EMERGENCY DEPARTMENT OVERCROWDING EFFECTIVELY ADDRESSING

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EFFECTIVELY ADDRESSING

EMERGENCY DEPARTMENT OVERCROWDING

A framework for designing regional coordination models

Master Thesis MSc Technology & Operations Management

University of Groningen, Faculty of Economics and Business

4 February 2019

A. Waldus

2325438

Supervisor / university

dr. ir. D.J. van der Zee

Co-assessor / university

dr. M. J. Land

Supervisors / field of study

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Abstract

Purpose - Many hospitals face Emergency Department overcrowding, threatening quality of care and patient health. Ambulance routing can foster patient health on a regional level by optimal patient distribution through resource pooling, i.e. hospital Emergency Departments within the network. This control measure, addressing Emergency Department input, has the potential to prevent and control overcrowding on a regional level. In order to implement this control measure at the right time in the right manner, a regional coordination model featuring a monitoring and control system should be established. Existing literature offers policy makers little support in designing such a regional coordination model. Therefore, this study aims to develop and evaluate a framework for designing an effective regional coordination model to reduce regional Emergency Department overcrowding and mitigate its effects on patient outcomes.

Method - To reach the research objective, a design science method is adopted. First, the problem is investigated. A literature review is conducted to study Emergency Department overcrowding within acute care networks, and addressing it by means of regional coordination. Second, the solution is designed. Existing regional coordination models are considered in-depth to identify relevant model elements and guidance on their construction. Starting from the literature review, model exploration and non-structured discussions with domain experts, the framework for designing regional coordination models is developed. Third, the design is validated. The functioning of the framework is illustrated and evaluated. It illustrates its use in dealing with a former situation, when a high degree of overcrowding was present in the Northern Netherlands. Finally, the usefulness of the framework is evaluated and discussed with domain experts. Results - This study develops and evaluates a framework that supports policy makers in designing a regional coordination model. A tailored regional coordination model enables effective monitoring and control of the acute care network and thereby, addresses Emergency Department overcrowding. The framework is applicable to a large range of acute care networks as the acute care network and region-specific characteristics are taken into consideration during the design process. The framework combines an initial blueprint and a step-wise design approach. The initial blueprint identifies and visualises generic model elements and relations. The model design approach guides the design process by indicating several phases and steps to be performed. In the end, the designed model is evaluated by means of stakeholder evaluation and by comparing model performance in relation to established regional coordination requirements. Conclusion- A regional coordination model featuring a monitoring and control system can effectively prevent and control overcrowding and thereby overcome its negative effects on patients and care providers within the acute care network. The objective of this study is achieved by indicating model elements and regional coordination requirements and then providing a framework to design a model that meets the requirements. The framework is evaluated to illustrate its functioning and address completeness of its output. This study supports policy makers in designing a regional coordination model by means of an initial blueprint and a step-wise model design approach. Taking research limitations into account, this study provides a starting point from which regional coordination models effective in addressing Emergency Department overcrowding can be further researched.

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Preface

This thesis resembles the completion of my master’s degree Technology and Operations Management at the University of Groningen. Writing this thesis was a long but rewarding journey. It has been a pleasure researching the challenge of addressing Emergency Department overcrowding by means of regional coordination, because the subject always gave me the feeling of actually contributing to a pressing societal problem. Studying this subject in such a thorough manner would not have been possible without the help and support of several people.

First of all, I would like to extend my profound gratitude towards my two supervisors, dr. ir. D.J. van der Zee and dr. M. J. Land for their critical remarks, constructive feedback and helpful guidance throughout the past five months.

Furthermore, I would like to thank drs. A.A.A.M. Koek and mr. drs. A.F. Boskma and colleagues from the Acute Zorgnetwork Noord Nederland for providing me with insights from the field of study. In addition, I am grateful for receiving such a warm welcome at their office and the opportunity to experience the day-to-day operations.

Moreover, I would like to thank Bert Pronk for providing me with excellent insights concerning the Emergency Medical Services in the Northern Netherlands. In addition, I would like to pronounce my appreciation towards Jaap Hatenboer for our fruitful discussions during which I gained extensive knowledge on acute care networks in the Northern Netherlands. Our conversations on healthcare management, a bit strayed from the thesis subject sometimes, have really spiked my interest to pursue a career in the healthcare sector.

Lastly, I would like to thank my family, friends and fellow students for always supporting and motivating me throughout this process.

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6.3.3 Framework use ... 42 6.4 Framework output... 42 7 Framework evaluation ... 43 7.1 Research approach ... 43 7.2 Framework input... 43 7.3 Framework illustration ... 44 7.4 Framework output... 46 7.5 Framework evaluation ... 48 8 Discussion ... 49 8.1 Research contributions ... 49 8.2 Research limitations ... 49 8.3 Future research ... 50 9 Conclusion ... 52 References ... 53

Appendix A – Literature review (extended) ... 57

A.1 Emergency department overcrowding ... 57

A.1.1 Emergency Department characteristics ... 57

A.1.2 Emergency Department overcrowding explained ... 58

A.1.3 Causes of Emergency Department overcrowding ... 59

A.1.4 Effects of Emergency Department overcrowding ... 60

A.2 Addressing Emergency Department overcrowding ... 60

A.2.1 Regional coordination of patient distribution ... 61

A.2.2 Ambulance routing: overcrowding prevention and control ... 62

A.3 Existing regional coordination models ... 64

A.4 Regional coordination model requirements ... 65

A.5 Model design support: initial blueprint and design directions ... 67

Appendix B – Hospital profiles Northern Netherlands ... 69

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1 Introduction

Nowadays, many hospitals face Emergency Department overcrowding and the increase thereof, caused by an increasing number of patients (Patel, Derlet, Vinson, Williams and Wills 2006; Di Somma et al. 2015). The increasing patient volume together with limited Emergency Department resources threatens to compromise patient care (Patel et al. 2006; McLeod et al. 2010). In order to limit the negative effects of overcrowding on patients and care providers, prevention and control of Emergency Department overcrowding is extremely important (McLeod et al. 2010). Due to the interrelatedness of operations and performances between Emergency Departments within an acute care network, coordinated interventions on a regional level are required (Alberti 2004; Schull, Vermeulen, Slaughter, Morrison and Daly 2004; Hagtvedt, Ferguson, Griffin, Jones and Keskinocak. 2009; Deo and Gurvich 2011).

Using a whole-system perspective, overcrowding is a supply and demand imbalance in health care needs and available services within the acute care network (Di Somma et al. 2015; Jeanmonod and Jeanmonod 2016). Often such imbalances are local, i.e. do not concern all Emergency Departments within the network at the same time, but a subset. This imbalance, and thereby overcrowding, can be addressed by establishing a match between demand and supply within the region (Deo and Gurvich 2011). This match can be established by resource pooling of care services through patient distribution on a regional level ( Richardson, Asplin, and Lowe 2002; Deo and Gurvich 2011). Regional distribution of acute care patients for a major part relies on ambulance routing. Therefore, ambulance routing can be effective in addressing Emergency Department overcrowding on a regional level (Deo and Gurvich 2011; McLeod et al. 2010; Kao, Yang, and Lin 2015). However, this effectiveness relies on the coordination of ambulance routing on a regional level. Therefore, a regional coordination model should enable well-founded decision making using a whole-system perspective on the use of ambulance routing within the acute care network (Shaw, Rosen, and Rumbold 2011; Nuño, Coleman, Bengoa and Sauto 2012; Jeanmonod and Jeanmonod 2016).

This research is motivated by the Acute Zorgnetwerk Noord Nederland. The Acute Zorgnetwerk Noord Nederland, representing the joint care providers in the region, experienced a significant increase in Emergency Department crowdedness in the Northern Netherlands. To address this crowdedness on a regional level, the Acute Zorgnetwerk Noord Nederland initiated a project seeking to improve management of Emergency Department crowdedness. In order to effectively monitor and control regional Emergency Department crowdedness in the Northern Netherlands, a regional coordination model including input related control measures should be established. Unfortunately, which key elements to include and how to design such a regional coordination model remains unclear.

Although much literature can be found that describes the importance of addressing Emergency Department overcrowding by means of regional coordination, there is still very little consensus on the design of regional coordination models. A few studies propose a regional coordination model that imply reduced Emergency Department overcrowding (Vilke et al. 2004; Patel et al. 2006; Shah et al. 2006; McLeod et al. 2010; South

Australia health policy 2017). Due to the focus on one research region and because of specific model

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the general case. Foreseen contributions of these models, concerning model elements selection, element configuration, element implementation and model design, will mainly arise from comparing models and by distilling their best practices.

The increasing societal problem of Emergency Department overcrowding, together with gaps observed in literature stress the need for a comprehensive approach towards the design of a regional coordination model in order to address overcrowding. Such an approach is meant to identify, configure and implement key model elements and provide decision support in doing so. The research objective of this study is therefore:

“Develop and evaluate a framework to support designing a regional coordination model in order to effectively address Emergency Department overcrowding.”

The framework strives to provide understanding how regional coordination models should be designed to effectively address regional Emergency Department overcrowding. Effectively comprises preventing and controlling overcrowding to provide acute care patients with the right care at the right location within the right period of time under all circumstances.

The scope of this research is narrowed down to regional coordination that addresses problematic Emergency Department input concerning patients transported by Emergency Medical Services. Emergency Department throughput and output are considered out of scope. Addressing Emergency Department throughput and output would concern local processes that are specific for each hospital. In addition, decision making on these processes is often autonomous for which regional coordination is considered undesirable. Likewise, the focus on patients arriving by Emergency Medical Services considers patients arriving by self-transport, possibly being referred by general practitioners or by self-referral out of scope. Clearly, the inclusion of the latter patient groups would be a worthwhile extension. However, their inclusion would imply a significant increase of model complexity, and would require more research resources than made available for this project. Therefore, the proposed framework can be considered a stepping stone towards a comprehensive regional coordination model including all patient arrivals.

In order to develop this framework, a design science method is adopted (Wieringa 2014). A review of related literature, an exploration of existing regional coordination models and non-structured interviews with domain experts will provide insights in regional coordination models. These insights comprise regional coordination requirements and model elements, their possible configurations and implementation possibilities. Building on these insights, a framework for the design of such coordination models is developed. To evaluate framework effectiveness and efficiency, its use will be illustrated by analysing an overcrowding situation in the Northern Netherlands.

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2 Research design

This chapter describes the research design. First, Section 2.1 presents the system model underlying this research. Next, the adopted research methodology is motivated in section 2.2. Finally, section 2.3 details the research plan.

2.1 System model

Figure 2.1 depicts the system model adopted for this research. The following sections will describe the elements of the model. It contains system input, the system (Emergency Medical Services, Emergency Departments and regional coordination), system output, environmental factors and performance indicators.

Figure 2.1: System model Input

The input of the system are patients suffering from immediately life- or limb-threatening health conditions in need of acute care services (Hirshon et al. 2013). Patients entering the system have certain characteristics, medical needs and are at a certain location. The acute care network, i.e. Emergency Medical Services and Emergency Department(s), will provide care to these patients.

System

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Regional coordination contains monitoring and control as main elements. Insights in system status should support decision making on ambulance routing to effectively address Emergency Department overcrowding. Emergency Medical Services and Emergency Departments perform operational processes in order to provide an effective response to an emergency call, often by providing patients with transport and treatment in the pre-hospital and hospital phase. Emergency Medical Services contain a dispatch centre, transport modalities, equipment and staffing. The Emergency Department is a department within a health facility that contains equipment and staffing in order to provide acute care.

Output

The output of the system are patients that are served by the Emergency Department and Emergency Medical Services. Their location, medical needs and characteristics are altered, depending on the transport and treatment these patients have received. Either the patient has been treated on the scene by Emergency Medical Services or the patient has been treated and transported to an Emergency Department. The patient leaves the system when the patient is treated on the scene without further medical transportation, or when the patient is discharged from the Emergency Department by means of hospitalisation, referral to an outpatient clinic or homewards.

Environmental factors

The system is affected by region-specific characteristics that are external to the system and cannot be influenced by the system. Depending on the region(s) in which the acute care network operates, certain environmental factors influence the system such as social, technology, economic, environmental, political, legal, ethical factors and demographics (Hans, Houdenhoven, and Hulshof 2012). Factors that are perceived to have a significant influence on the acute care network are demographic factors, legal factors and technology. These factors cover region-specific characteristics such as regulations concerning ambulance arrival times (legal), patient demand characteristics (demographic), and medical innovations and transport infrastructure within the region (technology).

Performance indicators

The proposed framework strives to support the design of regional coordination models that are effective in addressing Emergency Department overcrowding within a region. In which effective comprises preventing and controlling overcrowding to provide acute care patients with the right care at the right location within the right period of time under all circumstances. In order to indicate whether the acute care networks’ response is effective, indicators such as patient outcome, patient waiting time and total hours of ambulance diversion are common (Hoot and Aronsky 2008). The total hours of ambulance diversion is indicative of Emergency Department closures caused by overcrowding.

2.2 Research methodology

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aimed at solving a generic field problem, which is then assessed in terms of its real-world practical use to test its practical validity (van Aken and Romme 2012). The generic artefact to be developed in this research is a framework, i.e. a structure that provides support for understanding of, or building on, a certain concept (Wieringa 2014). The framework in this research, will combine a reference architecture, i.e. an initial blueprint, and a step-wise model design approach for designing regional coordination models. A regional coordination model tailored towards a region enables monitoring and controlling its acute care network in order to effectively address Emergency Department overcrowding. The problem experienced by the Acute Zorgnetwerk Noord Nederland will serve as a research vehicle.

In order to achieve the stated research objective, the set-up of this research is based on the four-phase design cycle of the design science methodology of Wieringa (2014). This method is appropriate since it identifies the requirements to develop a framework and to generalise theory. It describes four phases in order to establish this: (1) problem investigation (2) solution design (3) design validation and (4) design implementation and evaluation. The fourth phase is considered to be beyond the scope of this study. In order to improve the problematic situation, the problem of Emergency Department overcrowding within acute care networks should be identified, described, explained and evaluated (problem investigation). Regional coordination models will be explored. Based on this, and on the results of the problem investigation phase, a framework to support designing regional coordination models will be designed

(solution design). The proposed framework will be validated by illustrating its use, and by discussing

whether the research objective has been achieved and findings can be generalized with domain experts

(design validation) (Wieringa 2014).

2.3 Research plan

This section describes the research plan, depicted in figure 2.2 and described below. The research plan explains the order and the manner of research steps performed within the phases of the design cycle of Wieringa (2014) in rough detail. Some chapters require a more refined level of detail concerning the research approach therefore, these chapters include a research approach section in the beginning of the chapter.

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Problem Investigation

Review related literature: Chapter 3 will provide an answer to the question: Which guidance on designing regional coordination models, in order to address Emergency Department overcrowding, is provided in literature? This literature review will provide insight in Emergency Department overcrowding, addressing

it by regional coordination and existing regional coordination models. Regional coordination requirements are identified and generic key elements of a regional coordination model are depicted in the initial blueprint. Typify acute care networks: Chapter 4 will provide an answer to the question: How to typify the acute care networks and regional coordination? The Northern Netherlands is adopted as an example to typify

acute care networks. Networks are described in terms of network resources, network operations and region-specific characteristics, which should be considered when designing a regional coordination model. In addition, an analysis on overcrowding within the Northern Netherlands is performed, which indicates the need for regional coordination. Descriptions are based on literature, and documents, data and non-structured interviews with domain experts from the Acute Zorgnetwerk Noord Nederland and the dispatch centre. Solution design

Explore current models: Chapter 5 will provide an answer to the question: Which insights can be distilled from regional coordination models so far, concerning key elements, their configuration and their implementation and model design? Three selected regional coordination models will be explored, i.e.

characterised and assessed, and compared during an in-depth study. The aim of this exploration is to distil insights concerning possible model elements, their configuration, their implementation and model design. Exploration outcomes are discussed with domain experts in order to distil insights and good practices that will be used as building blocks for the framework design.

Framework design: Chapter 6 will provide an answer to the question: What are the key elements of a regional coordination model and which guidelines should be provided by the framework to support the design of regional coordination models? The proposed framework combines an initial blueprint and a

step-wise design approach to support designing a regional coordination model. The initial blueprint identifies and visualises generic model elements and their relations. The model design approach divides the design process into four phases, including several steps to be performed during the design process. The framework is developed based on the literature review, insights on acute care networks and distilled insights from the model exploration. A first validation step is performed by discussing the framework with domain experts. Design validation

Framework evaluation: The use of the proposed framework will be illustrated by applying it to the acute care network in the Northern Netherlands. Starting from this illustration, framework evaluation focuses on framework effectiveness, i.e. quality of the designed regional coordination model, and on framework efficiency, i.e. whether the model design process is clear, complete and feasible. The framework evaluation will be performed with the aid of non-structured interviews with domain experts.

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3 Literature review

This chapter will address the following question: Which guidance on designing regional coordination

models, in order to address Emergency Department overcrowding, is provided in literature? In order to

obtain an answer to this question, a literature review is conducted. This chapter discusses Emergency Department overcrowding and addressing it on a regional level in section 3.1. Section 3.2 explores model design support by existing regional coordination models. Section 3.3 identifies regional coordination requirements. Finally, section 3.4 describes the initial blueprint, indicating generic key elements. 1

3.1 Addressing Emergency Department overcrowding on a regional level: need for

coordination

Acute care is delivered by Emergency Medical Services and health facilities featuring Emergency Departments (Hirshon et al. 2013). Unfortunately, the increasing occurrence of Emergency Department overcrowding hampers the timely provision of the right acute care within the network (Moskop, Sklar, Geiderman, Schaers and Bookman 2009). Di Somma et al. (2015) and Jeanmonod and Jeanmonod (2016) state that overcrowding is not merely a matter of an Emergency Department not having adequate resources for the demand placed upon it by the patients or community. Overcrowding is a supply and demand imbalance in health care needs and services that results in undesirable outcomes for patients and care providers (Di Somma et al. 2015; Jeanmonod and Jeanmonod 2016). In addition, due to the interrelatedness of operations between Emergency Departments within an acute care region, overcrowding of one Emergency Department often leads to overcrowding of neighbouring Emergency Departments (Schull et al. 2004; Schneider et al. 2001). Therefore, there is a need for a whole-system perspective and coordinated interventions on a regional level, when it comes to addressing Emergency Department overcrowding (Alberti 2004; Schull et al 2004; Hagtvedt et al. 2009).

Deo and Gurvich (2011) state that pooling Emergency Department resources can address overcrowding by matching excessive patient demand with excessive Emergency Department capacity in the region. It does not expand capacity to match patient demand, it aims on a better patient demand distribution within the acute care network, to match Emergency Department capacity (Deo and Gurvich 2011). Patient demand distribution relies on ambulance routing, i.e. the route and therefore the destination of a patient transported by an ambulance (Kao, Yang, and Lin 2015). Ambulance routing can have two different purposes in addressing Emergency Department overcrowding, prevention of overcrowding and overcrowding control.

Prevention of overcrowding concerns proactive ambulance routing, i.e. taking available Emergency

Department capacity into account when deciding on a receiving health facility for a patient. Controlling

overcrowding concerns reactive ambulance routing, also called ambulance diversion, i.e. rerouting

ambulances away from overcrowded Emergency Departments to non-overcrowded Emergency

1_{An extended version of the literature review is provided in appendix A. This extended version elaborates}

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Departments (Ramirez-Nafarrate, Fowler, and Wu 2011; Kao, Yang, and Lin 2015). The purported benefits of ambulance routing presuppose an actual match between excess demand and excess capacity. However, this does require well-founded decision making on ambulance routing use within the region, for which several local and regional insights are needed (Kodner 2009). Therefore, a regional coordination model enabling monitoring and controlling its acute care network should be established.

3.2 Existing regional coordination models

Although much literature can be found that describes the importance of addressing Emergency Department overcrowding by means of regional coordination, there is still very little consensus on the design of regional coordination models. There are only a few studies proposing a regional coordination model that do show a reduction of Emergency Department overcrowding among participating hospitals (Vilke et al. 2004; Patel et al. 2006; Shah et al. 2006; McLeod et al. 2010; South Australia health policy 2017).

Patel et al. (2006) and Vilke et al. (2004) propose regional coordination models that solely enable the use of local control measures and lack a whole-system perspective when it comes to decision making on these control measures (Scheulen, Li, and Kelen 2001; Kao, Yang, and Lin 2015). Mcleod et al. (2010), Shah et al (2006) and the South Australia health policy (2017) do provide models that enable the use of control measures on a regional level, and use well-founded decision making with a whole-system perspective. However, being tailored towards one research region and using a specific model objective causes these models to vary widely concerning model set-up, i.e. model elements, configuration and implementation. The objective of Mcleod et al (2010) is to use a standardised approach for proactive ambulance routing. The model uses an automated decision making system based on an algorithmic model. Whereas Shah et al (2006) aims on a more patient specific approach. Capacity information is manually gathered by a physician and used to decide on ambulance routing for each patient in specific. The South Australian health policy (2017) focuses more on a balanced distribution of ambulances and highly emphasizes and clearly describes on when and how to use escalation and upscaling policies.

Unfortunately, it remains largely unclear whether overcrowding reductions are achieved by means of the regional coordination model and whether these reductions were in favour of patients. In addition, these models lack a firm underpinning of choices made in model set-up. Therefore, these models themselves offer limited support in addressing the general case. However, by performing an in-depth study (chapter 5), contributions of these models, concerning model elements and model design, are foreseen. Their contribution will mainly arise from model comparison and by combining distilled best practices.

3.3 Regional coordination model requirements

This section identifies and describes the requirements of a regional coordination model. The four identified model requirements origin from a variety of fields within literature such as general systems theory, supply chain literature and literature on healthcare integration.

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As described in section 3.2.1, addressing Emergency Department overcrowding requires regional interventions decided on using a whole-system perspective of the acute care network (Alberti 2004; Hagtvedt et al. 2009). Only when using a whole-system perspective and regional coordination for the use of control measures, an effective and structured inter-organisational response can be provided. Therefore, a regional coordination model should preclude sub-optimal decision making and independent functioning of actors (Alberti 2004; Shaw, Rosen, and Rumbold 2011). This requires mechanisms that enable well-founded decision making using a whole system perspective (Kodner 2009).

De sitter (1973) provides a theory that supports an organisation or network to be aligned with its environment, and for subsystems to be aligned within the organisation. Based on this alignment theory (De Sitter 1973), van Amelsvoort (1992) proposes a decision-making loop for an organisation or network to respond and therefore control itself for a changing external and/or internal circumstance. This loop enables effective control and decision making thereof by means of a four-step monitoring and control loop, depicted in figure 3.3. The loop enables decision making to be well-founded, i.e. based on measured information of the whole-system and assessed according to established norms (van Amelsvoort 1992).

Figure 3.3: Monitoring and control system (adapted from van Amelsvoort (1992)) The four elements of the monitoring and control loop are:

Measuring: observe current system state

Assessing: (1) compare: relate each aspect of the observation to a set standard. (2) Integral compare: combine all assessed aspects statuses into a whole-system perspective of the current state.

Deciding: decide on an effective intervention according to the assessed status and the desired status. Control: Implement the controls on which is decided, thus intervene.

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2. A regional coordination model should enable information sharing, communication and collaboration between stakeholders on multiple levels of the network

The monitoring and control system (van Amelsfoort 1992) does not elaborate on information sharing, communication and collaboration between stakeholders on multiple levels within the network (Kodner 2009). Stakeholder relationships within a regional coordination model are important to preclude sub-optimal cooperation and independent functioning of care providers (Alberti 2004; Shaw, Rosen, and Rumbold 2011). Healthcare integration literature states that these stakeholder relationships can be vertical or horizontal. Vertical integrations focuses on different organisations at different levels, for example Emergency Medical services’ relation with hospitals. Horizontal integration concerns similar organisations at the same level, for example two hospitals (Kodner 2009; Shaw, Rosen, and Rumbold 2011).

In order to support hospitals with expectations on arriving patients, hospitals require insights on the whole-system status and the current implemented controls. This requires information sharing and communication on both a horizontal and vertical level. When the authority of decision making on Emergency Department closures lies on a local level, hospitals need insights in Emergency Department statuses within the region. This stresses the need for information sharing and communication on a horizontal level between hospitals. (Kodner 2009; Handel et al. 2011). Information sharing and communication on a horizontal and vertical level are required for stakeholder collaboration. In addition, to overcome sub-optimal cooperation and independent functioning of actors, it is of high importance for policy makers to design and evaluate the regional coordination model together with stakeholders (Kodner 2009; Deo and Gurvich 2011; Shaw, Rosen, and Rumbold 2011).

3. A regional coordination model should be tailored towards its region by considering its acute care network and its external environment

Variations within acute care networks and its external environments require regional coordination models to be tailored towards a specific region in order to be effective in addressing problematic Emergency Department input (Kodner 2009). Acute care network aspects considered relevant for tailoring a regional coordination model are network resources, network operations, and region-specific characteristics (Kao, Yang, and Lin 2015).

4. A regional coordination model must enable the acute care network to provide an effective response under all circumstances while remaining feasible

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3.4 Model design support: initial blueprint and design directions

The insights from section 3.1, 3.2 and 3.3 provide initial support for designing a regional coordination model. Starting from this, these insights form the base of the initial blueprint, depicted in figure 3.4. The initial blueprint indicates the generic key elements of a regional coordination model. The initial blueprint contains the input, output, performance indicators and environmental factors as described in the system model in section 2.1.

Figure 3.4: Initial regional coordination model

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4 Acute care network description: Northern Netherlands

This chapter will address the following question: How to typify the acute care networks and regional

coordination? The Northern Netherlands is adopted as an example to typify acute care networks. Section

4.1 describes the research approach adapted for typifying acute care networks. Section 4.2 discusses its network resources, operations and region-specific characteristics. Section 4.3 discusses Emergency Department overcrowding and required regional coordination.

4.1 Research approach

The acute care network is described in terms of its network resources, network operations and region-specific characteristics. The description is based on literature and non-structured interviews with domain experts form the Acute Zorgnetwerk Noord Nederland and the Emergency Medical services. In addition, overcrowding and the need for regional coordination in the Northern Netherlands is analysed and discussed in section 4.3. Insights in Emergency Department closures are obtained from the administration of the dispatch centre in the Northern Netherlands and a non-structured interview with their emergency coordinator. Information on closures from week 12 up to and including week 50 of 2018 are examined. Due to privacy sensitive information, Emergency Department overcrowding and closures are analysed on a regional level without referring to specific Health Facilities.

4.2 Northern Netherlands’ acute care network

The region in which the Acute Zorgnetwerk Noord Nederland operates concerns the acute care network in the Northern Netherlands. It includes the three northern provinces: Friesland, Groningen and Drenthe, together with the four Frisian isles, Vlieland, Terschelling, Ameland and Schiermonnikoog. Figure 4.1 provides an overview of the Netherlands, with the acute care region of the Northern Netherlands highlighted in blue.

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4.2.1 Acute Zorgnetwerk Noord Nederland

The Acute Zorgnetwerk Noord Nederland is an organisation concerned with acute care in the Northern Netherlands. The main goal of the organisation is to support acute care providers and to strengthen the network within the Northern part of the Netherlands in order to safeguard regional access to acute care. Decisions concerning organisation and improvement of acute care provision within the region are made within a regional council (Regionaal Overleg Acute Zorg, ROAZ). Within the Northern Netherlands this council is divided in two operational councils (Tactisch ROAZ Drenthe/Groningen and ROAZ Friesland) and one executive council (Bestuurlijk ROAZ Noord Nederland). These councils are attended by representatives of care providers from the acute care network, such as Health Facilities, Emergency Medical Services and general practitioners. Representatives from both operational councils are concerned with further development and implementation of the project concerning regional coordination.

4.2.2 Acute care network resources in Northern Netherlands

An acute care network is constructed of network resources to provide patients with emergency medical care services. An acute care network generally consists of Emergency Medical Services featuring a dispatch centre and multiple health facilities featuring an Emergency Department.

Dispatch centre

People can reach out to the dispatch centre in case of a medical emergency by calling ‘112’ in the Netherlands. According to the location and emergency, the caller is connected with one of the regional dispatch centres. In the Northern Netherlands the emergency calls are answered by dispatchers at the Meldkamer Noord Nederland (MkNN). The Meldkamer Ambulance Noord Nederland (MkaNN) is responsible for dispatching Emergency Medical Services to patients in the provinces Friesland, Groningen and Drenthe.

Emergency Medical Services

The Emergency Medical Services organisations feature several ambulance stations, and transport modalities, staff and protocols. The stations store the transport modalities, medical equipment and other necessary supplies and tools. Most commonly, the Emergency Medical Services operations start from this point (Porton 2015). In the Netherlands, ambulance stations are located with the aim to be able to reach every emergency within the region within 15 minutes. At these stations, there is a variety of transport modalities present, which can vary both in physical aspect as in function.

Health Facilities

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facilities vary highly concerning specialisms. Therefore, patients routed towards these hospitals differ as well, the hospital profiles are described in appendix A.

4.2.3 Operational processes

Operational processes performed within the acute care network are discussed in broad terms in section 3.2.2 and visualised in figure 4.4. This section discusses the operational processes in more detail for the acute care network in the Northern Netherlands.

Figure 4.4: Operational processes Northern Netherlands Call triaging

An emergency call connects people with the dispatch centre in case of an emergency. At the dispatch centre, dispatchers answer and prioritise the call and allocate the best suited available resources to the patient (De Vries and Luitse 2001). In the Netherlands, a letter-number code indicates the prioritisation of an Emergency. The following four codes are in place; A1 and A2 level patients require very urgent and urgent dispatches. B1 (high risk) and B2 (low risk) level patients require non-urgent transportation to and from health facilities for research and treatment.

Resource allocation

The dispatcher will send an available transport modality and Emergency Medical Services personnel to the scene, based on a certain dispatch method. The medical needs, location and other patient characteristics determine which transport modality is most suitable. Utilisation and therefore availability of Emergency Medical Services transport modalities is continuously monitored by dispatchers.

Travel to scene

The allocated modality will travel to the patient’s location. The route is determined with the use of postal codes and a Global positioning system (GPS). Often the shortest route is chosen, but always taken into account the route which is faster. The aim for A1 level emergencies is to have a response time of maximum 15 minutes, for A2 a maximum of 30 minutes. The B1 and B2 transports can be planned in advance, the response time will depend on the situation.

Scene management

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decisions on whether patients need medical intervention at the scene or if they should be treated in a health facility with more advanced care.

Choice of receiving health facility

If the patient requires a medical retrieval, the Emergency Medical Services personnel will choose and transport the patient to a receiving health facility. This decision is guided with the use of a protocol and by the varying hospital profiles, indicating whether a certain health facility is capable of providing the care services according to the patient’s medical needs.

In the first place, medical needs dictate the health facility to which a patient is transported. If there are multiple adequate health facilities meeting care needs, the closest hospital is most favourable. If the patient needs quick stabilisation, the closest health facility is chosen even though they do not acquire the right capabilities for further treatment. In that case, the patient will be transported to the health facility with the right profile after stabilisation. Second, familiarity with a facility is considered. Transporting patients to specialists they are familiar with enables continuity of care which is known to improve quality of care. In the end, patient requests for a certain facility are also considered. Familiarity and patient requests are always respected concerning medical needs and longer transportation distances.

Medical transportation

The patient is transported to a health facility featuring an Emergency Department to receive further treatment. Similar to the process ‘travel to the scene’, the shortest or fastest route should be chosen for transport.

Receiving

When arriving at the health facility, the patient is handed over to the staff of the Emergency Department. During this process, information is shared between both parties in a timely matter after which the responsibility for care provision is shifted from Emergency Medical Services to the health facility. After arrival, patients are classified according to a specific triage level at the triage desk. The triage level is based on an acuity level and indicates a certain level of priority for resources that have to be allocated to the patient (Mackway-Jones, Marsden, and Windle 2013).

Treatment

Depending on the medical needs, established priority for the triage level and available resources, the patient has to wait or is immediately evaluated and treated (Mackway-Jones, Marsden, and Windle 2013).

Discharge

After treatment, the patient is discharged from the Emergency Department by means of hospitalisation, referral to outpatient clinic or discharged towards home with or without a check-up from a general practitioner (Asplin et al. 2003; Kao, Yang, and Lin 2015).

4.2.4 Region-specific characteristics

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Legal factors

These factors concern laws and regulations that are in effect in a particular region. These are set by the government and depict preconditions and guidelines for the provision of healthcare. For Emergency Medical Services important guidelines are accessibility targets, which refer to set times within which the service should be provided. The law, ‘Tijdelijke Wet Ambulancezorg’, forces Emergency Medical providers in the Netherlands to provide medical attention at the scene within 15 minutes for at least 95% of all urgent (A1) calls. Furthermore, regulations concerning the use of the ambulance diversion as a control measure or a certain blocking strategy may not be allowed within an acute care region (Burke et al. 2013).

Technological factors

Technological factors concern for example medical innovations, geography and transport infrastructure within a region. Geography and the infrastructure are of high importance for medical transportation within a region since it influences accessibility and travel distances and therefore timeliness. As discussed in section 3.2.2, ambulance routing is most beneficial in urban and suburban areas due to shorter travelling distance (Ramirez-Nafarrate, Fowler, and Wu 2011; Scheulen, Li, and Kelen 2001). Health facilities in the Northern Netherlands are located in urban and sub-urban regions. However, since emergency calls can come from anywhere within the region, the Northern Netherlands also deals with rural areas. In specific, timely patient transport from the Frisian Isles is challenging (Moraitis, Kausika, Nortier and van Sark 2018). Demographic factors

Demographic factors concerns the patient demand of the acute care network, relevant factors are patient volume and patient characteristics related to medical needs. The total patient demand for Emergency Medical Services increased over 20% between 2013 and 2016. Patient demand for Emergency Departments in Northern Netherlands has increased with 5.5% between 2013 and 2016, of which more than 50% is older than 65 years (Nederlandse Zorgautoriteit 2017). Seasonal effects such as the influenza epidemic in the winter highly affects elderly people and is known to increase the problem of Emergency Department overcrowding in the Northern Netherlands (Nederlandse Zorgautoriteit 2017).

4.3 Need for regional coordination

The acute care network in the Northern Netherlands faces the problem of Emergency Department overcrowding. The following insights describe the nature and the extent of overcrowding within the Northern Netherlands based on an analysis of Emergency Department closures.

- The total amount of closure hours within the network is examined. This shows an average amount of closures of 24 hours per week, with a maximum of over 44 hours and a periodical minimum of around 11 hours per week. On average a closure has a duration of 2 hours and 10 minutes.

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- Between one and five Emergency Departments were closed at the same time. This is in line with the statement of Emergency Medical Services that the total patient demand never exceeds the total regional capacity. However, this concerns total amounts without considering whether demand for specific medical needs exceeds these specific care services.

- Next to a lack of available physical space (beds) and available specialists, causes for the Emergency Departments closures concern equipment malfunctions (CT-scan and ICT), staffing (night shift understaffed) and overall Emergency Department problems (power outage and maintenance at the department).

As indicated, the Northern Netherlands faces the challenge of Emergency Department overcrowding. The overcrowding problem becomes increasingly challenging over time. This is not entirely unexpected due to the identified increasing patient demand in section 4.1.4. In addition, seasonal effects are visible. In specific, during winter periods a high peak in patient demand is experienced in the Northern Netherlands (Nederlandse Zorgautoriteit 2017).

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5 Exploration: Regional coordination models

This chapter will address the following question: Which insights can be distilled from regional coordination

models so far, concerning key elements, their configuration and their implementation and model design? It

provides an in-depth study, exploration, of three regional coordination models that address Emergency Department overcrowding. The first section, section 5.1, will discuss the research approach adopted for this in-depth study. Next, the models will be characterised in section 5.2. and assessed in section 5.3. Section 5.4 summarises insights that can be distilled from this study.

5.1 Research approach

This model exploration strives to distil insights concerning model elements, element configuration, element implementation and model design that are supportive in meeting regional coordination requirements. First, regional coordination models will be selected based on selection criteria, discussed in section 5.1.1. Model characterisation strives to characterise the models in terms of their model input, model elements and model use, discussed in section 5.1.2. Model assessment, section 5.1.3, explores and compares model functioning, model set-up and model performance with respect to the in section 3.4 established regional coordination requirements. Model characterisation and assessment are discussed with domain-experts to distil insights that will be used for development of the framework in chapter 6.

5.1.1 Regional coordination model selection

A first criterion for selecting regional coordination models is that the models are comprehensive enough to extract exemplary insights. In this study, models are considered comprehensive when they feature both monitoring and control elements, or provide an extensive description of decisions on either monitoring or control. This already reduced the selection to five comprehensive regional coordination models. The second criterion is that the models include controls used on a regional level. This eliminated another two models: Vilke et al. 2004 and Patel et al. 2006. These regional coordination models solely use regional coordination to steer local controls based on local decision making. Therefore, the following three regional coordination are selected for the model exploration. The models and their objectives are:

A. McLeod et al. (2010): Proactive destination selection through a real-time online system to enhance the ability of hospitals within the region to absorb the load of Emergency Medical Services transports with less overcrowding.

B. Shah et al. (2006): A voluntary, physician-directed destination-control program, to direct Emergency Medical Service units to the Emergency Department most able to provide appropriate and timely care to prevent Emergency Department overcrowding.

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5.1.2 Aspects for model characterisation

To provide insights in the configuration and implementation of model elements of the three coordination models, the models are characterised in terms of model input, model elements and model use. Table 5.1 provides the selected aspects. Establishment of these categorisation aspects is largely motivated by insights in regional coordination requirements (section 3.3) and the initial blueprint (section 3.4).

Table 5.1: Model characterisation aspects

Model characterisation

Model input Model elements Model use

Network resources Status measurement Required resources

Environmental factors Status assessment (norms) Decision making (norms)

Ambulance routing (proactive and reactive)

Remainder elements

5.1.3 Aspects for model assessment

Starting from the regional coordination requirements, section 3.3, the three models will be assessed concerning the model assessment aspects provided in table 5.2. Exploring and comparing models with respect to these aspects aims on providing insight in model functioning, model set-up and model performance.

Table 5.2: Model assessment aspects

Model assessment

Decision making

Whole-system perspective

Well-founded (complete, sequential monitoring and control loops)

Information sharing, communication and collaboration between stakeholders

Horizontal - Between health facilities

Vertical - Between health facilities and Emergency Medical Services

Model tailored towards its region

Network resources

Region-specific characteristics

Effective response under all circumstances while feasible

Applicability Results Limitations

Labour intensiveness

5.2 Model characterisation

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Model characterisation aspects A: McLeod et al. (2010) B: Shah et al. (2006) C: South Australia health policy (2017) Mo d el in p u t Netw o rk re so u rce s EMS

remains unclear 46 ALS and BLS EMS agency operating within the

region

EMS agencies within South Australia

Hospitals 3 tertiary adult care hospitals 1 Academic hospital (100 ED beds) _{1 Academic-affiliated Community hospital (18 ED beds)} Hospitals within South Australia, several acute _{care networks}

Non participating 1 child care hospital 3 independent Community hospitals Women's and Children hospitals

En vir o n me n tal fac to rs

Demographic Calgary: 1.1 million residents (+/- 200 visits each _day) Rochester (metropolitan New York): 1 million residents -

Legal - - -

Technological Developed urban area Developed urban area _{Distance between hospitals 1,5 miles} Developed urban and peri-urban area

Mo d el e le m en ts Statu s m eas u re me n t

Status considered ED capacity status ED capacity status _{EMS capacity status} ED capacity status

Status indicators

ED: number of patients currently receiving care (code/trauma patients, total admits, CTAS 2&3 patients in waiting rooms, patients in EMS park) and patients incoming <45 minutes

ED: available inpatient IC beds, monitored and unmonitored inpatient & ED beds, ED waiting times EMS: patient volume in system

ED: availability of IC beds, cardiac services, burns, renal services, stroke services and mental health

ED: ambulances arriving (hourly basis)

Data gathering

Automatic: ED capacity (link with hospital and EMS information system)

Manual: Incoming patients (information entered at the dispatch centre)

Manual: the on-duty destination-control physician performs hourly calls (less if needed) with ED and EMS staff to obtain information on system capacities. Information is reported on paper by the physician.

Automatic: ED capacity (link with hospital information system)

Information richness Quantitative (numerical information and colour _codes) Quantitative and qualitative numbers Quantitative (numerical information and colour _codes)

Statu s a ss e ss me n t (no rms )

Assessment Objective: system pre-set triggers Subjective: on-duty destination-control physician

judges

Objective: system pre-set triggers

Assessment indicators

Status colours determined by pre-set triggers: favourable (green/yellow) and unfavourable (orange/red) status. Overall ED capacity status is determined by an 'average' of each status indicator colour

- Status indicator colours are determined by

pre-established triggers: green - orange - red

Status presentation

Real-time dashboard

Local: hospitals insight in own capacity status EMS: categorized overview of the hospitals capacity status

- Real-time dashboard

Local: hospitals insight in own capacity status Dispatch centre: insight in all ED statuses

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Mo d el e le m en ts De ci si o n makin g ( n o rms )

Roles destination-control physician. Destination-control

physician recommends an ED

Decision making norms

The system categorizes EDs on a list. The hospital with the highest unfavourable colour is placed at the bottom, EMS has instructions to avoid this ED. Recommended destination is placed on top: ED with the highest favourable capacity status

During the call physician is provided with and considers:

1. EMS providers input and patients input for a specific ED

2. Patient characteristics (clinical status, ED/specialist familiarity)

3. System characteristics (ED beds available, hospital crowding, ED wait time, patient flux towards an ED within recent time frame)

EMS considers patient characteristics, ambulance thresholds, hospital clinical service profiles, hospital capacity, EMS operational requirements, familiarity (patient request considered if in line with other aspects)

Exception(s)

STEMI/acute stroke and major trauma patients should always be allocated to one specific hospital

- Under exceptional circumstances ambulance

routing may be changed (f.e. deteriorating condition) A mb u la n ce ro u ti n g (p ro ac ti ve ) Roles

EMS decides on receiving hospital based on the systems list

EMS makes final decision Remains unclear whether the regional

coordination model and its real-time dashboard are used for proactive ambulance routing Routing strategy

Most favourable ED, according to system categorization based on available capacity and pre-set triggers is chosen

Match between patient characteristics (medical needs, familiarity) and system capacity and capability: ED, EMS and hospital

Exception(s)

If EMS are in a colour red (all EMS units tied up with patients and no free units available for new cases) always closest hospital

- A mb u la n ce ro u ti n g ( re ac ti ve )

Roles ED requests 1 hour closure _{Regional administrator grants closure or not} ED staff can change the official hospital closure status. EMS shifts use from the ambulance threshold _{to use of maximum threshold level}

Indication closure

ED status indicators reaches predetermined criteria identifying critical capacity challenge, regional administrator examines this

remains unclear ED that reaches its ambulance threshold:

established normal usual distribution of ambulances per hour at that ED. When all EDs within the region have reached their threshold, the threshold is increased up to a maximum threshold for that remaining hour.

blocking authorization

Regional (regional administrator) ED staff EMS

blocking strategy Complete blocking remains unclear remains unclear

Routing strategy

Closed ED are categorized at the bottom of the system's list, EMS avoids this ED

Physician operates independently from the official status, but is expected to be aware of it since hourly ED communication

Tried to spare closed ED from new patients

Model use Required resources

System synchronized with ED and EMS systems Regional administrator and a working place (24/7)

Destination-control physician and a working place (24/7)

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The model characterisation shows that the models do vary highly concerning model elements, element configuration and implementation. Model assessment addresses model functioning, model set-up and model performance, provided in table 5.4. A short discussion is provided relevant differences and commonalities between the models that provide insights in how model element selection, configuration and implementation influences the networks response and its effectiveness.

Table 5.4: Model assessment

Model assessment aspects A: McLeod et al. (2010)

Decision making

Whole-system perspective Yes

Well-founded Only well founded if hospital capabilities are all the same (unclear) Otherwise, _{too standardised only available beds considered}

Information sharing, communication and collaboration

Horizontal -

Vertical Information sharing and collaboration

Model tailoring

Network resources Only 4 hospitals mentioned (of which one excluded from research: children's _{hospital) Remains unclear what distances are between hospitals} Region-specific characteristics Urban area: easily accessible, favourable for ambulance routing

Applicability Applicable for non-overcrowding and local overcrowding scenarios

Results Significant increase in receiving hospital statuses being favourable _{Significant decrease of total ED Closures} Limitations Overcrowding is reduced, however internal ED changes (f.e. capacity _{expansion) and patient outcome are not considered}

Labour intensiveness Not labour intensive

Model assessment aspects B: Shah et al. (2006)

Decision making

Well-founded Elements lack status assessment norms. Assessment performed manually, _{subjectively by the destination-control physician}

Horizontal -

Vertical Communication, information sharing and collaboration

Model tailoring

Network resources Only 2 out of 5 hospitals considered. _{Distance between is considered negligible, favourable for ambulance routing} Region-specific characteristics Urban area: easily accessible, favourable for ambulance routing

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Results

Significant decrease of ED closures

For 1866 patients (69%) EMS voluntarily called. 253 patients received another destination than before the program, 48% due to ED capacity insights Limitations Limited environment (2 out of 5 hospitals) studied for only one month. Patient _{outcome is not considered} Labour intensiveness Highly labour intensive (EMS needs to call, physician has to be able to answer _{calls 24/7).}

Model assessment aspects C: South Australia health policy (2017)

Decision making

Well-founded Yes

Horizontal Information sharing (in crisis situations: protocol enables communication and _{collaboration)}

Vertical Information sharing and collaboration

Model tailoring

Network resources _{remains unclear since it covers a whole state with multiple acute care networks}

with varying areas

Region-specific characteristics

Applicability Applicable in every situation (discusses crisis plan)

Results remains unclear

Limitations Priority 1 and 2 ambulances are not taken into consideration. _{Patient outcome is not considered}

Labour intensiveness

Not labour intensive (normal and local overcrowding) Medium labour intensive (regional overcrowding) High labour intensive (crisis situations)

Well-founded decision making

All three models do consider a whole-system approach within their limited research region. Decision making in model A is considered well-founded when hospital profiles are the same. Only a colour code is provided, indicating capacity status, without providing insights in available specialisms are provided. Model B relies on the manual information gathering of the control-physician and the manual information provision of the Emergency Department and Emergency Medical Services staff. This is considered to be rather subjective. However, they do argue that an algorithm cannot take into consideration all the factors that the control-physician is taking into consideration when deciding on ambulance routing.

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Model tailoring

Model A and model B are located in an urban environment. The distance between health facilities of model B is considered negligible. An urban environment and negligible distances are considered favourable for ambulance routing since it indicates a low in traveling times. This is related to less risk for patients and less increase in Emergency Medical Services utilisation. Tailoring for model C is not considered, since this model describes multiple networks and the whole South Australian state, indicating a large variety in factors. Effective response under all circumstances while feasible

Applicability: This aspect concerns the applicability of the model in situations with varying degrees of

overcrowding. To provide an indication, non-overcrowding, local overcrowding, regional overcrowding and a crisis situation are considered. The system of model A is too standardised to consider high degrees of overcrowding, it will simply ignore Emergency Department closures and colours and will allocate patients to the closest location. Model B could be used in all situations, however the maximum capacity of phone calls towards one physician is not indicated, which might increase with an increase of overcrowding. Whereas model A and model B lack an upscaling and escalation plan, model C clearly describes thresholds indicating which degree of overcrowding is present and describes controls for each degree of overcrowding.

Results and limitations: Results of model A and B are significant, however their research concerns multiple

limitations. It remains unclear whether results are not achieved by means Emergency Department capacity expansion and whether regional coordination was in favour of the patients. In addition, either not all hospitals within the network are considered (model A and model B) or not all ambulance routes are considered (model C). Therefore it remains unclear whether the Emergency Departments and patients transported, outside the scope, have benefited or suffered from these regional coordination models.

Labour intensiveness: Model A and model B show that a more situation-specific approach increases labour

intensiveness compared to a more standardised and automated approach. Whereas, model C shows multiple levels of labour intensiveness within one model, it indicates increasing labour intensiveness for increasing degrees of overcrowding within the region.

5.4 Discussion: insights distilled

This exploration strives to distil insights concerning good practices of model element selection, element configuration and implementation and model design that are supportive in meeting regional coordination model requirements. Established insights will be taken into account for framework development, both for the initial blueprint and the model design approach. In order to distil insights, the model characterisation (section 5.2) and assessments (section 5.3) are discussed with domain experts.

EMERGENCY DEPARTMENT OVERCROWDING EFFECTIVELY ADDRESSING

EFFECTIVELY ADDRESSING