Lean techniques for the improvement of patients' flow in emergency department

BACKGROUND: Emergency departments(EDs) face problems with overcrowding, access block, cost containment, and increasing demand from patients. In order to resolve these problems, there is rising interest to an approach called "lean" management. This study aims to(1) evaluate the current patient flow in ED,(2) to identify and eliminate the non-valued added process, and(3) to modify the existing process.METHODS: It was a quantitative, pre- and post-lean design study with a series of lean management work implemented to improve the admission and blood result waiting time. These included structured re-design process, priority admission triage(PAT) program, enhanced communication with medical department, and use of new high sensitivity troponin-T(hsTnT) blood test. Triage waiting time, consultation waiting time, blood result time, admission waiting time, total processing time and ED length of stay were compared.RESULTS: Among all the processes carried out in ED, the most time consuming processes were to wait for an admission bed(38.24 minutes; SD 66.35) and blood testing result(mean 52.73 minutes, SD 24.03). The triage waiting time and end waiting time for consultation were significantly decreased. The admission waiting time of emergency medical ward(EMW) was significantly decreased from 54.76 minutes to 24.45 minutes after implementation of PAT program(P<0.05).CONCLUSION: The application of lean management can improve the patient flow in ED. Acquiescence to the principle of lean is crucial to enhance high quality emergency care and patient satisfaction.

Forecasting patient demand at urgent care clinics using explainable machine learning

Urgent care clinics and emergency departments around the world periodically suffer from extended wait times beyond patient expectations due to surges in patient flows.The delays arising from inadequate staffing levels during these periods have been linked with adverse clinical outcomes.Previous research into forecasting patient flows has mostly used statistical techniques.These studies have also predominately focussed on short‐term forecasts,which have limited practicality for the resourcing of medical personnel.This study joins an emerging body of work which seeks to explore the potential of machine learning algorithms to generate accurate forecasts of patient presentations.Our research uses datasets covering 10 years from two large urgent care clinics to develop long‐term patient flow forecasts up to one quarter ahead using a range of state‐of‐the‐art algo-rithms.A distinctive feature of this study is the use of eXplainable Artificial Intelligence(XAI)tools like Shapely and LIME that enable an in‐depth analysis of the behaviour of the models,which would otherwise be uninterpretable.These analysis tools enabled us to explore the ability of the models to adapt to the volatility in patient demand during the COVID‐19 pandemic lockdowns and to identify the most impactful variables,resulting in valuable insights into their performance.The results showed that a novel combination of advanced univariate models like Prophet as well as gradient boosting,into an ensemble,delivered the most accurate and consistent solutions on average.This approach generated improvements in the range of 16%-30%over the existing in‐house methods for esti-mating the daily patient flows 90 days ahead.

Performance Modelling of Patient Flow Scheduling Through a Formal Method

Smart environment is being used in many areas to deliver more services to individuals in a physical space, such as a hospital. In the UK, the National Health Service(NHS) provides free and high quality healthcare service for all residents. Smart hospital environment is able to support NHS and provide more convenience. Patient flow scheduling is a crucial section in a smart hospital environment. Smart hospital environment aims to provide a smart environment in the hospital to facilitate individual experience and improve the quality of healthcare service.First of all, this paper investigates a real world patient flow scenario of a hospital in the UK and models a general scheduling scheme based on the scenario using a compositional formal approach, i.e. performance evaluation process algebra(PEPA). This scheduling scheme uses an easy-implemented solution(the grouping scheme) to reduce the waiting queue in the hospital. Secondly, fluid flow analysis is used for the performance analysis by generating a set of ordinary differential equations(ODEs) in terms of the PEPA model.

CEREBRAL BLOOD FLOW AND METABOLISM EVALUATION IN COMATOSE PATIENTS BY DYNAMIC SPECT

Thirty patients in coma state underwent dynamic SPECT with 133Xe, a validated technique for the quantitation of CBF by SPECT, using a new brain dedicated tomograph: CERTO-96. CMRO2 was computed by multiplying the mean CBF by AVDO2 according to the Fick’s principle. The mean values of CBF, AVDO2 and CMRO2 in patients with good outcome were significantly different from those with worse outcome. On the basis of the best "discriminant threshold", CBF and AVDO2 demonstrated an intermediate accuracy in separating the two groups, while CMRO2 showed a satisfactory accuracy.

The effects of decompressive craniectomy on cerebral blood flow volume and brain metabolism in different aged patients with severe traumatic brain injury

Objective To explore effects of decompressive craniectomy on cerebral blood flow volume and brain metabolism in different aged patients with severe traumatic brain injury. Methods 71 cases were divided into three groups according age: group A( 【 30 years) ,group B ( 30 ～ 50 years) 。

四川省住院患者空间流向及其影响因素分析

目的分析住院患者跨区县就医现状,并从流入地和流出地2个维度分析其影响因素。方法以四川省作为研究区域,利用2019年第四季度病案首页数据,分别以患者所在区县、住院机构所在区县、流动患者数量作为空间流向的起点、终点和强度分析患者空间流向,并结合患者个人层面、医疗机构层面及区县层面的信息,从流入和流出的维度建立两水平随机截距logistic回归分析探究其影响因素。结果四川省跨区县就医占比22.90%,千人以上流向集中在东部地区,但西部地区跨区县就医患者比例更高。成都、绵阳同时是最大的患者流出地和流入地。患者层面汉族(49%,P<0.001)、男性(2%,P<0.001)、稳定的收入(6%,P<0.001)、更好的医疗保障(16%,P<0.001),机构层面更好的资源,区县层面更高的经济(20%,P<0.001)和医疗水平(5%,P<0.001)会促进患者跨区县就医。结论四川省跨区县住院患者从周边流向区县中心,也从各地流向成都。全面推进分级诊疗,促进患者合理就医,应从加强患者健康教育、提高机构服务水平和促进经济与医疗协调发展等多个方面进行协同。

Effects of Micro Vibration Therapy Nursing Care on Muscle Hardness and Skin Blood Flow: A Pre/Post Group Comparison Study

Purpose: The purpose of this study was to investigate the effects of Micro Vibrational therapy (MVT) on muscle stiffness and blood flow in the skin before and after Micro Vibrational therapy in healthy subjects in order to scientifically verify the effects of MVT. Methods: Micro Vibrational therapy is nurse care use in Japan. It was performed on the backs of 30 subjects (8 males and 22 females) in their 20 s to 50 s according to the eligibility criteria. The resting state before implementation was set as the baseline for the control group, and after 30 seconds of MVT was set as the intervention group. The effects of the MVT were statistically analyzed by these factors and subjective sensation by Visual Analog Scale. Results: The muscle hardness of the area where the MVT was applied for 30 seconds decreased to 29.54 (SD 5.04) after the application, compared to 30.45 (SD 5.05) before. A corresponding t-test showed a significant difference (p = 0.019). Skin blood flow increased from a median of 0.76 (variance 0.062) before to a median of 0.86 (variance 0.16) after the procedure. The Wilcoxon rank test showed a significant difference (p = 0.000). Circulatory response was confirmed by SBP, DBP, and HR. SBP of 108.6 mmHg (SD 14.8) before the study decreased to 105.7 mmHg (SD 15.0) after the study, and DBP of 65.6 mmHg (SD 11.1) before the study decreased to 62.7 mmHg (SD 11.8) after the study. HR decreased from 71.6 beats per minute (SD 10.3) before to 69.2 beats per minute (SD 11.7) after. There was a significant difference in all cardiovascular indices (p < 0.05). VAS (pain, stiffness, and fatigue) was significantly decreased after MVT (p < 0.05). Conclusion: Micro Vibrational therapy tended to decrease muscle hardness and increase skin blood flow even in the short time of 30 seconds. The results suggest that local vibration stimulation is not likely to cause a sudden increase in blood pressure or pulse rate fluctuation. These results suggest that hand vibration nursing care may be applicable to acute patients with unstable circulatory conditions.

基于麻雀搜索算法考虑病患流的医院诊疗设备维护优化研究

针对医院诊疗设备出现故障后对病人的影响不可控、产生的维修费用高等问题,提出了一种基于病患流分布不均的预防性维护决策模型。首先,针对医院诊疗设备退化速度受病患流分布影响的特点,采用病患流因子反映其人流量变化规律,并基于设备衰退演化规则构建了设备退化过程模型。其次,通过将量化的诊疗设备故障风险成本以及延迟或提前维护带来的变动成本纳入成本计算体系,提出了病患流分布不均状况下以故障风险值为约束的设备维护策略。最后,采用麻雀搜索算法进行寻优获取关键初始变量,并对模型进行数值仿真分析,结果表明,新维护策略在保障诊疗设备可靠度的同时,也能保持较低的维护成本。

紧密型县域医共体医保打包支付对患者就诊流向的影响

为分析紧密型县域医共体医保打包支付对患者就诊流向的影响,选取福建省某国家试点医共体为研究对象,采用描述性分析和间断时间序列分析等方法研究该医共体实行医保打包支付前后患者就诊流向指标变化。结果显示,改革后门诊患者县域内就诊人次、县域就诊率上升,住院患者县域内住院人次占比下降趋势放缓;门诊患者基层就诊率下降,住院患者的基层住院人次及占比下降趋势放缓。医共体实行医保打包支付有助于引导患者回到县域内就诊,但尚未推动患者向基层分流。未来需进一步完善医保打包支付机制,提升医共体整体及基层服务能力,落实配套制度建设,引导患者合理就医。

“医患沟通流程图”在肾内科住院医师规范化培训中的应用

目的通过调研并设计医患沟通流程图,提高肾内科住院医师规范化培训学员医患沟通能力。方法对2021年5月到2022年5月在肾内科进行住院医师规范化培训的医师,指导使用医患沟通流程图,并就入科及出科医患沟通能力进行评估。结果分别使用两个版本医患沟通流程图培养学员医患沟通能力,使用医患沟通流程图前,两组学员医患沟通能力无差异(P=0.56)。使用医患沟通流程图后两组学员医患沟通能力均有提高(P<0.01),并且,使用第二版医患沟通流程图的学员医患沟通能力优于使用第一版医患沟通流程图的学员(P=0.002)。结论医患沟通流程图有利于提升规范化培训学员医患沟通能力,可在肾内科规范化培训学员带教过程中推广使用。

患者自控镇痛泵的质量控制检测与分析

探讨患者自控镇痛(PCA)泵的应用质量检测,根据PCA泵的原理结构、技术指标及相关的国家检测标准,梳理PCA泵的主要质量控制参数,结合IDA4Plus型输液设备分析仪分析检测方法和检测步骤。对PCA泵的负荷量、流速精度、流量精度、PCA剂量、锁定间隔、保持静脉开放(KVO)流速、阻塞压力以及报警功能进行检测获得数据,采用计量手段将示值和测量值分别进行对比分析,评估PCA泵的质量是否符合要求。

价值共创视角下患者参与医疗服务创新路径构建

通过整合COM-B模型、MTE治疗参与模型详细阐述了患者参与价值实现的路径,基于服务主导逻辑的价值共创视角并结合知识基础观理论,从而构建出患者参与医疗服务创新价值共创路径。患者参与的能力、动机与机会促进患者参与行为的产生,知识流动、资源整合与开发、激励机制和医患价值评估与反馈体系在医疗服务创新中发挥了重要作用。最后,分析了患者参与医疗服务创新价值共创面临的问题并提出了相应的管理策略,以期为医疗服务创新价值包括患者价值与医院价值在内的双重提升做出理论贡献。

超声诊断在精索静脉曲张诊断中的应用价值

目的研讨精索静脉曲张诊断中应用超声诊断的效果。方法取2020年7月-2022年7月本院精索静脉曲张患者100例,归为观察组;同期取100例体检健康者,归为对照组,两组均接受超声诊断,对比两组的诊断结果差异。结果观察组舒张期流速、反流时间、平均速度均快于对照组;观察组的睾丸体积、睾丸回声强度均低于对照组;观察组的精子密度与成活率均低于对照组(P<0.05)。观察组疾病患者的超声分型结果与“金标准”一致(P>0.05),包括35例Ⅰ型、54例Ⅱ型、11例Ⅲ型。超声显示,大部分(81.00%)精索静脉曲张患者均在左侧患病,右侧患病率相对较低(10.00%),双侧患病者更少(9.00%);影像学特征显示:患者阴囊根部的精索结构呈蜂窝状,个别管腔中还伴有云雾状回声,回声较低。通过Valsalva试验发现内径尺寸增大。彩超下显示,蜂窝状结构处的静脉血流还伴有红蓝交叉的信号,反流信号也十分明显,信号反流持续时间均在1s以上。结论超声诊断的价值较为显著,能够鉴别出精索静脉曲张患者与正常人的区别,同时也能清晰显示出睾丸和静脉的具体情况。

高流量氧疗联合系统化护理在撤离机械通气重症患者中的应用效果

目的:探讨高流量氧疗联合系统化护理在撤离机械通气重症患者中的应用效果。方法:选取2019年6月—2021年12月徐州市肿瘤医院重症医学科收治的重症患者78例作为研究对象,采用随机数字表法分为试验组与对照组,各39例。对照组采用人工面罩湿化吸氧,实施常规护理,试验组采用高流量氧疗及系统化护理。比较两组患者气道湿化效果、呼吸相关指标及临床指标。结果:试验组患者气道湿化效果优于对照组,差异有统计学意义(P=0.045)。撤机48 h,试验组患者动脉氧分压、血氧饱和度高于对照组,二氧化碳分压、呼吸频率低于对照组,差异有统计学意义(P<0.05)。试验组患者撤机48 h纤维支气管镜吸痰次数、48 h再插管率低于对照组,舒适性评分高于对照组,撤机后住院时间短于对照组,差异有统计学意义(P<0.05)。结论:高流量氧疗辅以系统化护理模式可有效提高成功撤离机械通气重症患者的气道湿化效果,改善呼吸相关指标,减少纤维支气管镜吸痰次数,提升患者的舒适性,缩短住院时间。

经鼻高流量湿化氧疗联合振动排痰对高龄卧床吸入性肺炎患者疗效及炎症因子水平的影响

目的观察经鼻高流量湿化氧疗联合振动排痰治疗高龄卧床吸入性肺炎的效果及对患者血清炎症因子水平的影响。方法选取120例高龄卧床吸入性肺炎患者,按治疗方法分为对照组(n=55)和观察组(n=65)。对照组在常规治疗基础上经鼻持续正压通气联合人工叩背排痰,观察组经鼻高流量湿化氧疗联合振动排痰,对比两组的疗效、肺部CT分级、血清C反应蛋白(CRP)、白细胞介素-6(IL-6)、降钙素原(PCT)水平以及抗生素治疗时间、住院时间。结果观察组的临床疗效和肺部CT分级情况明显优于对照组(P<0.01)。治疗后,两组患者的血清CRP、IL-6及PCT水平均明显降低,且观察组变化更显著(P<0.01)。观察组抗生素治疗时间和住院时间较对照组短(P<0.05或0.01)。结论经鼻高流量湿化氧疗联合振动排痰治疗高龄卧床吸入性肺炎效果显著,有助于减轻患者机体炎症反应,缩短治疗时间。

106551例急诊患者疾病谱与就诊规律分析

[摘要]目的探讨我院急诊疾病谱的构成特点，为急诊流程优化、急诊医护人员的弹性配置提供数据支持。方法分析我院2010-01-01～2014—12—31急诊科就诊资料完整的106551例患者，采用描述性的统计方法对患者的就诊时间（季节、月份、星期及时段）的流量等进行分析。结果急诊就诊病例以消化系统疾病（28571例）和呼吸系统疾病（26836例）为前两位，占急诊患者52．0％。急诊患者就诊量存在着季节波动，冬季（26．6％）和秋季（26．0％）就诊量最多，春季就诊量较少（22．1％）。急诊就诊量存在着月份波动，就诊高峰在每年12月（9．9％）和1月（9．6％），最低在4月（7．0％）。急诊科每日时段就诊量存在着两个就诊小高峰，第一个就诊高峰8：00—10：00，第二个就诊高峰出现在18：00～20：00。急诊就诊量不存在星期波动。结论本研究揭示了我院急诊疾病谱构成、常见病种、急诊患者就诊高峰时段的分布特点。急诊医疗资源需求具有波动性。在调整急诊科救治流程、调配医护人员及物资准备时需要考虑这一规律，有利于合理统筹分配急诊医疗资源。

某三级甲等医院急诊科患者流量和拥挤程度的调查

目的通过调查某三级甲等医院急诊科患者流量和拥挤程度的变化规律,分析急诊科拥挤昼夜节律的变化。方法收集某三级甲等医院2012年3月1-31日急诊各科工作日报统计数据,观察患者流量24h变化节律,并与医护人员主观拥挤度评分进行比较。结果急诊科工作日24h患者流量高峰在18:00-22:00,低谷在2:00-6:00,周末患者流量高峰则在8:00-12:00;护士主观拥挤度评分的变化规律与24h患者流量变化规律相似。急诊科就诊流量前五位的科室是内科、骨科、外科、神经科及脑外科,占急诊总人次的79.9%。结论不同时间段的急诊资源需求不同,合理调整工作时间和工作班次可最大限度地满足患者的就诊需求。

安徽省基本药物改革前后新农合住院病人流向与医疗费用比较

目的:比较分析安徽省基本药物改革前后新农合住院病人流向和医疗费用变化情况。资料与方法:抽取安徽3个县新农合数据,并对3个县卫生行政部门和6个乡镇卫生院的关键知情者进行访谈。结果:基本药物制度改革以后,样本地区参合人员总住院数量下降了13.80%,其中乡镇卫生院下降了55.07%,县级医院和县级以上医院分别上升了12.17%和20.81%;总的次均住院费用和次均住院自付费用分别增长了29.32%和32.07%,住院总费用增长了11.48%。结论:基本药物制度改革以后,新农合病人在乡镇卫生院住院大幅减少,县级及以上医院住院增长明显;乡镇卫生院次均住院费用得到控制,但由于县级以上医院次均住院费用和住院人数增长,导致住院总费用上涨、参合病人的实际补偿水平下降。

基于单病种付费的分级诊疗实施效果及影响因素研究

目的:探索基于单病种付费的分级诊疗对于引导住院患者合理流动的政策实施效果,分析政策范围内住院患者机构选择的主要影响因素。方法:本研究以甘肃省渭源县新农合住院患者为研究对象,对比政策前后住院患者就医流向变化情况,并采用logistic回归分析乡级分级诊疗病种范围内住院患者就诊流向的影响因素。结果:病种分级诊疗实施后,住院患者选择乡级医疗机构的比例呈上升趋势,选择县级医疗机构的患者比例呈逐步下降趋势,住院患者县域内就诊率2016年达89.69%;分级诊疗住院病种范围内住院患者就医流向趋于合理。年龄、疾病种类、距县医院车程、患者居住地所在乡镇卫生院服务能力均为影响乡级病种范围住院患者就诊流向的重要因素。结论:基于单病种付费的分级诊疗其对政策范围内住院患者的流向起到了积极的引导作用,制定合理分级诊疗病种,提升基层医疗机构能力是保障政策发挥积极作用的关键。

下肢静脉血流流速监测对神经外科术后患者深静脉血栓风险筛查的临床价值

目的 探讨超声监测下肢静脉血流流速对筛查下肢深静脉血栓(DVT)风险的临床价值。方法 选取陆军军医大学第二附属医院神经外科2020年4月—2021年4月收治的353例术后患者,使用彩色多普勒超声对其术后第1~3天进行每日4次下肢静脉血流流速监测。根据患者住院期间是否发生深静脉血栓,分为DVT组和非DVT组,并对数据进行分析,对监测下肢血流流速筛查下肢深静脉血栓风险的价值进行分析和评估。结果 DVT组与非DVT组之间的股总静脉、腘静脉和大隐静脉血流流速存在显著差异(P<0.01)。术后第1天ROC曲线分析显示腘静脉血流流速筛查神经外科患者术后血栓风险AUC最大,当截断值为13.504 cm/s时,灵敏度为99.7%,特异度为100%。结论 监测下肢静脉血流流速,特别是腘静脉血流流速,对筛查神经外科患者术后深静脉血栓形成的风险具有重要临床价值。