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Welcome! June 16, 2017 Dr. Gary Teare, CEO, Health Quality Council

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Today’s session: Health System Modelling for Strategic Planning to Reduce Emergency Department Wait Times Adrienne Danyliw & Yuan Tian

The Presenters Yuan Tian Adrienne Danyliw Project and Policy Consultant, ED Waits and Patient Flow Initiative, Researcher, Health Quality Council Health Quality Council

What is simulation modelling? Real-world applications in modelling and simulation Flight Simulator Life Simulation Games Spread of a Zombie Disease Outbreak Rocket Launcher Simulator

What is Simulation Modelling? 1. Simulation modelling is NOT breaking news. 2. There are well-established methodologies to analyze inefficiencies in health care system or processes. A. Discrete-event Simulation B. Agent-based Simulation C. System Dynamics 3. You can develop and use simulation modelling to design and evaluate solutions that will improve quality of care, patient flow, patient safety and cost-effectiveness in health care.

Why we use computer simulation modelling? System Experimentation Health Care System Experiment with the actual Experiment with a system health care system simulation model Risky Disruptive Costly Time-consuming Using “Virtual Pilots” to better inform actions

Case Study: Using Simulation Modelling for Strategic Planning to Reduce Emergency Department Wait Times

Current State of Emergency Department(ED) Waits 1. What is emergency department crowding? 2. Why should we care? 3. How to measure crowding in emergency? 4. What are the causes of crowding in emergency? 5. How we used modelling to help set strategies?

Emergency Department Crowding Emergency department overcrowding is a situation in which demand for service exceeds the ability to provide care within a reasonable time, causing physicians and nurses to be unable to provide quality care. Canadian Association of Emergency Physicians

Negative Impacts of Long Wait Times in Emergency Department Increase in mortality, costs and length of stay. Increase in adverse outcomes for time- sensitive conditions. Decrease in patient satisfaction.

Emergency Department Waits and Patient Flow Initiative

Emergency Department (ED) Wait Time Measures Total ED Length of Stay (admitted) Total ED Length of Stay (non-admitted) Waiting Time for Time Waiting for Physician Initial an Inpatient Bed Assessment (WPIA) (TWIB) Leave ED ED Physician Decision to (Move to Registration / Initial Admit (or Triage Assessment Inpatient Ward) Discharge)

Areas for Improvement to Decrease Emergency Department Wait Times Throughput Output Input • ED Visits with Family • Inability to discharge • Staff scheduling Practice Sensitive Alternate Level of • ED resources and Conditions Care (ALC) patients to capacity appropriate setting. • Hospitalization for Ambulatory Care • Lack of coordinated Sensitive Conditions care in the care transition from hospital to home. • Continuity of Care With Family What are the root causes of Medicine Physicians long wait times in SK hospitals? Where should we act, given limited resources?

Cross-Functional Planning Emergency department waits is a system issue

Framework for Cross-functional Planning Current state, identifies gaps/opportunities. Recommendations What can we adapt? What Advisory Group and do we already do well? other stakeholders

Health System Modelling for Patient Flow in Saskatchewan Emergency Department Acute Care Post-acute Care and Community Demo of ED in Royal University Hospital SK Population By Age and Gender

Model Structure Model Structure Patient Flow in ED and Acute Care were simulated for 6 hospitals: • Regina General Hospital • Pasqua Hospital • Saskatoon City Hospital • St. Paul’s Hospital • Royal University Hospital • Victoria Hospital

Model Calibration and Validation Internal Validation

Model Calibration and Validation External Validation

Areas for Improvement to Decrease Emergency Department Wait Times Throughput Output Input • ED Visits with Family • Inability to discharge • Staff scheduling Practice Sensitive Alternate Level of • ED resources and Conditions Care (ALC) patients to capacity appropriate setting. • Hospitalization for Ambulatory Care • Lack of coordinated Sensitive Conditions care in the care transition from hospital to home. • Continuity of Care With Family What are the root causes of Medicine Physicians long wait times in SK hospitals? Where should we act, given limited resources?

What if… What if we can reduce potentially avoidable ED visits for FPSCs during evening hours by 50%? What will be the impact on ED wait times? Developed by Alberta Health Quality Council, FPSCs are “ Emergency department or urgent care centre visits for health conditions that may be appropriately managed at a family physician's office .” – Alberta Health

What if… What if we implement “High Quality Care Transition” for medical patients? What impact would this have on ED wait times?

What if… What if we have more physician coverage in ED for busy hours (e.g. 9am to 12pm). How would this impact ED wait times?

What ifs… Component Intervention/Factor Description Effect Size Current Level of Care Relevant Reference CIHI. 2014. Sources of Potentially Reducing Potentially Avoidable 50% Reduction for ED visits for FPSCs (Mon-Fri 9%-19% (with variation across EDs) Avoidable Emergency ED Visits for FPSCs 9am to 7pm) Department Visits. Shift 10% in the "low" and "moderate" CIHI. 2014. Continuity of Care With Improve Continuity of Care categories to "high" category respectively. 60.7%-71.68% (with variations Family Medicine Physicians: Why It (measured as UPC Index) Reduce ED visits for FPSCs and hospitalization across regions) Matters. for ACSCs. CIHI. 2014. Sources of Potentially Reducing Potentially Avoidable 10% reduction in avoidable ACSC Input % varies across hospitals. Avoidable Emergency Hospitalizations for ACSCs hospitalization. Department Visits. Whittaker, W., et al., 2016. Associations between extending access Reducing Potentially Avoidable 50% Reduction for ED visits for FPSCs (Mon-Fri to primary care and emergency ED Visits for FPSCs via extending 9%-19% (with variation across EDs) 7pm-12am) department visits: a difference-in- hours in primary care differences analysis. PLoS Med, 13(9), p.e1002113. Throughput Extra Physician Coverage in EDs 6-7 additional hours of physician coverage with variation across ED daily Sutherland, J.M. and Crump, R.T., 2013. Alternative Level of Care: Canada's Reduce ALC hospital days 100% reduction in ALC hospital days Hospital Beds, the Evidence and 3.5% of hospital days (with Options. Healthcare Policy, 9(1), p.26. variation across hospitals) El-Eid, G.R., Kaddoum, R., Tamim, H. and Hitti, E.A., 2015. Improving hospital Shift time of inpatient discharge 33%-69% of admitted patients Output Safely discharge patients by 2 hours earlier on discharge time: a successful by 2 hours earlier on average (on discharged before 1pm (with average Implementation of Six Sigma a daily basis) variation across hospitals) methodology. Medicine, 94(12), p.e633. LOS for medical patients: 8-35 Shepperd S et al. 2013. Discharge High quality care transition (or reduction in readmission rate (RR=0.82) and days (with variation across planning from hospital to home. discharge planning) LOS (0.91 days) for medical patients Cochrane Database Syst Rev. hospitals)

Modelling Results: Royal University Hospital Reduce ED visits for FPSCs during evening hours No Intervention (less wait times for an inpatient bed) (current state) Add physician coverage in ED Reduce ALC Better hospital days High Quality Care Transition Better (less wait times for physician initial assessment)

Lessons Learned & Next Steps Lessons: • Use the right tools for strategic planning • Work tirelessly to ensure collective wisdom Next steps: • Connected team based care • Create space for sharing and learning • Align with existing provincial work

Other Applications & Future Opportunities in Health Care • Hospital scheduling and organization • Infection and communicable disease • Screening programs • Costs of illness and economic evaluation

Questions? About modelling: Ytian@hqc.sk.ca About Patient Flow: Adanyliw@hqc.sk.ca

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