelly ‘04, Day ’13, Ward ’14

• Assist in pharmaceutical allocation and

trial design Barrett ‘12

• Decrease inpatient boarding Levin ‘08, Hung ‘09, Khare ‘09

• Evaluate ED/EMS interventions

Stahl ‘03, Chase ‘06 • Study interactions between providers

Genuis ‘13, Lim ‘13

• Identify bottlenecks in a continuum of care * Noonan ’09, Santos ‘13

1975: First proposed… in the economics literature (Hannan 1975)

1989: First published simulation of ED flow (Saunders 1989)

2001: Second article, proof-of-concept model (Coats 2001)

Although there are some good examples…

2001 – 2015: Discrete Event Simulation to: • Optimize physician and staff scheduling

Hung ‘07, Brenner '10*, Day ’15

• Analyze & visualize patient flow Codrington-Virtue ’05, *Mes ‘12, Batarseh ‘’

• Optimize unit bed capacity Zhu ’12, Santos ‘13

• Forecast near-future operating status

Hoot ‘08, Hoot ‘09

• Assist in ancillary service design (e.g., pharmacy)

Reynolds ‘11

• Compare alternative triage processes Connelly ‘04, Day ’13, Ward ’14

• Assist in pharmaceutical allocation and

trial design Barrett ‘12

• Decrease inpatient boarding Levin ‘08, Hung ‘09, Khare ‘09

• Evaluate ED/EMS interventions

Stahl ‘03, Chase ‘06 • Study interactions between providers

Genuis ‘13, Lim ‘13

• Identify bottlenecks in a continuum of care * Noonan ’09, Santos ‘13

1975: First proposed… in the economics literature (Hannan 1975)

1989: First published simulation of ED flow (Saunders 1989)

2001: Second article, proof-of-concept model (Coats 2001)

Although there are some good examples…

2001 – 2015: Discrete Event Simulation to: • Optimize physician and staff scheduling

Hung ‘07, Brenner '10*, Day ’15

• Analyze & visualize patient flow Codrington-Virtue ’05, *Mes ‘12, Batarseh ‘’

• Optimize unit bed capacity Zhu ’12, Santos ‘13

• Forecast near-future operating status

Hoot ‘08, Hoot ‘09

• Assist in ancillary service design (e.g., pharmacy)

Reynolds ‘11

• Compare alternative triage processes Connelly ‘04, Day ’13, Ward ’14

• Assist in pharmaceutical allocation and

trial design Barrett ‘12

• Decrease inpatient boarding Levin ‘08, Hung ‘09, Khare ‘09

• Evaluate ED/EMS interventions

Stahl ‘03, Chase ‘06 • Study interactions between providers

Genuis ‘13, Lim ‘13

• Identify bottlenecks in a continuum of care * Noonan ’09, Santos ‘13

1975: First proposed… in the economics literature (Hannan 1975)

1989: First published simulation of ED flow (Saunders 1989)

2001: Second article, proof-of-concept model (Coats 2001)

… and a few who champion SE in healthcare…

…so Why the disconnect?

Bottom

Line!

? ? ? 2 = ( O - E ) 2

E

Best

Methods!

How do we link SE and healthcare

(in the minds of physicians)?

Exploratory (sandbox)

Knowledge and

cognitive systems

Tech develop-

ment

• STEP 0: Change the

approach, to accommodate

– Low engineering literacy

– Physician egos

– Reluctance to change

– Need for visceral impact

How do we link SE and healthcare

(in the minds of physicians)?

• STEP 1: Approach (the

right groups) with caution.

• STEP 2: Frame systems

problems in clinical terms.

• STEP 3: Slowly translate

into SE terms.

• STEP 4: …

• STEP 5: Profit.

Thank you one and all.

• Especially:

– Bob Malins

– Ajay Thukral

– Chris Unger

– Anyone still awake

– Ola Batarseh

– Eugene Day

– Nathan Hoot

– Mike Ward