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For patients arriving in Emergecy Departments (ED), particularly those with minor injuries, imaging services such as x-rays are often used to inform the process of making a diagnosis. In current practice, patients need to be seen by their consultant a second time after imaging, to finalise the diagnosis. This often requires patients to go back to the main ED waiting room until a consultation can take place to decided what, if any, treatment is required, i.e. either to admit patients to the hospital or discharge them.
Dedicated training for radiographers to interpret imaging could enable them to discharge patients at radiology without a follow-up with the consultant. Evidence from a pilot study in Mid Yorkshire suggests that moving towards radiographer-led discharge can significantly reduce time in ED for those being discharged, as well as for all other patients.
This project had two aims which are closely linked with each other:
To develop a visual pathway model in order to accurately capture current practice at Yeovil District Hospital (YDH). This output was used to inform training of radiographers in terms of describing the actual pathway in the ED. The visualised pathway also serves as a conceptual model and is a major input for mathematical modelling, which will take place following the analysis of the status quo.
Based on the first aim, we developed a simulation model of the ED pathway showing the potential impact of introducing radiographer-led discharge. The simulation model is a Discrete Event Simulation (DES) to quantify the potential benefits of early discharge of patients. The DES model captured the actual process in the ED but allows changes to be made to the pathway. These changes were then evaluated in a computer simulation study without making changes to the real system.
During several inter-disciplinary meetings with clinicians, information analysts and modellers at YDH, the ED pathway for minor injuries was captured on a whiteboard. This process map was transferred into a standardised visualisation, which is widely used to capture business processes. The Business Process Modelling Notation allowed us to focus on the structure and the required sequence of tasks.
The conceptualised flow chart below was the main source of input for the DES model. The simulation model captured the major steps along the pathway and was used to experiment with the system layout. This allowed us to make changes to the computerised system instead of implementing changes directly at the ED.
An analysis of historic data records then allowed us to populate the simulation model and to conduct studies. Those studies assessed the impact of changes to the system on key performance measures such as patient waits and staff utilisation.
Using historic data records, the model was used to quantify the beneficial impact of radiographer-led discharge. The simulation model reported changes to the time patients spent in the ED, which has enabled YDH to assess quality improvement in terms of patient experience. The model can also be used as a tool to communicate its results and the likely impact on work in the ED.
Based on an analysis of the historic data provided, the model indicated that the length of stay in A&E for discharged patients could potentially be reduced by 35-40 min on average if radiographer-led discharge was introduced, when an average time for the actual discharging process of 10-15 minutes is taken into account.
Rachuba S, Knapp K, Ashton L, Pitt M. Streamlining pathways for minor injuries in Emergency Departments through radiographer-led discharge. Operations Research for Healthcare 2018; DOI:10.1016/j.orhc.2018.03.001
Since the model user can set model parameters according to available data or expert knowledge, a number of experiments can be conducted together with clinicians at YDH to demonstrate the impact of re-designing the pathway for minor injuries.
These modelling results feed into a larger Medical Imaging project run by the University of Exeter's Medical Imaging team, and have been reported to Health Education England South West. They are currently looking at developing a follow-on implementation project, using the results of this work.
Yeovil District Hospital NHS Foundation Trust
Health Education England South West