S uccessful delivery of healthcare is based more on responsiveness to demand for services than any other variable. Healthcare organizations must be able to adapt care delivery resources to meet fluctuations in demands for care. The ability to tailor care services based on demand for services is at the core of Patient Centered Care (PCC), a developing conceptual care model that has gained momentum recently.
Unpredictable demands for care are typically seen in variable workload areas of the hospital such as the emergency department, out-patient laboratory, and other similar diagnostic settings as well as in-patient care centers. When hospitals or other healthcare organizations have an inflexible care delivery model, a state of disequilibrium exists when demands for care exceed available resources resulting in an “hourglass syndrome”.
The “hourglass syndrome” in healthcare is manifested by a high demand for services with an inflexible service delivery and distribution platform that results in extended waiting times for care, increased patient holding times, and a decrement in patient dispositional outflow. The issues of primary concern with inflexible delivery platforms are elevated risks for medical errors – which can be several – diminished quality of care delivered, reduced patient privacy, and an overall delay in care. All of which can be seen when inflexible delivery platform attempts to meet care demand exacerbations.
The flow chart below shows the elements of the hourglass syndrome in an overview perspective. Using and emergency department as an example, demands for care services are experienced from three main sources.
1. Emergency medical services (EMS) represent all incoming patients from ambulance traffic. This is a highly unpredictable and volatile form of demand that encompasses huge variations in patient acuity.
2. Emergency department (ED) triage which is a primary source for care demand services that also is highly unpredictable and can have large variations in acuity too, but typically this demand source has a lower acuity than EMS demand, but not always.
3. In-hospital critical care demand represents an infrequent source of demand in which a facility’s critical care bed space is full and an inpatient emergency takes place elsewhere in the hospital requiring that patient to be transferred to an acute care are, in this case, the emergency department. For example, if a patient has a cardiac arrest on a medical-surgical floor and the ICU is full, assuming that the patient is successfully resuscitated they will need to be transferred to an ICU bed. If no beds are available, that patient is likely to be transferred to the emergency department while bed arrangements can be coordinated. Clearly this is not a frequent event in any hospital and it is likely more often to be seen in smaller acute care facilities as opposed to larger ones.
The central element is the inflexible care delivery platform itself that is represented by an hourglass shape in which one end has a large opening for receiving demands for services from several sources, and the other end represents the dispositional outflow of patients to any number of continued care targets. The center of the hour glass represents the multitude of services provided by the emergency department that are large consumers of time, bed space, personnel, and consumable resources which are typically finite. This is where patient flow becomes stenotic as care is being delivered during demand exacerbations. As demand decreases the hourglass center expands which would represent a more equitable relationship between department resources and overall demand for care.
On the tail end of the hourglass are several continued care target areas where patient flow is directed. These areas are receivers from the emergency department and may also be represented in the center of this chart. These care targets will (and quite often do) impact on the overall patient dispositional outflow rate from the hourglass. If any one of the care targets is operating in a high demand for services period, then dispositional outflow from the ED will be negatively affected. For example, a patient is ready to be admitted to a telemetry unit. The telemetry unit workload is very high and resources from the telemetry unit are not ready to be committed to the new demand for services (the patient). This causes a reduction in dispositional outflow from the ER.
This is part one of a two part posting. Part two will be posted in the coming days and will offer some options for improving patient flow.