A decision framework for organizing interfacility patient transportation in multihospital systems

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A decision framework for organizing interfacility patient

transportation in multihospital systems

Master Thesis

MSc. Technology & Operations Management MSc. Supply Chain Management

University of Groningen, Faculty of Economics and Business

S. Sinnema 2877104

s.sinnema.1@student.rug.nl

Supervisor university dr. ir. D.J. van der Zee

Co-assessor university dr. J.A.C. Bokhorst

Supervisor field of study ir. J. Hatenboer UMCG Ambulancezorg

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Abstract

Purpose. The demand for interfacility patient transportation is growing, especially in

multihospital organizations. This requires organization of these interfacility patient transfers in a system, to ensure efficient and effective interfacility patient transportation. Therefore, the objective of this study is to develop a framework for the design of an efficient and effective interfacility patient transportation system.

Method. A design science research approach is adopted for the development of this framework.

For the identification of the interfacility patient transportation system and the development of the decision framework, literature is used. The validation of the system and the framework is based on interviews with domain experts. The framework is evaluated by applying it to two cases, concerning interfacility patient transport in Canada and interfacility patient transport caused by COVID-19. To test the design, a small simulation study is performed.

Results. An interfacility patient transportation system can be divided into multiple system

elements; operational process elements, resource elements, and control elements. For every system element, multiple decisions to take are identified. The decision making process is guided by the framework, which is divided into three elements; requirements, framework, and deliverables. In the framework, the impact of requirements are identified, the decisions for each system element ,and the testing and assessing of the decisions determined. The evaluation of the framework and the application to the cases, led to the identification of a working system design.

Conclusions. The developed decision framework provides steps to take and decisions to make

for the design of an efficient and effective interfacility patient transportation system, which can be applied to multiple interfacility patient transportation issues. This is seen as a benefit of the system.

Keywords: Interfacility patient transportation, framework, system design, multihospital system,

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Preface

This master’s thesis research is the final phase before completing my double degree master program, Technology & Operations Management and Supply Chain Management. After five years of study, one university bachelor and two master programs, this thesis also characterizes the end of my student career. The thesis’s objective is to support ambulance care organizations and hospital organizations with organizing interfacility patient transportation.

Performing research to solve a growing healthcare issue has been a very satisfying process for me. This research allowed me to implement aspects that I learned during my studies, for example, performing design science research and a simulation study.

I would like to thank Mr. Hatenboer of UMCG Ambulancezorg for his guidance from the perspective of practice and for his time. I enjoyed our conversations about interfacility patient transportation and the other recent healthcare changes caused by the COVID-19 virus. Additionally, I would like to thank Mrs. Heidstra of ZorgnaZorg for providing insights into current interfacility patient transportations and possible systems to use. Furthermore, I would like to thank all other people that helped me during my research.

In particular, I would like to thank Mr. Van der Zee for his guidance, time, and feedback during my master’s thesis. I appreciated our sessions, where you provided me with clear, constructive, and focused feedback. Additionally, I would like to thank Mr. Bokhorst for his input and time in the co-assessor role. I also appreciated the input of Leon Paauw during our group feedback sessions. Furthermore, I would like to thank Lars Kuperus and Laurens Stellingwerff for their cooperation during my student career, which made it a fun and nice period.

Finally, I would like to thank my friends and family for their support during my research and study.

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4.1 System overview ... 18 4.2 Operational processes ... 19 4.3 System resources ... 21 4.4 Control elements ... 25 5. Framework design ... 29 5.1 Framework set-up ... 29 5.2 Requirements ... 31 5.3 Framework ... 34 5.4 Deliverables ... 44 6. Evaluation of framework ... 46 6.1 Evaluation set-up ... 46 6.2 Case descriptions ... 47

Edmonton and Calgary interfacility patient transportation case ... 47

COVID-19 case ... 48

6.3 Requirements ... 49

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6.5 Deliverables ... 59

6.6 Framework application to COVID-19 case ... 60

6.7 Summary of findings ... 61

7. Discussion ... 63

8. Conclusion ... 65

References ... 66

Appendices ... 74

Appendix 1 Scheduling and routing method algorithms ... 74

Appendix 2 Conceptual model simulation study ... 78

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1. Introduction

Hospitals face a burgeoning pressure on increasing efficiency, caused by the amplifying demand for low-cost, high-quality healthcare (Fong, Smith, & Langerman, 2016). A recent trend in healthcare, which introduces a new aspect of healthcare efficiency, is the enlarged number of hospital collaborations in multihospital systems (Lomi et al., 2014; Warren et al., 2016). Hospitals, in multihospital systems, know a high level of specialization (Naboureh & Safari, 2016). Hence, patients with specific care needs require interfacility transportation, as services asked for are distributed over multiple hospitals (Blakeman & Branson, 2013). As the numbers of patients to be transported increase, pressure is put on organizing this process efficiently (Ardekani, Haight, Ingolfsson, Salama, & Stanton, 2014).

This research is motivated by the dilemma faced by UMCG Ambulancezorg, an ambulance care provider in the northern part of the Netherlands. It faces growing demand for non-urgent interfacility patient transport in its region, as regional hospitals start to cooperate and redistribute their services over the involved hospitals to increase overall efficiency. Currently, UMCG Ambulancezorg has multiple ambulances available for non-urgent interfacility transportations, but they experience low utilization and high costs. Basically, ambulances operate like beds in the “old days”, where patients are transported between departments in the same hospital, being called at short notice. In working towards an efficient and effective non-urgent interfacility patient transportation system, UMCG Ambulancezorg would like to be informed on a decision framework entailing steps to take and options to choose from.

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6 This research aims to contribute to the prior literature by designing a decision framework for efficient and effective patient transfers in a multihospital system. Where the framework will especially focus on integrating hospital planning and non-urgent interfacility patient transportation scheduling, as a means to enhance overall system efficiency and effectiveness. The decision framework is meant to provide guidance to ambulance care providers on organizing an interfacility patient transportation system. It does so by providing a stepwise approach, identifying key decisions to make, and alternative options to choose from.

For developing this decision framework, a design science research methodology will be adopted (Wieringa, 2014). The Main steps include; problem investigation, framework design, and evaluation. Framework evaluation will be based on multiple case applications, with the usage of a small simulation study.

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2. Theoretical Background

2.1 Towards multihospital systems

Traditionally, hospitals work separately and provide a broad range of healthcare services (Lee, Chun, & Lee, 2008). This traditional view on hospitals is changing, and in the field is an increasing amount of hospital collaborations identifiable (Lomi et al., 2014). Hospitals can differentiate in the degree of collaboration, where a multihospital system is the most intense collaboration (Warren et al., 2016). A multihospital system is described as “the collaboration of two or more hospitals that are owned, leased, or sponsored by a central organization” (Warren et al., 2016, p. 16). Another type of collaboration is a diversified single hospital system, which is defined as: “Three or more hospitals and at least 25%, of their owned or leased nonhospital preacute or postacute healthcare organizations are members of the organization.” (Warren et al., 2016, p. 16).

Hospital specialization is distinctive for collaborations in multihospital systems (Naboureh & Safari, 2016). Accordingly, the intrahospital patient pathways change to interhospital patient pathways, because of the distributed care services in multihospital systems (Fan, Zhao, & Peng, 2019). Patients with specific care needs should be transported to the hospital in the multihospital system that has the ability to provide the required care service (Blakeman & Branson, 2013). Therefore, patient transportation has to change from intrafacility transportation where all care services are provided in one hospital to interfacility transport where the care services are divided over multiple hospitals to provide the patient with the care needed (Mathison, Berg, & Beaver, 2013).

The trend toward interfacility transport, as clarified by the rising number of patients involved, highlights the need towards organizing it efficiently (Fong et al., 2016), thereby minimizing costs, and satisfying patients (Cardoen, Demeulemeester, & Beliën, 2010).

2.2 Interfacility patient transportation system

2.2.1 Elements of interfacility patient transportation systems

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Figure 2.1 Interfacility patient transportation system

The patient transportation elements are the operational processes of the interfacility patient transportation system. In Bourn, Wijesingha, & Nordmann (2018) six phases in the patient transportation process of critically ill patients are identified, for example, the need for a transfer and handover from care staff to the transfer team.

The system resources can be divided into transportation mode, staff (qualifications), and equipment (Mathison et al., 2013). The transportation necessity determines the priority of patient transportation (Gratton, Ellison, Hunt, & Ma, 2003). Based on priority, there is the possibility to identify three types of patient transfers, namely emergency transfer, urgent transfer, and non-urgent transfer (Robinson, Goel, Macdonald, & Manuel, 2009). The patient transfer type identifies the transportation mode and the staff qualifications needed; for example, an urgent transfer needs an Advanced Life Support (ALS) ambulance (Van Den Berg & Van Essen, 2019) and nurses with higher professional education (Ambulancezorg Nederland, 2020a).

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2.3 Towards a decision framework for designing non-urgent interfacility patient transport systems

2.3.1 Decision framework: definition and role in designing non-urgent interfacility patient transport systems

Due to the transition from intrafacility transport to interfacility transport, a new patient transportation system should be developed. This entails making decisions on the key elements of an interfacility patient transportation system, thereby identifying and assessing alternative options for implementing each element and their joint configuration.

Literature on designing non-urgent interfacility patient transportation systems is scarce, therefore other study fields should be addressed. Hans et al. (2012) state in their research that creating a decision framework is an appropriate method for designing healthcare systems. National Research Council (2013) defines decision frameworks as: “principles, processes, and practices to proceed from information and desires to choices that inform actions and outcomes.”(p. 70). Decision frameworks can facilitate as a dialogue between parties, for example multihospital organizations and ambulance care providers. This is crucial for translating the objective of the parties, into an effective and efficient healthcare system (Hans et al., 2012). In light of this research, the decision framework should provide a stepwise approach for developing an interfacility patient transportation system, by providing key decisions to take.

A decision framework can contribute in multiple ways. Renaud, Dun, Warner, & Bogardi (2011) state in their research that a decision framework provides a point of departure for how a system should be designed. Decision frameworks can also provide insight into deficiencies, for example conflicting objectives and lack of coherence between planning functions of the stakeholders (Hans et al., 2012). Lastly, decision frameworks can also explain the different hierarchical decision levels; strategic level, tactical level, and operational level (Hans et al., 2012; Osorio et al., 2015).

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10 2.3.2 Decision frameworks in Emergency Medical Services (EMS) research

In the literature concerning decision frameworks in EMS systems, multiple researches are performed (Chong, Henderson, & Lewis, 2016; Thelen, Schneiders, Schilberg, & Jeschke, 2014; Zhen, Sheng, Xie, & Wang, 2015). Different parts of EMS systems are addressed in these researches, namely multifunctional telemedicine systems (Thelen et al., 2014), vehicle mix decisions (Chong et al., 2016), and EMS scheduling (Zhen et al., 2015).

In the research of Thelen et al. (2014), a framework is created for multifunctional telemedicine systems, where the design of the system is divided into three different steps. The steps identified are; use-case and main requirements, system architecture overview, and device and service integration. These steps link to the notion of a decision framework. On the other hand, Zhen et al. (2015) designed five modules for EMS scheduling; request receiver module, instruction sender module, travel time analysis, ambulance management module, and decision making module, which is more linked to the control elements of a system. Chong et al. (2016) create a model that focuses on the vehicle mix decision, which is an aspect of the research of Zhen et al. (2015).

The before mentioned EMS research is relevant on different perspectives for the design of an interfacility patient transportation system. The research of Thelen et al. (2014) is relevant to the structure of a decision framework. For example, first identifying the requirements of a system, followed by the identification of the system elements. On the other hand, Zhen et al. (2015) and Chong et al. (2016) provide insight into issues to address and solution directions, for example, the implementation of ambulance management in the control element of the interfacility patient transportation system.

2.3.3 Decision support in healthcare research

The literature from the EMS research field already provided multiple insights on designing a decision framework for designing an interfacility patient transportation system, but to gather more relevant literature the broader healthcare research field will be addressed. Literature on decision frameworks in healthcare is, for example, focusing on service supply chains (Baltacioglu, Ada, Kaplan, Yurt, & Kaplan, 2007), blood supply chains (Osorio et al., 2015) and healthcare planning and control (Hans et al., 2012).

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11 and operational decision level. Similarly, Hans et al. (2012) identify decisions at the same hierarchical decision levels. Osorio et al. (2015) state in their research that the models and methods created can be used for other areas that contain distribution decisions. The strategic decisions in their framework encompass decisions about choice of types of vehicles, capacity, and staff. The decisions made here affect the tactical decisions about routing and allocation (Osorio et al., 2015).

The identified literature from the healthcare research field is also relevant on different perspectives for the design of an interfacility patient transportation system. Baltacioglu et al. (2007) provide relevant aspects as capacity- resource-, and demand management. These aspects also play a role in an interfacility transportation system, for example, the demand determines the resources needed and the capacity used. These are decisions on the strategic level, as identified by Hans et al. (2012) and Osorio et al. (2015). Other decision levels should also be applied to the design of interfacility patient transportation system design. The control elements are on the strategic decision level, system resource elements on the tactical decision level, and the operational process elements on the operational decision level.

2.3.4 Decision support in other study fields

The healthcare research field is discussed in the previous sections, but other research fields could also address support for framework structures or solution directions. An interfacility patient transportation system concerns a production (hospital) and transportation (ambulance care provider) question. Therefore, the production and transportation research field should also be addressed in this theoretical background. Whereas, this study field will be used for identifying key decisions to be made in setting up transportation systems. In production and transportation research, the term used for transportation design issues is supply chain scheduling (Zegordi & Beheshti Nia, 2009). Another research field that could be relevant for the design of an interfacility patient transportation system is the supply chain management literature, especially when focusing on the set up of effective coordination (de Vries & Huijsman, 2011). The literature discussed in this section is divided into supply chain scheduling, scheduling decisions, and supply chain integration.

Supply chain scheduling

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12 scheduling, but consider aspects that could also be considered in the decision framework for non-urgent patient transportation. For example, Liu, Li, Li, & Zou (2020) are concerning production sequence and order batching, which are elements that could be incorporated in the decision framework to make the interfacility transportation as efficient as possible. Besides, Karaoğlan & Kesen (2017) focus in their research on products with short lifespans, which can be compared with patients in multihospital systems. In multihospital systems, operations are performed at one hospital and perform nursing ward at another hospital, to protect the operating hospital from overcrowding (Bahadori, Teymourzadeh, Ravangard, & Raadabadi, 2017). On the other hand, neither of the researches created a decision framework and only focused on optimizing scheduling. So, there can be concluded that these researches only contribute to a decision framework for interfacility patient transportation by specifying issues to address and solution directions.

Scheduling decisions

Researches that focused in their research on scheduling decisions, are the research of De Matta & Miller (2004) and Bonfill et al. (2008). De Matta & Miller (2004) identify in their research aspects that affect scheduling decisions, for example, plant capacity and transportation modes. These aspects fit the elements identified for the non-urgent interfacility patient transportation system in section 2.2. Therefore, this research is useful for creating the decision framework and should therefore be considered during the design of the interfacility patient transportation system. Meanwhile, in the research of Bonfill et al. (2008), a complete decision framework is created for incorporating production scheduling with transportation scheduling. For the transportation schedule, multiple entities are identified in the framework, namely transport route, transport stage, transport operation, transport order, associated transport order, vehicle, and location. These entities could also be included in the non-urgent interfacility patient transportation system identifiable, for example, vehicles and prioritizing. This framework can help to develop the decision support framework for interfacility patient transportation. Summarizing, De Matta & Miller (2004) and Bonfill et al. (2008) contribute by providing issues to consider in the decision framework.

Supply chain integration

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13 processes throughout the supply chain (Vanpoucke, Vereecke, & Muylle, 2017). In the case of an interfacility patient transportation system, this will be a relationship between the hospitals and the ambulance care organization. An essential aspect of the integration of the supply chain is the exchange of information between the supply chain partner and linkage of the information to the operational processes. (Vanpoucke et al., 2017). That means for an interfacility patient transportation system, the integration of the hospital activities with the transportation activities of the ambulance care organization.

Concluding, the research fields outside the health care sector also provide insights for the design of a decision framework for an interfacility patient transportation system. The production and transportation research field mainly gives insight into detailing steps and issues to consider. For example, capacity and transportation modes considerations, as described by De Matta & Miller (2004), which can be linked to resources of the system. The supply chain integration research provides guidance in how to integrate elements and where to focus on the integration of supply chain partners. So, this literature is relevant to the decisions concerning the control elements. The operational process elements are less considered in the broader research field.

2.4 summary of findings

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3. Research design

3.1 Motivation of research

This research is motivated by a question asked by UMCG Ambulancezorg. UMCG Ambulancezorg is a Dutch ambulance care provider in the provinces of Drenthe and Friesland. Besides the emergency medical services (EMS), they also perform non-urgent patient transportation between hospitals in a multihospital system, where the trend for a growing number of non-urgent patient transportations is identifiable for UMCG Ambulancezorg. On the other side, a well-organized non-urgent patient transportation system is lacking, because the current utilization of the ambulances for interfacility patient transportation is low. Therefore, the question stated by UMCG Ambulancezorg, “How should we organize an effective and efficient non-urgent patient transportation system between hospitals in a multihospital system?” proposed this research. A decision framework for non-urgent interfacility patient transportation systems is lacking.

3.2 Research objective

This research aims to provide guidance on setting up a non-urgent interfacility patient transportation system, by developing a decision framework. The decision framework can be used as a stepwise approach for ambulance care providers, who face an increase in non-urgent interfacility patient transportation requests. Therefore, the following main research objective is determined:

Developing a framework for effectively and efficiently managing and organizing non-urgent patient transport between hospitals in a multihospital system.

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3.3 Conceptual model

In order to design and evaluate the decision framework for organizing non-urgent interfacility patient transportation systems, a conceptual model is created to define the framework and its context (Wieringa, 2014). Figure 3.1 shows the conceptual model.

Figure 3.1 Conceptual model

Interfacility patient transfers can be performed in multiple ways, among others a non-urgent interfacility patient transportation system. To design a non-urgent interfacility patient transportation system, decisions have to be made for operational processes, system resources, and control. The decisions for the system elements can be fulfilled in multiple manners, where the decision framework will provide options to choose from. The impact of the requirements of the environment will be considered during the decision making process. The performance of the non-urgent interfacility patient transportation system is measured in the number of ambulances used and the delivery time of patients.

3.4 Research outline

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16 structuring the research. Based on the engineering cycle, four phases can be distinguished (Table 3.1).

Research phase Thesis chapter

Problem investigation Chapter 2 Theoretical background

System characterization & solution exploration

Chapter 4 Characterization of Non-urgent interfacility patient transportation

Design of the framework Chapter 5 Framework design

Framework evaluation Chapter 6 Framework evaluation

Chapter 7 Discussion Chapter 8 Conclusion Table 3.1 Research phases and chapters

Problem investigation

In the first phase of this engineering cycle, a literature review is performed by reviewing existing literature for the elements of non-urgent interfacility patient transportation systems, and the structure of decision frameworks that may be helpful in their design. Furthermore, unstructured interviews, with domain experts in the field of patient transportation, are used for investigating the problem.

System characterization & solution exploration

In this phase, the physical architecture of the patient transportation process is designed and the characteristics of the decision framework are identified. The physical architecture of the interfacility patient transportation system will mainly be based on literature, with additions from interviews with domain experts. Once the interfacility patient transportation process is described, the multiple activities, elements, and decisions of a non-urgent interfacility patient transportation system will be identified, based on literature and domain experts. The knowledge and information collected in this phase will be the basis for the development phase of the decision framework.

Design of the framework

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17 lead to the aimed decision framework. The validation of the decision framework will be based on literature and interviews with domain experts.

Framework evaluation

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4. Characterization of interfacility patient transportation

systems

This chapter is intended to clarify the focus of the decision framework for interfacility patient transportation by characterizing its key elements and identifying decisions to be made on their implementation. First, an overview of the system will be provided (section 4.1). Followed by the operational processes of an interfacility patient transportation system (section 4.2). Thereafter, the system resources (section 4.3) and the control elements (section 4.4) are characterized.

4.1 System overview

Figure 4.1 shows the elements of an interfacility patient transportation system. The interfacility patient transportation system is divided into three main elements, i.e., the operational processes, control elements, and system resources. For each element, several parameters are acknowledged that define their configuration. System developments boil down to decision making on the choice of parameter values. For example, decisions about the vehicle type to use for serving patients in the interfacility patient transportation system.

The system description for interfacility patient transportation is mainly built on literature and is supplemented by information from interviews with domain experts.

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4.2 Operational processes

In this section, the operational processes of the interfacility patient transportation system are discussed. The operational process steps are mainly based on the research of Bourn et al. (2018), supplemented by other research and interviews with domain experts. In figure 4.2, the operational processes are provided.

Figure 4.2 Operational processes of interfacility patient transportation

Identify need to transfer a patient

In this phase, the need to transfer is identified, which is determined by the senior clinicians (Bourn et al., 2018). The need to transfer a patient can be determined based on multiple arguments. The first distinction can be made between the determination of the need for transfer, which can be differentiated between transfer based on contracts (Barlow & Köberle-Gaiser, 2009) and transfer based on the patient’s individual situation. The contracts can determine when and which patients should be transferred. On the other side, there is also the possibility that the need for transfer is determined for every patient individually. Reasons to transport patients can be the need for a care specialty (Naboureh & Safari, 2016), or the capacity of the hospitals (Stolte, Iwanow, & Hall, 2006). Here is also the possibility of applying a combination of both identification methods, which will lead to individual identifications for the need for transfer when the patient’s situation is not included in contracts.

Agreement between referring and accepting senior clinicians

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20 situations the agreement is based on contracts and for the more unusual situations the agreement has to be settled between hospitals for those specific cases. If the decision is made in favour of achieving agreement for every patient, this could be done via phone, mail, or a patient portal.

Handover patient to transfer team

In the operational process of interfacility patient transport, there is the moment in which the patient is handed over from the hospital personnel to the transfer team (Bourn et al., 2018). Based on interviews, there are differences in the physical handover of the patient to the transfer team. The first option is that the patient is ready at the exit of the hospital and is waiting for the transfer team to arrive. The other option is that the patient is waiting for the transfer team at the department where the patient was staying. In that situation, the transfer team has to prepare the patient for transport, instead of the nursing personnel in the hospital.

Transfer between care facilities

When the patient is handed over to the transfer team, the patient is transferred to the hospital where the patient’s treatment will continue (Bourn et al., 2018). For the transfer of the patients, multiple decisions have to be made. Sharma & Kumar (2019) describe in their research that there is the choice between different route selections, for example, the shortest route or the quickest route with minimum traffic congestion. Another aspect of the transfer that should be considered is the speed of the vehicle, where Chung et al. (2010) describe in their research that the speed of the vehicle can have impact on the situation of the patient. The last aspect that should be considered is the usage of lights and sirens during the interfacility patient transfer. The usage of lights and sirens during the transport of patients decreases the transportation time significantly and therefore the usage of lights and sirens should be considered for the interfacility patient transportation (Hunt et al., 1995).

Handover from transfer team to hospital personnel

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Return with or without other patient

When the patient is handed over to the personnel of the receiving hospital, the ambulance has to perform another transfer or returns to the dispatch. The new transfer can be at the same hospital where the previous transfer is finished or can be at another hospital. This views the three options for the ambulance after a transfer has finished, namely pick up a new patient at the hospital, drive without a patient to the other hospital to pick up a patient, or the ambulance returns to the dispatch to end the shift. These options are based on interviews.

In table 4.1, an overview of the parameters of the operational process elements and their key decision options is provided.

Parameters Key decisions

Identify need for transfer 1. Determination based on contracts

2. Determination for every patient individually.

3. Combination

Agreement between hospitals 1. Agreement based on contracts

2. Agreement for every patient individually

3. Combination

Handover patient to transfer team 1. Patient is waiting at exit

2. Patient is waiting at department

Transfer between hospitals 1. Shortest route

2. Quickest route 3. Speed

4. With lights and sirens 5. Without lights and sirens

Handover patient to hospital personnel

1. Medical examination available during the whole day

2. Medical examination available during specific time slots

Return with or without other patient

1. New transfer starts from hospital, where last transfer finished

2. New transfer starts at other hospital 3. Back to dispatch

Table 4.1 Operational process elements and key decision options 4.3 System resources

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Vehicles

For the vehicles, different parameters should be considered. The patient’s transportation mode involves multiple decisions, for example, vehicle capacity, care possibilities, and vehicle type (Hains et al., 2011). The different decision options are provided in table 4.1.

Capacity:

The first parameter of the vehicles discussed here is the capacity of the ambulance in number of patients. In general, an ambulance can transport one patient at a time, but there are also ambulances that can transport multiple patients (Koutitas et al., 2019). The decision that should be made here, is whether to transport one patient or multiple patients at a time. This will also influence the vehicle type later discussed.

Care possibilities:

Dependent on the seriousness of the patient, the care possibilities should be indicated. There are three care possibility types for ambulance vehicles, namely Advanced Life Support (ALS), Basic Life Support (BLS) (Van Den Berg & Van Essen, 2019), and Mobile Intensive Care (MIC) (Gebremichael et al., 2000). MIC is the most intense care provided by an ambulance, followed by ALS and BLS. Dependent on the patient type to serve with the system, the care possibilities of the vehicles should be chosen.

Vehicle type:

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Capacity 1. One patient at a time

2. Multiple patients at a time

Care possibilities 1. BLS

2. ALS 3. MIC

Vehicle type 1. Car transportation 2. Bus transportation 3. Helicopter transportation

Table 4.2 Vehicle parameter decision options

Staff

In an interfacility patient transportation system, there is also staff needed, which entails the nursing personnel, ambulance drivers, and supporting staff. About these parameters of the staff, there are multiple key decisions identifiable. The key decision options for the staff parameters are provided in table 4.3.

Nursing personnel:

Based on the seriousness of the patients, the educational requirements for the nursing personnel are determined. In general, the requirements for the nursing personnel of ambulance transport differ between countries (Ambulancezorg Nederland, 2020a; ANWB, 2020; Dick, 2003; Roessler & Zuzan, 2006). Corresponding, the requirements for BLS care are lower than for ALS care, and that the requirements for MIC care are the highest. Therefore, the decision about the requirements for nursing personnel can be chosen from lower education, medium education, and higher education degree. This should match with the decision made concerning the care possibilities of the vehicles.

Drivers/Pilots:

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24 Supporting staff:

Besides the nursing personnel and the drivers, there are also other staff members needed to support the interfacility patient transportation system. Examples of tasks of the supporting staff are the scheduling personnel, vehicles, transport and the communication in the system. Based on interviews, there are two options identified for designing supporting staff departments, namely to combine the supporting staff department with the EMS supporting staff department or to design a separate interfacility patient transportation department. This is dependent on the nature of transportation and the number of transportations performed by the system.

Another possibility for supporting staff is the addition of an employee in the hospitals involved in the interfacility patient transportation system, which coordinates the transports in the hospital, prepares patients, and receives patients.

Nursing personnel 1. Lower educational level 2. Medium educational level 3. Higher educational level

Drivers/Pilots 1. Standard ambulance driver education 2. Extended educational level

Supporting staff 1. Interfacility patient transport support department

2. Combination with EMS support department

3. Additional support staff in hospitals 4. No additional support staff in

hospitals

Table 4.3 Staff parameter decision options

Equipment

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Equipment 1. Minimal required equipment

2. Extension of the minimal required equipment.

Table 4.4 Equipment parameter decision options

Communication resources

In an interfacility patient transportation system, there is communication between the different stakeholders in the system. Wu et al. (2012) reviewed multiple researches and identified different communication resources. The five most common communication resources are alphanumeric pagers, hands-free communication, mobile phones, smartphones, and task management systems. The different communication resources were applied in multiple healthcare researches, for example, research about communication in operating rooms between multiple hospital, and communication between inpatient departments in one hospital (Wu et al., 2012). Table 4.5, provides an overview of the decision options.

Parameter Key decisions

Communication resources 1. Via alphanumeric pagers 2. Via hands-free communication 3. Via mobile phones

4. Via smart phones

5. Via task management systems

Table 4.5 Communication resource parameter decision options 4.4 Control elements

Scheduling and routing method

Scheduling and routing methods are used in an interfacility patient transportation system to design the vehicle routes, pick-up times, and delivery times to transport patients to the different hospitals in the system. For example, determine the sequence in which the patients are transported (Van Den Berg & Van Essen, 2019).

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26 The dial a ride problem, as applied by Van Den Berg & Van Essen (2019), focuses in their research on the offline and online scheduling of interfacility patient transportations. When the decision is made to work with online scheduling, transport coordination is needed to dynamically coordinate and relocate ambulances to the interfacility patient transportation request (Billhardt, Lujak, Sánchez-Brunete, Fernández, & Ossowski, 2014). This dynamic ambulance coordination and relocation is based on algorithms. If there is not chosen for online scheduling, then this dynamic coordination and relocation of the ambulances are not needed, because the schedule is made up front and the ambulance knows for the whole day which transports should be performed.

Another possible approach for the scheduling and routing of the interfacility patient transportation is the mind-set behind the bus scheduling and routing, as described in Yan & Chen (2002). Where there is the situation of bus scheduling between different cities. The decision for the scheduling and routing method should be based on the method that fits the most with the situation of the operational processes, which provides the most efficient outcome, and the schedule should be integrated with the schedule of the hospitals..

Communication procedures

There are also key decisions concerning the communication procedures for the interfacility patient transportation system. Genovesi et al. (2019) describe in their research that interfacility transfer policies facilitate communication between the hospitals and lead to improved patient safety and satisfaction, caused by written procedures to follow. The communication in interfacility patient transportation is often fragmented and between the successive care providers, for example, between the sending hospital and the ambulance provider, and the ambulance provider and the receiving hospital (Amedee, Maronge, & Pinsky, 2012). Another communication approach is the usage of a centralized communication center, where the communication between all the stakeholders is integrated into one communication system that covers the whole interfacility patient transportation system (National Highway Traffic Safety Administration, 2006).

Patient handover coordination

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27 standardization of the hand-off process, decisions should be made which mnemonic should be used (Wood et al., 2015). Mnemonics applicable for ambulance transportation hand-offs are ASHICE, DeMIST, MIST, and SOAP (Riesenberg, Leitzsch, & Little, 2009). In table 4.6, a description of the hand-off mnemonics applicable for ambulance transportation is provided. Decisions made for the patient handover coordination should be about which mnemonic should be applied for the interfacility patient transportation system, especially when considering which Mnemonics fits the most with the patient type transported.

In table 4.7, an overview of the decision options concerning the control elements is provided.

Mnemonics Description

ASHICE Age; Sex; History; Injuries; Condition;

Expected time of arrival.

DeMIST Patient Demographics; Mechanism injuries;

Injuries sustained; Symptoms and signs; Treatments given.

MIST Mechanism of injuries; Injuries sustained or

suspected; Sign – vital signs; Treatment initiated (and timing).

SOAP Subjective information about the patient’s

concerns, sensations, and/or behavior related to the problem; Objective information related to the problem; Assessment of the patient’s condition as substantiated with the data from S and O and an indication of the direction of change in the patient’s condition; Plan of what has or should be done for/with the patient.

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28

Scheduling and routing method 1. Vehicle routing problem with time windows

2. Dial-a-ride problem - Dynamic ambulance

coordination and relocation - No dynamic ambulance

coordination and relocation. 3. Fixed route and time scheduling Communication procedures 1. Fragmented and decentralized

communication

2. Central communication center Patient handover coordination 1. ASHICE

2. DeMIST 3. MIST 4. SOAP

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29

5. Framework design

This chapter focuses on the development of a stepwise approach for designing an interfacility patient transportation system in terms of making decisions on the implementation of system elements. The chapter is divided into multiple sections. Section 5.1 will explain the set-up for developing the framework. Next, the requirements to be met by the solutions provided by the framework (section 5.2) are discussed. In section 5.3, the framework will be presented and explained. The last section will provide the framework’s deliverables.

5.1 Framework set-up

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30

Figure 5.1 Overview of framework set-up

Requirements

The requirements for the framework can be described as the characteristics of the environment, having their influence on the decisions made in the framework. The requirements for the interfacility patient transportation system are determined based on the possible impact on the decisions identified in chapter 4. The requirements are reviewed by domain experts in the field of ambulance transportation. In section 5.2 is elaborated upon the requirements of the interfacility patient transportation system.

Framework

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31 system design approach, where first the details on the lower level are determined, followed by the decisions on higher levels (Crespi, Galstyan, & Lerman, 2008). This approach is portrayed in the framework by starting with decisions for the operational processes, followed by the system resources and the control elements, respectively. Before the decisions can be made, the impact of the requirements should be determined. After the decisions concerning operational processes, system resources, and control elements, the last phase is implementing the system in practice by testing and evaluating the system’s performance.

The phases in the framework provide direction in the design of an interfacility patient transportation system, and should support an efficient and effective design process. The decisions made in the system should contribute to the system, otherwise the topic of that decision should be left behind. The steps are described in section 5.3. To make the right decision, the framework provides guidelines, good practices, and methods. On the other hand, the opinion of domain experts could also be considered during the decision making.

Another situation that could appear, entails multiple parameters options to be suitable in the interfacility patient transportation system that is designed. This leads to a trade-off between the possibilities. To provide guidance for these situations, it is important to consider the purpose of the designed system and choose the parameter option that serves the purpose the most. On the other hand, scenarios during the design process could be considered, for example, alternative levels of demand. This could have impact on the design of the interfacility patient transportation system.

Deliverables

The deliverable of the framework is the design of the interfacility patient transportation system. The design encompasses all the decisions made in the framework, which should be tested in practice. In section 5.4 the framework deliverables are discussed.

5.2 Requirements

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32 Interfacility patient transport demand

The demand for interfacility patient transportation is determined by the requests for interfacility transfers and the prediction of interfacility patient transportation demand in the future. Based on interviews and literature, the expectation is that the demand for interfacility patient transportation will grow extensively and therefore these transports should be organized systematically (Singh & MacDonald, 2009). On the other hand, not all situations have enough demand for the implementation of a complete interfacility patient transportation, which should be determined for every single situation. The demand for interfacility patient transportation determines how extensive the system will be, because it is the main driver of the interfacility patient transportation system.

Service

The service that should be delivered by the interfacility patient transportation system can influence the decision for the design. The requirements set on the service to be provided, are determined by the stakeholders of the interfacility patient transportation system. Possible stakeholders of an interfacility patient transportation system involve hospitals, ambulance care organizations, authorities, ambulance manufacturers, and patients. Requirements on the service are, for example, on-time delivery, safe and comfortable transport, and cost-efficient system.

Infrastructure

The infrastructure is also an important characteristic of the surrounding of the designed system, because the infrastructure can influence the speed and comfort of the transport. The infrastructure involves multiple types, namely the roads between the hospitals, the IT infrastructure, and the intra-hospital infrastructure. The infrastructure can set requirements and restrictions to the interfacility patient transportation system. Therefore, the impact of the infrastructure in the surrounding of the system should be taken into account.

Regulations

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33 slightly differ from the regulations set in the law. These regulations impact the design of the system and should, therefore, be considered in the design.

Restrictions

Restrictions refer to the restrictions set by the environment of the interfacility patient transportation system, for example the available number of staff, vehicles, equipment, and financial resources. This means that the system should be created without exceeding the restrictions. Therefore, the restrictions should be taken into account for decisions which involve the elements with restrictions.

Weather conditions

The weather conditions can impact the transport of the patient between hospitals. The weather conditions include rain, wind, storms, and fog. The weather conditions can impact the speed, safety, and scheduling of interfacility patient transportations. So, it is important to consider the weather conditions in designing an interfacility patient transportation system.

Requirements Issues to be considered

Interfacility patient transportation demand - Fluctuations in demand (day in the week, moment of the day)

Service - Patients have to be on time

- Safe and comfortable transport - Maximum capacity for receiving

patients

- Cost-efficient system

Infrastructure - Bad quality of the road network - Speed limits

- High traffic intensity

Regulations - Equipment requirements for vehicles - Education requirements for staff - Requirements per patient type

Restrictions - Budget for the system

- Amount of available staff - Amount of available vehicles - Amount of available equipment

Weather conditions - Climate

- Speed reduction caused by rain

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34

5.3 Framework

In this section, detailed descriptions of the steps to take and the decisions to make is provided.

Step 1: Assess the impact of the requirements

In this step of the framework, the impact of the framework input characteristics on the design of an interfacility patient transportation system is assessed. Table 5.2 can be used for determining the impact of the framework requirements on the decisions to be made later in the framework. The requirements from the environment of the system can have impact on the decisions made in the next steps of the framework, which can lead to exclusion of parameters or parameter options.

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35 Framework requirements Factors Impact on system elements Interfacility patient transportation demand - Rates - Times - Locations Yes or no, how? Service - Hospitals - Clinicians

- Ambulance care organizations - Authorities

- Patients

Yes or no, how?

Infrastructure - Road type - Road quality - Speed limitations - ICT infrastructure Yes or no, how? Regulations - Vehicle - Equipment - Ambulance license

- Management of ambulance services - Returns and reports

- Qualifications of attendants Yes or no, how? Restrictions - Staff - Vehicles - Equipment - Financial resources Yes or no, how?

Weather conditions - Rain - Wind - Storm - Fog

Yes or no, how?

Table 5.2 Impact of framework requirements

Step 2: Determine the operational process parameters

Based on the bottom-up design approach, step 2 contains the determination of the operational process parameters. The decisions will be based on the key decisions, as described in section 4.2. Support for making decisions for the operational parameters is provided below. This support consists of guidelines, good practices, and methods from literature.

1. Identify need for transfer

Decision influenced by: Interfacility patient transportation demand and Service

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36 inter-organizational relationship of the hospitals, concerning the patient transfers. When there is a close relationship and there are many patient transfers between the hospitals, it is efficient to identify the need for transfer based on contracts. On the other hand, when there is no close relationship and less demand for patient transfers, it is not needed to sign contracts and the identification of the need for transfer can be performed for each individual patient. When the hospitals also want the possibility to transfer patients where the situation is not included in the contracts, there is also the option to identify the need for transfer for this single patient.

2. Agreement between hospitals

Decisions influenced by: Interfacility patient transportation demand, Service, Infrastructure, and Availability

For the transportation of the patients between two hospitals, there is agreement between the hospitals needed. For this decision, there are three options to choose from, namely agreement based on contracts, agreement for a single patient’s situation, and a combination of the two. The same way of thinking about the identification of the need for transfer, is needed for this decision. So, when there is a close relationship and there are many transfers between the hospitals, it is advisable to sign contracts. In the situation, where there is not a close relationship and there is a lower demand for interfacility patient transport, there is the possibility to reach agreement for each single patient individually. In the situation of combining the options, agreement for the main group, which is included in the contract, will be based on contracts, and the agreement for the other patients will be reached for every patient individually.

3. Handover patient to transfer team

Decisions influenced by: Service and Restrictions

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37 hospitals, the availability of time at the ambulance personnel, and the presence of supporting staff at the hospitals.

4. Transfer between hospitals

Decisions influenced by: Interfacility patient transportation demand, Service, Time, Infrastructure, Regulations, and Weather conditions

The transfer is the main operational process of the interfacility patient transportation system. There are multiple decisions to be made considering the transfer between hospitals, which are mainly determined by the type of patient which is served by the system. If the situation of the patient is urgent, no time should be wasted: the fastest route, the maximum speed allowed for ambulances, and the usage of lights should be chosen. These choices ensure the situation of the patient the most, but involves the highest cost. When the situation of the patient is less urgent, the shortest route, the normal speed, and the transport without lights and sirens can be chosen. The transport of non-urgent patients has less pressure on the budget than the transportation of urgent patients.

Besides, the decisions for the transport considering the patient type, the quality of the infrastructure and the weather conditions have their impact on the route and speed used during the transfer. If the quality of the infrastructure is insufficient, the route or the speed should be adapted. Bad weather conditions also lead to adaptions in the speed and the route. Therefore, these factors should also considered for the transfer between hospitals.

5. Handover patient to hospital personnel

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38 medical examinations during the whole day, the decision will be made for medical examination during specified time slots.

6. Return with or without other patient

Decisions influenced by: Interfacility patient transportation demand and Service

This process entails the decision about how to continue after delivering a patient to the receiving hospital. There are multiple options identified, namely start a new transfer at the hospital where the previous transfer finished, start a new transfer at another hospital, or go back to dispatch. These decisions are influenced by the stakeholders (service) in the system and especially the demand for interfacility patient transportation. On the other hand, this decision is also influenced by the scheduling manner. When there is a high demand for interfacility patient transportation, it is for more patient transportations possible to start a new transport at the hospital where the last transport finished. If this situation occurs, there should be tried to schedule the transportations in a way that this fits, saving time and money. Caused by the fact that the ambulance does not has to travel to a new hospital to start a new transportation. If the demand for interfacility patient transportation is lower, the possibility of starting at the same hospital where the last transport finished is smaller. When the shift is ended, the ambulance drives back to the dispatch.

Step 3: Determine the system resource parameters

This step entails the determination of the system resource parameters that should support the operational process. Decision support for the key decisions is provided, where quantitative methods play a role in the determination of the number of resources.

1. Vehicles

There are multiple vehicle parameters to decide on, namely capacity, care possibilities, and vehicle type. Decision support for all these parameters is provided below. The main requirement for the patient transportation vehicle is that it meets the requirements set in the regulations.

- Capacity

Decision influenced by: interfacility patient transportation demand and Availability

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39 important characteristic is the demand for interfacility patient transport, because when there is not enough demand to drive with vehicles with a larger capacity these should not be bought. The number of vehicles and the capacity of the vehicles can be determined using quantitative methods, for example, the methods described at the scheduling and routing method.

- Care possibilities

Decisions influenced by: Service, Interfacility patient transportation demand, Regulations and Restrictions

The care needs of the patient determine which service should be provided to the patient. There are in general, three care possibilities to identify, namely BLS, ALS, and MIC. In the healthcare regulations, is described which care the patient type should be given. So, the minimal care possibilities needed in the vehicles is determined by the patient type that the system has to serve. Another factor that influences the care possibilities are the restrictions for the system, namely the availability of staff and the budget. The degree of care possibilities determines the nursing staff’s educational level and the costs involved with buying the vehicles. More care possibilities determine a higher educational level of the nursing personnel and higher costs for the vehicle. So, these decisions are related to each other and therefore these decisions should be made at the same moment.

- Vehicle type

Decisions influenced by: Service, Restrictions, Interfacility patient transportation demand and Infrastructure

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40 2. Staff

The staff also consists of multiple parameters to decide on. In this section, decision support is provided for different parameters. The decisions concerning staff are overall influenced by regulations in ambulance care, which determine the staff requirements for providing care to a patient type.

- Nursing personnel

Decisions influenced by: Service, Restrictions, and Regulations.

The decision concerning this parameter consists of the educational level of the nursing personnel on-board of the ambulance. There are multiple possibilities; low educated nurses, medium educated nurses, and highly educated nurses. The type of patient is essential for this decision, because there are regulations that define which qualifications a nurse needs for providing care to patients. So, the care possibilities are chosen for the vehicle decisions also determine the nursing personnel’s educational level. When there is chosen for BLS possibilities, lower educational nursing personnel is sufficient. For ALS possibilities, the medium educational should serve the purpose of the system. Where higher educational nursing personnel is needed for MIC possibilities. Besides, the availability of financial resources is also important for this decision, because the level of education determines the salary of the nurse.

- Driver/Pilots

Decisions influenced by: Service, Availability, and Regulations

This decision entails the education of the driver/pilot. There are standard requirements for drivers/pilots described in regulations, and there is also the possibility of extended education for drivers/pilots. This decision also involves the type of patient, because this determines the request for a higher education level for the driver/pilot. In situations where the driver has to provide care, for example, when loading the patient, the higher educational level is important. This decision also involves the availability of financial resources, because the salary for the driver/pilot is higher when the extended educational level is possessed.

- Supporting staff

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41 transportation. This decision has to be made and is influenced by the ambulance care organization, the demand for interfacility patient transport, and the availability of staff and financial resources. If the current EMS support department is able to support also the interfacility patient transportation system, it is possible to design a combined support department.

The other decision concerning the supporting staff, is the decision of supporting staff for coordination of interfacility patient transport in the hospitals. This decision is influenced by the demand for interfacility patient transport and the availability of financial resources. When there is a high demand for interfacility patient transport, the implementation of supporting staff in the coordination at the hospitals could support the efficiency and effectiveness of the system. On the other side, the usage of these support staff also involve higher costs for the system. Therefore, it is important to make the trade-off between the available financial resources and the contribution of the supporting staff in hospitals. When the demand for interfacility patient transportation is low, the usage of support staff in the hospitals is not advisable.

3. Equipment

Decisions influenced by: Interfacility patient transportation demand, Service, Regulations, and Restrictions

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42 4. Communication resources

Decisions influenced by: Service and Restrictions

The last decision made concerning the system resources, is the decision about the communication resources. There are multiple options to choose from for communication resources, namely alphanumerical pagers, hands-free communication, mobile phones, smartphones, and task management systems. The decision made here is influenced by the stakeholders and the availability of financial resources. For example, the ambulance organizations and the hospitals have to work with the communication resources, so they have to decide which communication device is the most user friendly. On the other hand, the financial resources determine whether it is possible to use a specific communication resource, considering the cost. For example, a complete task management system is more expensive than alphanumerical pagers.

Step 4: Determine the control parameters

The next step in the framework involves the determination of control parameters. For each of the control elements there will be decision support provided.

1. Scheduling and routing method

Decisions influenced by: Service, Interfacility patient transportation demand, Infrastructure, and Weather Conditions

In an interfacility patient transportation system, multiple aspects need to be scheduled, for example, patient transportations, vehicles, and staff. To design an effective and efficient system, the most appropriate scheduling and routing method should be selected. Three scheduling methods are identified in literature that could fit with an interfacility patient transportation system, as described in section 4.4. The scheduling methods used different programming methods, namely linear programming and simulation. The algorithms for the different scheduling methods are provided in appendix 1.

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43 approach is suitable for transporting patients between hospital facilities, because the scheduling method is specially designed for interfacility patient transport (Ardekani et al., 2014).

Van Den Berg & Van Essen (2019) base their scheduling method on the dial-a-ride problem, which consists of designing vehicle routes to fulfill pick-up and delivery request of patients. This scheduling approach is based on integer linear programming. As a result, the scheduling method provides efficient schedules and routes for interfacility patient transport. An implication of the provided scheduling method, is that the implementation of the scheduling algorithm can involve high costs and is time consuming (Van Den Berg & Van Essen, 2019). This scheduling approach is also suitable in an interfacility patient transportation system, because this scheduling algorithm is especially designed for transport of patients between hospitals (Van Den Berg & Van Essen, 2019).

The last scheduling method, identified for the interfacility patient transportation system is the bus scheduling method described in Yan & Chen (2002). In the research, the focus is on designing timetables and bus routes, by solving a mixed-integer multiple commodity network flow problem. The research is not performed in a patient transportation environment, therefore it is uncertain if the scheduling approach is suitable in an interfacility patient transportation system.

The integration and coordination of the scheduling method should also be considered. When the aim for the design of an interfacility patient transportation system is to integrate the supply chain of a hospital organization, the methods of Ardekani et al. (2014) and Van Den Berg & Van Essen (2019) are the most appropriate scheduling methods to choose from. These scheduling methods are more flexible in pick-up and drop-off than the scheduling method designed by Yan & Chen (2002), where the scheduling methods design fixed departure and arrival times.

2. Communication procedures

Decisions influenced by: Service, Infrastructure, and Restrictions

A decision framework for organizing interfacility patient transportation in multihospital systems