Using Poisson Modeling and Queuing Theory to Optimize Staffing and Decrease Patient Wait Time in the Emergency Department

Introduction: Studies have shown Emergency Department (ED) crowding contributes to reduced quality of patient care, delays in starting treatments, and increased number of patients leaving without being seen. This analysis shows how to theoretically and optimally align staffing to demand. Methods: The ED value stream was identified and mapped. Patients were stratified into three resource-driven care flow cells based on the severity indices. Time observations were conducted for each of the key care team members and the manual cycle times and service rate were calculated and stratified by severity indices. Using X32 Healthcare’s Online Staffing Optimization (OSO) tool, staffing inefficiencies were identified and an optimal schedule was created for each provider group. Results: Lower Severity Indices (higher acuity patient) led to longer times for providers, nurses, patient care assistants, and clerks. The patient length of stay varied from under one hour to over five hours. The flow of patients varied considerably over the 24 hours’ period but was similar by day of the week. Using flow data, we showed that we needed more nurses, more care team members during peak times of patient flow. Eight hour shifts would allow better flexibility. We showed that the additional salary hours added to the budget would be made up for by increased revenue recognized by decreasing the number of patients who leave without being seen. Conclusion: If implemented, these changes will improve ED flow by using lean tools and principles, ultimately leading to timeliness of care, reduced waits, and improved patient experience.

Confounders in Adenoma Detection at Initial Screening Colonoscopy: A Factor in the Assessment of Racial Disparities as a Risk for Colon Cancer

Background and Aims: The incidence and mortality of colorectal cancer is persistently highest in Black/African-Americans in the United States. While access to care, barriers to screening, and poverty might explain these findings, there in increased interest in examining biological factors that impact the colonic environment. Our group is examining biologic factors that contribute to disparities in development of adenomas prospectively. In preparation for this and to characterize a potential patient population, we conducted a retrospective review of initial screening colonoscopies in a cohort of patients. Methods: A retrospective review was performed on initial average risk screening colonoscopies on patients (age 45 - 75 years) during 2012 at three institutions. Descriptive statistics and multivariable logistic regression models were used to examine the relationship between potential risk factors and the detection of adenomas. Results: Of the 2225 initial screening colonoscopies 1495 (67.2%) were performed on Black/African-Americans and 566 (25.4%) on Caucasians. Multivariable logistic regression revealed that older age, male sex, current smoking and teaching gastroenterologists were associated with higher detection of adenomas and these were less prevalent among Black/African-Americas except for age. Neither race, ethnicity, BMI, diabetes mellitus, HIV nor insurance was associated with adenoma detection. Conclusion: In this sample, there was no association between race and adenoma detection. While this may be due to a lower prevalence of risk factors for adenomas in this sample, our findings were confounded by a lower detection rate by consultant gastroenterologists at one institution. The study allowed us to rectify the problem and characterize patients for future trials.

Impact of type 2 diabetes on adenoma detection in screening colonoscopies performed in disparate populations

BACKGROUND The Black/African Ancestry(AA)population has a higher prevalence of type 2 diabetes mellitus(T2DM)and a higher incidence and mortality rate for colorectal cancer(CRC)than all other races in the United States.T2DM has been shown to increase adenoma risk in predominantly white/European ancestry(EA)populations,but the effect of T2DM on adenoma risk in Black/AA individuals is less clear.We hypothesize that T2DM has a significant effect on adenoma risk in a predominantly Black/AA population.AIM To investigate the effect of T2DM and race on the adenoma detection rate(ADR)in screening colonoscopies in two disparate populations.METHODS A retrospective cohort study was conducted on ADR during index screening colonoscopies(age 45-75)performed at an urban public hospital serving a predominantly Black/AA population(92%)(2017-2018,n=1606).Clinical metadata collected included basic demographics,insurance,body mass index(BMI),family history of CRC,smoking,diabetes diagnosis,and aspirin use.This dataset was combined with a recently reported parallel retrospective cohort data set collected at a suburban university hospital serving a predominantly White/EA population(87%)(2012-2015,n=2882).RESULTS The ADR was higher in T2DM patients than in patients without T2DM or prediabetes(35.2%vs 27.9%,P=0.0166,n=981)at the urban public hospital.Multivariable analysis of the combined datasets showed that T2DM[odds ratio(OR)=1.29,95%confidence interval(CI):1.08-1.55,P=0.0049],smoking(current vs never OR=1.47,95%CI:1.18-1.82,current vs past OR=1.32,95%CI:1.02-1.70,P=0.0026),older age(OR=1.05 per year,95%CI:1.04-1.06,P<0.0001),higher BMI(OR=1.02 per unit,95%CI:1.01-1.03,P=0.0003),and male sex(OR=1.87,95%CI:1.62-2.15,P<0.0001)were associated with increased ADR in the combined datasets,but race,aspirin use and insurance were not.CONCLUSION T2DM,but not race,is significantly associated with increased ADR on index screening colonoscopy while controlling for other factors.

Accessory Breast Tissue in Pregnancy

Accessory breast tissue development frequently occurs in addition to physiologic breast development and is a common congenital condition with an occurrence of 0.4% to 6% in women and 1% - 3% in men. A 31-year-old G1P0 female presented to our triage at 20 + 4 weeks gestation with a one-week history of painful bilateral axillary lumps. Her last menstrual period was consistent with an estimated gestational age of 39 + 3 weeks by LMP. She had emigrated from Bengal three years earlier with no other gynecological complaints and knew of no abnormalities on physical exam. The painful axillary lumps were found to be accessory breast tissue. This entity is presented as a palpable thickening that is most prevalent along the milk line in the region immediately below the breasts, along the abdomen, in the axilla and in the groin region adjacent to the vulva. Affected individuals may undergo premenstrual changes such as tenderness, swelling, and difficulty with shoulder range of motion and irritation. The onset of pregnancy stimulates the tissue and makes it more evident as it did with our patient.

Lean Management in Obstetrics and Gynecology: Application in the Ambulatory Clinic Pre- and Post-Kaizen

OBJECTIVE: The ambulatory clinic was an important departmental problem. Providers hated working there and patients complained about the wait times there. It seemed there were equal numbers of patients and provider complaints. In the spirit of solving the problem, data was gathered, a LEAN intervention was planned, and data was collected. METHODS: We defined the service families in the clinic as registration, vital signs, provider or ultrasound visit, nursing visit, and registration for the return visit. We walked the Gemba engaging all the staff in the process. Many observations pointed to long waits between and among the five stations. In order to study the current state, time data was collected by attaching a sheet of paper to a folder that the patient would carry themselves to all the clinical steps. On the sheet of paper each station logged the time that patient appeared and the time the patient left their sight. Data was gathered each day and every day from October 2016 to the summer of 2017. The data was analyzed. Leadership met and identified value and waste in the process. A Kaizen event was scheduled after the first set of measurements engaging all the staff. After the data was thoroughly analyzed and digested, brainstorming occurred. Together we determined our future state. We created a vision and strategic goals to reach our future state. RESULTS: The data pre-Kaizen event showed that the process of arrival to leaving took 124 minutes. We discovered that not every patient passed through each station. We learned the patients were on time or early for their visit most of the time. The providers were late most of the time by 1 - 1.5 hours. We learned how long each station took from the patient’s point of view. There were no statistically significant differences between ultrasound and provider visits;there were no statistically significant differences between midwife and physician visits. Each day of the week was similar. The arrival rate was higher in the morning because of the template. After the event, the total time in clinic did not change however the variability in time between and among each station decreased in variance. We informed the staff of these findings so that they could take responsibility for their part in the process. The atmosphere in clinic changed dramatically and the complaints from both providers and patients stopped. CONCLUSION: LEAN management was used to improve the clinic. It yielded important results, got the staff engaged in the process, and provided a way for the patients to see the efforts made by staff to improve.

Established and Emerging Optical Technologies for the Real-Time Detection of Cervical Neoplasia: A Review

Cervical cancer remains a critically important problem for women, especially those women in the developing world where the case-fatality rate is high. There are an estimated 528,000 cases and 266,000 deaths worldwide. Established screening and detection programs in the developed world have lowered the mortality from 40/100,000 to 2/100,000 over the last 60 years. The standard of care has been and continues to be: a screening Papanicolaou smear with or without Human Papilloma Virus (HPV) testing;followed by colposcopy and biopsies and if the smear is abnormal;and followed by treatment if the biopsies show high grade disease (cervical intraepithelial neoplasia (CIN) grades 2 and 3 and Carcinoma-in-situ). Low grade lesions (Pap smears with Atypical Cells of Uncertain Significance (ASCUS), Low Grade Squamous Intraepithelial Lesions (LGSIL), biopsies showing HPV changes or showing CIN 1);are usually followed for two years and then treated if persistent. Treatment can be performed with loop excision, LASER, or cryotherapy. Loop excision yields a specimen which can be reviewed to establish the diagnosis more accurately. LASER vaporizes the lesion and cryotherapy leads to tissue destruction. Under long term study;loop excision, LASER, and cryotherapy have the same rate of cure. The standard of care is expensive and takes 6 - 12 weeks for the individual patient. During the last twenty years, new technologies that can view the cervix and even image the cervix with cellular resolution have been developed. These technologies could lead to a new paradigm in which diagnosis and treatment occurs at a single visit. These technologies include fluorescence and reflectance spectroscopy (probe or wide-field, whole cervix scanning approaches) and fluorescence confocal endomicroscopy or high resolution micro-endoscopy. Both technologies have received Federal Drug Administration (FDA) and have been commercialized. Research trials continue to show their remarkable performance. These technologies are reviewed and clinical trials are summarized. Emerging technologies are coming along that may compete with those already approved and include optical coherence tomography, optical coherence tomography with autofluorescence, diffuse optical microscopy, and dual mode micro-endoscopy. These technologies are also reviewed and where available, clinical data is reported. Optical technologies are ready to diffuse into clinical practice because they will save money and 3 or 4 visits in the developed world and offer the same standard of care to the developing world where more cervical cancer exists.