MODELING OF FACILITIES FOR HEAD INJURIES IN LONDON - A CASE STUDY

PRESENTED BY: MOHSIN DALVI M.TECH (INDL. ENGG.) SEM 1

MODELING OF FACILITIES FOR HEAD INJURIES IN LONDON

INTRODUCTION PROBLEM DESCRIPTION

PROBLEM FORMULATION
RESULTS CONCLUSIONS AND RECOMMENDATIONS

INTRODUCTION

INTRODUCTION
Throughout England and Wales, injury is the main single cause of death and disability in both sexes in 15- 34 years age group and is the third most common cause of deaths in all ages. This study is part of a greater effort of the London Severe Injury Working Group that is aiming to the improvement of care, treatment and transfer of severely injured patients in London

INTRODUCTION
The aim is to position the minimum number of trauma centers within a network of existing hospitals and minimize the total traveling time of patients, from the place of injury to the hospital of final treatment in such a way that everyone in the entire population of London can reach a trauma center within acceptable time limits. Location Set Covering Type of Problem.

INTRODUCTION
Location problems have been attracting the attention of academics and practitioners since 17 th century when Fermat and Torricelli posed the Euclidean minisum problem (given a set of existing points, locate a point X in a way that the sum of distances from existing points to point X is minimized) Since late 1950's, location problems began to be viewed in a mathematical programming and optimization context.

INTRODUCTION

x3 x1

x5 x6

x2
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MODELING OF FACILITIES FOR HEAD INJURIES IN LONDON

INTRODUCTION PROBLEM DESCRIPTION

PROBLEM FORMULATION
RESULTS CONCLUSIONS AND RECOMMENDATIONS

PROBLEM DESCRIPTION
London has 26 hospital sites with full Accident and Emergency Departments that can offer initial treatment to severely injured patients. Statistics show only one third of the patients are transferred directly to a hospital that can provide them with neurosurgical care. The remaining patients after initial care are later transferred to a hospital that has the facilities required for their treatment.

PROBLEM DESCRIPTION
PATIENT TREATMENT PROCESS FLOW CHART SHOWING EXISTING CONDITION

PROBLEM DESCRIPTION
The time spent before the patient receives the first help and the inter-hospital transportation time are of great risk and extremely critical for the survival and full recovery of the severely injured patients. The average time between injury and admission to the proper hospital is approximately 4-6 hours.

PROBLEM DESCRIPTION
The Royal College of Surgeons Commission on the Provision of Surgical Services reports that above 30% fatalities could have been prevented and were the result of failure to stop bleeding and absence of, or delay in surgical treatment.

PROBLEM DESCRIPTION
In the United States trauma systems are well developed since the 1980's, but are not so in Europe. Current services in London are neither well located nor well coordinated to provide the best care to patients. The initial goal set was to improve the current situation, but it had to be translated to criteria.

PROBLEM DESCRIPTION
Three criteria were selected to improve accident response system:
All patients should be able to reach a hospital with A&E facilities within acceptable time limits. The time patients have to travel to the hospital of their final treatment should be minimized. Cost should be reduced by minimizing the number of hospitals that will retain their A&E Centres considering the political aspects of closing down the A&E Centres.

PROBLEM DESCRIPTION
26 hospitals have been included in the analysis.
7 hospitals having neurosurgery facilities are called main hospitals. The remaining 19 hospitals that cannot treat trauma patients are called local hospitals.

Only head injured patients were considered in view of the fact that more than 50% of the severely injured patients suffer from head injury and the relevant data was available.

PROBLEM DESCRIPTION

PROBLEM DESCRIPTION
PROPOSED PATIENT TREATMENT PROCESS FLOW CHART

MODELING OF FACILITIES FOR HEAD INJURIES IN LONDON

INTRODUCTION PROBLEM DESCRIPTION PROBLEM FORMULATION RESULTS CONCLUSIONS AND RECOMMENDATIONS

PROBLEM FORMULATION
Observation sets: M = set of main hospitals with neurosurgery facilities. m = index referring to a main hospital. L = set of local hospitals that cannot treat patients suffering from severe head injury. l = index referring to a local hospital. R = set of regions in the city r = index referring to a region.

PROBLEM FORMULATION
Time variables: mtimer,m = time taken to travel from region r to main hospital m. ltimer,l = time taken to travel from region r to local hospital l. c = time spent in l before they are transferred to m. lmtimel,m = time taken to travel from local hospital l to main hospital m. Average speed of ambulance is assumed as 30km/h.

PROBLEM FORMULATION
Binary variables: loc_retl = 1 if l retains its trauma centre, else 0. main_retm = 1 if m retains its trauma centre, else 0. to_locr,l,m = 1 if patient from region r travels to l first and then to m, else 0. to_mainr,m = 1 if patient from region r travels to m directly, else 0. Other variables: patientsr = number of patients coming from region r.

PROBLEM FORMULATION
Minimise objective function

[loc_retl + main_retm] + [(ltimer,l + lmtimel,m + c) * to_locr,l,m * patientsr] + [mtimer,m * to_mainr,m * patientsr]

Subject to constraints

to_locr,l,m loc_retl . . . . . (1) [to_locr,l,m + to_mainr,m] main_retm

. . . . . (2)

PROBLEM FORMULATION
to_locr,l,m + to_mainr,m = 1
. . . . . (3)

ltimer,l * to_locr,l,m 20 . . . . . (4) lmtimel,m * to_locr,l,m 60 . . . . . (5) mtimer,m * to_mainr,m 20 . . . . . (6) where r R, l L, m M.

PROBLEM FORMULATION
Two conflicting objectives:
Reduce hospitals thereby increasing travelling time Reduce travelling time thereby increasing hospitals.

Minimising main_retm means closing down a trauma unit in main hospital - political ramifications. No costs used in objective function - solving the problem would give fiscally impractical solutions by suggesting opening of new trauma centres to reduce travelling times.

PROBLEM FORMULATION
Decomposition of the problem will allow trading-off the number of kept trauma centers at main hospitals against the number of trauma centers at local hospitals. The modified algorithm is of an iterative type and follows the following four steps:

PROBLEM FORMULATION
STEP 1: Calculate minimum number of local hospitals retaining their trauma centers if only one main hospital maintains its trauma center. Model MINLOC Minimise

loc_retl
subject to

main_retm = 1

. . . . . (7)

and constraints 1 to 6 from original problem.

PROBLEM FORMULATION
STEP 2: Repeat the calculation for different number of main hospitals (RHS value in constraint 7) ranging from 2 to m. is the minimum number of local hospitals obtained. STEP 3: Identify the main and local hospitals that should retain their trauma centers for one main hospital and local hospitals in order to minimize the total traveling time weighted by the number of patients coming from each region.

PROBLEM FORMULATION
Model MINTIME Minimise

[(ltimer,l + lmtimel,m + c) * to_locr,l,m * patientsr] + [mtimer,m * to_mainr,m * patientsr]

subject to

loc_retl =
and constraints 1 to 7.

PROBLEM FORMULATION
STEP 4: Repeat the calculation and determine the main and local hospitals that should retain their trauma centers for 2 to m main hospitals and local hospitals

MODELING OF FACILITIES FOR HEAD INJURIES IN LONDON

INTRODUCTION PROBLEM DESCRIPTION

PROBLEM FORMULATION
RESULTS CONCLUSIONS AND RECOMMENDATIONS

RESULTS
The results from the model MINLOC suggest that we can achieve full coverage and satisfy all constraints if we maintain at least 2 trauma centres in main hospitals and 8 in local hospitals or for more than 2 main hospitals retaining their trauma centers 7 local should maintain theirs.

RESULTS
The results from the model MINTIME give the specific hospitals that should retain their trauma centers in order to minimize the traveling time from the place of the injury to the hospital of definitive care (weighted by the number of patients that come from each region).

RESULTS

RESULTS
The six different scenarios have been compared. Figure presents the average traveling time for reaching a hospital for patients going directly to a main hospital and going to a local hospital first.

RESULTS
Since in medical emergencies time is an extremely critical issue, an important aspect in comparing the solutions is the number of patients that can go directly to a main hospital for the different scenarios.

MODELING OF FACILITIES FOR HEAD INJURIES IN LONDON

INTRODUCTION PROBLEM DESCRIPTION

PROBLEM FORMULATION
RESULTS CONCLUSIONS AND RECOMMENDATIONS

CONCLUSIONS AND RECOMMENDATIONS

In this paper, an alternative scheme of transferring severely head injured patients to hospitals that can offer neurosurgical care was investigated and proposed. The specific configurations of the network of existing hospitals that should retain their trauma centers so as to minimize the traveling time of patients and the number of trauma centers and achieve full coverage of the London population were identified.

CONCLUSIONS AND RECOMMENDATIONS

The proposition has been included in the London Severe Injury Working Group report regarding the modernization of trauma services in London [London Severe Injury Working Group (2001)]. Moreover, the assumptions made in the problem formulation, such as the exclusion of capacity and workload constraints and the assumed best possible cooperation between hospitals receiving severely injured patients, became their recommendations in order to improve the NHS (National Health System) of London.

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