Urgent Care Center

Problem Description
Problem Statement
The administration of the SM Municipal Hospital is anxious to evaluate the possible benefit of some
procedural changes relating to the operation of its Urgent Care Clinic (UCC) that that is associated with
the Emergency Department but operates (more or less) independently from it. To a large extent these
changes have their origins in the need to meet new turn-round standards for patients that are being
discussed at the provincial level. A decision was recently made to undertake a simulation study to gain
some insight into the impact of these policy changes upon the flow of patients through the UCC.
The issue to be explored in the study is a means for resolving the frequent complaints about excessive
waiting time for a second consultation with a doctor following the completion of diagnostic tests.
SUI Details
Care Center Resources
Information System: The hospital has embraced information technology and, in particular, uses an
information system (IS) that supports the progress of patients through the various stages of care both in
the Emergency Department and in the UCC. The IS includes real-time patient tracking, clinical charting
and clinician order entry, charge capture, and comprehensive reporting capabilities. Patient tracking
assists UCC staff in allocating patients who are
(a) waiting for an interview with the triage nurse,
(b) waiting for a first consultation with an UCC doctor,
(c) waiting for diagnostic tests,
(d) waiting for test results to be returned to the examining doctor.
Personnel: The medical personnel of the UCC consists of a triage nurse and two doctors dedicated to
the treatment of UCC patients. Periodically special emergency circumstances can occur during which
the doctors from the UCC are temporarily reassigned to assist in the Emergency Department.

UCC Center Layout: The center consists of:

A triage station to receive arriving patients
Four treatment rooms where doctors see patients
A waiting area for patients waiting to see one of the UCC staff.
The following diagram shows the layout of the Center.
Door to other
hospital
departments

Triage Station

Treatment
Room 1

Treatment
Room 2

Waiting
Area

Treatment
Room 3

Treatment
Room 4

Washroom
Doors used by
arriving patients

Patient Care
UCC Patients: The UCC provides a medical care facility for patients who are suffering from ailments
that are not life-threatening (e.g., abdominal pain, eye infection, lacerations, breathing issues, etc). They
are sub-divided into two categories following a screening by the triage nurse, as outlined below.
Emergency Patients: High-risk patients arriving at the hospital (typically those arriving by ambulance
and requiring immediate care) are treated in the Emergency Department. With this organizational
structure, the medical staff of the Emergency Department is immediately available to provide emergency
care for arriving patients who are in life-threatening circumstances.
Triage
The first stage in the treatment of drive-in patients is an assessment by the triage nurse consisting of
o An interview during which the patients ailment is evaluated.
o Basic medical data such as blood pressure and temperature are acquired together with key
facets of medical history; e.g., medications being taken.
On the basis of the information acquired, the triage nurse assigns one of two priority designation to
the patient:
o NIA : needs immediate attention
o CW: can wait
The assigned designation has an impact on the immediacy with which subsequent treatment is
allocated.

Treatment of CW (Can Wait) Patients

Priority:
o A CW-patient sees a doctor only when there are no NIA-patients waiting for a first
treatment;
o CW patients are treated before any NIA patients that are waiting for a second treatment
by a doctor (see the next section).
o CW-patients are treated on a first-come first-serve basis;
Following their consultation with a doctor, CW patients leave the hospital with suitable
recommendations, and possibly a prescription, provided by the doctor.
Treatment of NIA (Need Immediate Attention) Patients
Priority when waiting for first treatment
o NIA patients waiting for their first treatment with a doctor have the highest priority and
see a doctor before any CW patient
o NIA patients are treated on a first-come first-serve basis
If after the first treatment, no further treatment is required, the patient leaves the hospital with
suitable recommendations, and possibly a prescription, provided by the doctor.
If after the first treatment, the outcome of their first treatment by the doctor results in the need for
one or more diagnostic tests to be carried out, the patient is directed to the appropriate area where
the prescribed tests are carried out (e.g., blood and/or urine tests, x-rays, CT scans etc.).
Following the completion of these tests the patients return to a waiting area where they await the
processing of the tests.
Patients wait for a second consultation with a doctor once the test results become available (via
the EDIS).
Priority when waiting for second treatment
o This second consultation takes place only when there are no patients of either category
(CW or NIA) waiting to see a doctor for a first treatment.
After the second treatement, as an outcome of the discussion of the test results, the patient either
leaves the hospital or is admitted for continuing treatment. In either case the patients
involvement with the Emergency Department ends.

Project Goal
As outlined earlier (section 1.2.3) patients waiting for a second consultation with a doctor to review the
diagnostic test results must wait until there are no patients waiting for a first consultation with a doctor.
Circumstances often arise where this policy results in an unreasonable delay for patients awaiting a
second consultation. To rectify this situation, a proposal has been made whereby a consultation of a CW
patient with a doctor is interrupted by a patient waiting for a second consultation if the wait time of that
patient has exceeded 30 minutes. A goal of the simulation study is to obtain some insight into the impact
of this policy change.
Parameters

niaPriority2ndTreatmentPolicy: Determines which policy to apply to NIA-patients waiting for their

2nd treatment after results from diagnostic testing is available. This parameter can assume one of two
values:
o NOTIMING: Indicates the default priority policy where the second treatment for NIA-patients
takes place only when there are no patients of either category (CW or NIA) waiting to see a
doctor for a first treatment.
o WITHTIMING: Indicates the alternate priority policy where the treatment of a CW patient will be
interrupted by an NIA patient waiting for a second consultation if the wait time of that NIA
patient has exceeded 30 minutes.

Experimentation
Study: Steady state study.
Observation Interval:
Time units are minutes
Cannot be predetermined because a steady state study is required
Base Case: Case where niaPriority2ndTreatmentPolicy = NOTIMING.
Alternate Case: Case where niaPriority2ndTreatmentPolicy = WITHTIMING.
Output
The following output data has been identified as having particular relevance to achievement of the
project goal as outlined in section 2.1.

The following output is used to measure the achievement of the project goal:
a) avgNIANumWaiting2nd: The average number of NIA patients waiting to see a doctor for a
second consultation to discuss the results of diagnostic tests,
b) avgNIAWaitingTime2nd: The average time spent waiting by NIA patients waiting to see a
doctor for a second consultation to discuss the results of diagnostic tests.

The following output is used to measure waiting times, queue lengths and utilization of resources to
help explain the results of the simulation experiments:
a) avgNumTriage, avgWaitingTimeTriage: The average number of patients waiting to see the
triage nurse and the average time spent waiting.
b) avgCWNumWaiting, avgCWWaitingTime: The average number of CW patients waiting to see a
doctor and the average time spent waiting
c) avgNIANumWaiting1rst, avgNIAWaitingTime1rst:The average number of NIA patients waiting
to see a doctor for a first consultation and the average time spent waiting.
d) triageNurseUtil: The percentage of time the triage nurse is busy.
e) doctorsUtil: The percentage of time the doctors are busy (this can be determined by
determining the average number of patients being seen by a doctor and dividing by 2).
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ABCmod Conceptual Model

High Level Conceptual Model
Simplifications
a) As Noted in the SUI Details, both doctors are sometimes required to assist in the hospitals
emergency department when special circumstances arise. Because the occurrence of such special
circumstances is infrequent, this behaviour will not be incorporated in the model.
b) Following their first consultation with the doctor each NIA patient may be required to undergo one or
more diagnostic tests. The number of such tests assigned to each patient and the duration of each
test (which would necessarily include time spent waiting for access to the testing facility) are
random variables. This facet of the UCCs operation will be simplified by assuming a single random
variable that will represent the time taken for diagnostic tests by any particular patient. In other
words this random variable will consolidate the number of tests and their individual durations.
c) The doctors are not explicitly modeled and are represented as a resource group with a size of 2 (i.e.
only two patients can be treated at the same time and hence only 2 patient entities can be member
of this resource group).
d) To model the priority in which patients are seen by doctors, two queues are used. A priority queue
is used to model the priority of CW patients and NIA patients waiting to see a doctor for the first
time. A separate FIFO queue is used to represent the order in which NIA patients waiting to see a
doctor for the 2nd time (the priority of these patients relative to the patients in the priority queue
depend on the value of the parameter niaPriority2ndTreatmentPolicy)

Structural View
R.Nurse

Q.Triaged

Q.JustArrived

iC.Patient

RG.Doctors
Q.ReceivedTests

Figure 1 Emergency Room Structural Diagram

Entity Categories
1. Patient: A consumer entity category representing the patients that requires the services in the
emergency room. This entity category has a scope = Class. Patient entities have the attribute
Type set to either NIA (needs immediate attention) or CW (can wait).
2. Nurse: represents the triage nurse receiving and classifying patients, one at a time.
3. Doctors: A resource group entity used to represent the two doctors that are available to treat
patients.
4. JustArrived: represents the queue of patients waiting for the triage nurse.

5. Triaged: represents the queue of patients waiting to see a doctor for the first time. The queuing
discipline used places CW patients at the end of the queue, and NIA patients before the first CW
patient in the queue.
6. ReceivedTests: represents the queue of NIA patients waiting to see a doctor for a second time
after tests results have been received.
Notes:
The Patient entitys attribute TimeEnteredQueue allows the possibility of selecting patients from
Q.ReceivedTests before CW entities at the head of Q.JustArrived during the alternative case and
to interrupt FirstTreatment activities involving CW patients.
Note that a single queue with a priority discipline will be used for dealing with arriving patients
rather than two separate queues. This will require two attributes for Q.Triaged; namely,
numNIA, numCW, to keep track of the number of NIA patients and number of CW patients
respectively in the queue.
Behavioural View

Patient Life Cycle

Arrivals

Triage

CW Patients

NIA Patients

FirstTreatment

Doctor Life Cycle

LabTests

FirstTreatment

CW Patients
SecondTreatment

SecondTreatment

NOTES:
- Both CW-Patients and NIA-Patients start with the same life cyle, that is, they are involved in the
Arrivals action, the Triage activity, and a FirstTreatment activity. Subsequent progression of the
life-cycle differs for the CW-Patient and NIA Patient.
- FirstTreatment activity instances involving CW Patients may be interrupted while those
involving NIA patients cannot. The interruptions only occur during the alternate case of
experimentation, that is, when niaPriority2ndTreatmentPolicy = WITHTIMING.
- CW Patients always exit the model after the FirstTreatment activity instance in which they
become involved has terminated.
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NIA patients after the FirstTreatment activity may exit the model or become involved in a
LabTests activity instance which implies they become involved in a SecondTreatment activity
instance before leaving the model.

Input
Variable
Name

Exogenous Input (Entity Stream)

Description
Domain Sequence
Range Sequence

uPatient(t)

This input
RVP.DuPatient()
N/A; 1 patient arrives at each arrival
entity stream
time.
represents the
arriving
patients.
Endogenous Input (Semi-Independent)
Variable Name
Description
Value(s)

uTirageTime
uPatientClassification
uTreatTimeCW
uTreat1TimeNIA
uTreat2TimeNIA
uLabTestTime(t)
uNeedTest

duration of visit with triage nurse by

arriving patients.
type designation (CW or NIA) of
arriving patients
duration of the treatment provided by
a doctor for CW patients
duration of first treatment provided by
a doctor for NIA patients
duration of second treatment provided
by a doctor for NIA patients
duration of diagnostic tests undertaken
by NIA patients
TRUE when NIA-patient needs a
diagnostic test and false otherwise.

RVP.uTirageTime()
RVP.uPatientClassification()
RVP.uTreatTimeCW()
RVP.uTreat1TimeNIA()
RVP.uTreat2TimeNIA()
RVP.uLabTestTime()
RVP.uNeedTest()

Annex A Data Modelling

TABLE 1 Acquired Data Modelling Information
Feature
Arrival rate of UCC
patients
Triage processing time
CW vs NIA distribution
Treatment time for CW
patients
Treatment time (first)
for NIA patients
Percentage of NIA
patients requiring
diagnostic tests
Treatment time (second)
for NIA patients

Outcome of Data Analysis

Exponential distribution with mean of 30 minutes
Between 5 and 15 minutes
45% of patients fall into the CW category while 55% fall into the
NIA category
Normal distribution with mean = 30 minutes and variance = 15
Normal distribution with mean = 45 minutes and variance = 20
75%

Normal distribution with mean = 15 minutes and variance = 5