Journal of the Academy of Hospital Administration

A Study on Emergency Care and Patient Discharge Process Application of Network Analysis Author(s): B. Krishna Reddy*, G.V.R.K. Acharyulu** Vol. 15, No. 1 (2003-01 - 2003-06) Key Messages:
Emergency Care and Patient Discharge processes are important parameters in ensuring Patient Satisfaction. Application of Network Analysis to hospital processes will result in optimisation of resources and continuous Quality Improvement. Keywords: Emergency Care and Patient Discharge Process, Network Analysis

Introduction
The demand for effective health services is ever increasing. As a result, hospitals are absorbing tremendous amount of resources. Healthcare emerged as one of the major areas concerning the human beings in the recent past. With healthcare being considered as an industry today, corporate players have entered the foray as healthcare providers. The healthcare industry has a turnover of Rs. 1,00,000 crore per annum and growing annually at a rate of about 13%. Healthcare industry is the fastest growing category of private consumption with a 26% compounded annual growth rate (ET Intelligence report 2001). In the present competitive environment, quality healthcare delivery is gaining importance. Amongst various factors affecting the healthcare emergency care and the discharge are important parameters in ensuring patient satisfaction. These are having two important features, namely, the first has no predecessors and the second has no successors as far as the healthcare facility is concerned. The effective planning and use of resources will play an important role in attending emergency cases at the "golden hour". The instantaneous care will help to save many lives. Soon after completion of the treatment, patient as well as his/her accompanies expect to the relieved off immediately. The delay in the discharge process lead to dissatisfaction and affects the image of the hospital.

Objectives
The present paper, has two major objectives:

First is to study the Process of Emergency Care associated with Emergency department of a corporate hospital and develop network diagram. Second is to study the Patient Discharge Process and develop network diagram.

Methodology
The study is organized on two aspects. The first aspect is on Emergency department, the second is on the Discharge Process. Process of Emergency care: The role of Emergency department is vital in providing critical care. It requires the skilled personnel, critical care equipment and specialised procedures. There can be emergency centers located in different areas and are interconnected to the main hospital. The workflow of an Emergency Room is depicted below.

The layout and flexible design are crucial factors for emergency service department in a corporate hospital. The emergency room amongst others consists of beds, doctors table, nursing station, dressing and injection room, minor OT. The patients arrive either directly or by ambulance service of the hospital. Referrals come from other nursing homes or hospitals which do not have adequate emergency facility. The patients leave the emergency department on discharge or go to Operation Theatre, Intensive Care Unit for further treatment/ investigations or to the mortuary in case of death.

Data on Emergency care
A total of 100 Emergency cases are observed. Out of these, 15 cases brought to the main hospital after receiving an emergency call on the emergency number of the hospital and the rest 85 of the cases arrived on their own or in other"s ambulances.

Activities comprising the processes in the Ambulance and the Emergency Room are shown in the network diagrams which are divide into two phases. Phase 1 comprises of all those activities involved from "receiving an emergency call for an ambulance service", to "ambulance arriving at the hospital after the pick up of emergency case". The phase II includes all the activities performed after the entry of the patient in the Emergency room. It includes the initial stabilization, investigations, treatment, observation and ends with the exit of case from Emergency room.

Activities of Phase-I: (Ambulance process)
1. 2. 3. 4. 5. 6. 7. 8. 9. Time between the call start and call end Time taken for call end and confirmation Time taken to call the driver Time taken to call emergency medicine technician Time taken for the driver to reach ambulance and start Time taken for the Technician to reach ambulance with instrument/equipment Time taken to reach the patient"s location Time taken to start from the patient"s location Time taken to reach the hospital from the patient"s location

Activities of Phase - II (Emergency Room process)
1. Time taken by the patient to be shifted from the ambulance to the Emergency Room 2. Time taken for the physician to attend to the patient 3. Time taken for the nurse to attend to the patient 4. Time taken for the Technician to attend the patient 5. Time taken for specialist to attend the patient 6. Time taken for registration, billing and pharmacy 7. Time taken for performing X-ray, CT scan, labs investigation minor procedures etc. 8. Time taken for report arrival from labs/diagnostics 9. Time between getting the report and emergency room exit The process flow in the ambulance and in the emergency room is shown in Fig.1 and Fig.2 which identifies the critical path in the emergency care process. The average time taken for each activity is arrived through frequency distribution of all observed patients. It can be noted that the minimum time by which the patient reached is "1" minute and the maximum time by which the patient reached is "2" minutes, where as "1.5" minutes is the most likely time. Taking Earliest Start Time (EST) and Latest Finish Time (LFT) from Phase I the Phase II is continued and is shown in Fig.3. The expected time for various activities is shown in Table -1

Expected time Activity A B C D E F G H I J K L M N O P Q R
t

o

t

m

t

p

Te=(t + 4t

o m + tp)/6

1.00 0.40 0.05 0.10 0.10 0.05 5.00 2.00 3.00 0.30 0.01 0.02 0.01 1.00 3.00 5.00 3.00 1.00

1.50 1.30 0.30 0.20 0.40 0.50 13.30 8.00 12.50 2.00 0.90 0.80 0.40 15.20 13.10 17.40 7.50 20.90

2.00 2.00 1.50 0.40 2.00 1.25 29.00 14.00 21.00 7.10 4.00 10.00 2.00 32.00 23.20 30.00 37.00 66.00

1.50 1.27 0.46 0.21 0.61 0.55 14.53 8.33 12.33 2.56 1.27 2.20 0.60 15.63 13.10 17.43 11.66 25.10

Table-1 Expected time for various activities

Interpretation
The duration for Activities of Ambulance process (Phase-I) (involving activities A to I) is 39.29 minutes. (Fig.1) The duration for Activities Emergency Room process (Phase-II) (involving activities J to R) is 87.68 minutes. (Fig.2) The total duration for Ambulance process (Phase-I) and Emergency Room process (Phase-II ) is 126.89 minutes. (Fig.3) The critical path for the Ambulance process (Phase-I) is:

• • • • • • •

A - Time between the call start and call end B - Time taken for call end and confirmation D - Time taken to call emergency medicine technician F - Time taken for the technician to reach ambulance with instrument/equipment G - Time taken to reach the patient"s location H - Time taken to start from the patient"s location I - Time taken to reach the hospital from the patient"s location

The critical path for Emergency Room process (Phase-II) is:

• • • • • • •

J - Time taken by the patient to be shifted from the ambulance to the Emergency Room L - Time taken for the nurse to attend to the patient N - Time taken for specialist to reach the patient O - Time taken for registration, billing and pharmacy P - Time taken for performing X-ray, CT scan, Diagnosis, labs, minor procedures etc. Q - Time taken for report arrival from labs/diagnostics R - Time between getting the report and emergency room exit

Patient Discharge Process
For a period of one month, the discharge process of patient discharge process is shown in Fig.4. which identifies the critical path. The average time taken for each activity is arrived through frequency distribution of all observed patients.

Activities in patient discharge process:
1. 2. 3. 4. 5. 6. 7. 8. 9. Consultant checks the patient"s status Consultant informs the ward in-charge that the patient can be discharged Consultant issues prescription Ward in-charge informs the Resident doctor about the discharge Resident Doctor prepares the discharge summary Discharge summary is checked and signed by the consultant Discharge summary is sent to the typing pool to be typed Typed discharge Summary is sent to be consultant for final check and attestation Ward in-charge informs the ward secretary and staff nurse so that patient can be prepared for discharge 10. Excess medication is sent to pharmacy and prescription medicine is intended for 11. k - Activity card is sent to Inpatient Billing

Te=

Activity a b c d e f g h i j k l m n o p q

Predecessor a a b d e f g d c j j l m n o p,i,h

t

o

t

m

t

p

(t +4t

o m+tp)/6

9 3 8 4 20 9 30 6 2 12 8 7 20 4 6 6 10

16 4 10 5 30 10 45 10 5 15 10 8 31 11 9 16 20

17 7 12 6 40 11 60 14 8 18 12 21 36 12 18 20 30

15 5 10 5 30 10 45 10 5 15 10 10 30 10 10 15 20

EST (min) 0 15 15 20 25 55 65 80 25 25 40 50 60 90 100 110 125

LST (min) 0 50 15 55 60 90 100 115 120 25 40 50 60 90 100 110 125

Float 0 35 0 35 35 35 35 35 95 0 0 0 0 0 0 0 0

Table-2: Float for various activities
l - Pharmacy Bill is sent to Inpatient Billing
• • • • •

m - Preparation of the bill n - Rechecking of the bill o - Payment of the bill and issue of receipt p - Issue of Discharge intimation slip to the ward secretary through ward boy q - Patient is instructed and discharged

Interpretation
The total duration for discharge process is 145 min. i.e., 2 hours and 25 minutes. The float for various activities is shown in Table 2 The critical path (float is zero for critical activities) is:

• • • • • • • • • •

a - Consultant checks the patient"s status c - Consultant issues prescription j - Excess medication is sent to pharmacy and prescription medicine is intended for k - Activity card is sent to Inpatient Billing l - Pharmacy Bill is sent to Inpatient Billing m - Preparation of the bill n - Rechecking of the bill o - Payment of the bill and issue of receipt p - Issue of Discharge intimation slip to the ward secretary through ward boy q - Patient is instructed and discharged.

Applications of network techniques in hospitals
Network techniques (pert and CPM) can effectively be employed for minimizing process times associated with many areas in hospital environment. Some of them include:
• •

Process of Patient Treatment Billing process

• • • • • • •

Scheduling of Operation Theatres (surgical) Appointment Work allocation and workflow Maintenance of Critical Care Equipment Construction of new hospital buildings Setting up of new equipment. Marketing survey and Advertising Campaigns for launching new healthcare products.

• • •

Preparation of Budgets Planning and Research and Development Organisation of medical camps and conferences.

Conclusions
The various conclusion which may be drawn from the study are:

• •

Total quality management is the key for success of any hospital. Bench marking of various processes for their times costs are very important factors leading to patient satisfaction. The present study can help in Bench Marking the procedures/process time of emergency care. Trade off between cost and time linked with optimum utilization of scarce resources can provides a competitive advantage to a hospital. This study is useful to determine the number of specialists required in order to provide optimum service, better usage of equipment, materials, human resource skills and technology. It should be kept in mind that reduction in time for various activities associated with emergency care is the key. Business Process Re-engineering (BPR) for various internal methods and procedures can bring strategic advantages to a hospital in future plans. Adoption of latest technology can make all the difference.

References
1. Edward M. Knod, Richard J. Schonberger., "Operations Management-Meeting customers" demands", Mc Graw Hill international, 7th editions, 2001. 2. Lee J. Krajewski, Larry P. Ritzman., "Operations Management-Strategy and analysis", Addison Wesley (Pearson Education), 5th edition, Indian Reprint 2000. 3. Billy E. Gillett., "Introduction to Operations Research ? A computer oriented Algorithmic approach", Tata Mc Graw Hill publishing Company, 8th reprint, 1989. * Associate Professor, Dept. of Business Management Osmania University, Hyderabad - 500007, India E-Mail: drbkrishnareddy@yahoo.co.in ** Faculty, Apollo Institute of Hospital Administration Hyderabad-500033, India E-mail: acharyulu_gvrk@yahoo.com

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