Thesis

Predicting the effectiveness of early senior decision-making in urgent internal medical care : application of a hybrid agent-based and discrete event systems simulation model to evaluate UK healthcare policy recommendations

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Awarding institution
  • University of Strathclyde
Date of award
  • 2024
Thesis identifier
  • T16845
Person Identifier (Local)
  • 201863987
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Department, School or Faculty
Abstract
  • Hospital systems face year-upon-year rises in demand for in-patient services. Moments when urgent care departments are overwhelmed with more patients than they are resourced to provide care for (overcrowding) frequently emerge due to poor availability of hospital beds. Policymakers and healthcare leaders in the UK recommend an early senior decision-making (ESDM) strategy to divert suitable patients away from in-patient services at the time of referral into urgent care. Policies also advise expert clinicians – the highest grade of clinical staff - should perform this task. This research specifically explored the effectiveness of the ESDM strategy when applied to urgent internal medical populations – the largest consumers of in-patient services – with the intention of informing a cost-effectiveness analysis of ESDM. A systems simulation model (SSM) combining agent-based and discrete event systems simulation model was created to reproduce ESDM in a representative acute medical unit in the UK. Data to inform model conceptualisation, programming, and parameter inputs was gathered via observational ethnography, analytic autoethnography of expert early decision-making in urgent care, and prospective data collection of patient-reported outcomes. Outputs aligned with the goals of patients, staff, and provider goals were defined. Upon validation, the model was used to predict how outputs could change with different configurations of expert and non-expert staffing in the decision-maker role. Staffing strategies were analysed at increasing levels of tolerated overcrowding in the department to mimic high hospital occupancies that limited transfer from the unit. Modelled outputs were analysed for meaningful differences and trends. Early senior decision-making realised meaningfully fewer moments of overcrowding and delays, but only when departmental overcrowding was enforced. This occurred via of intuitive decision-making by clinical experts - a phenomenon not previously reported in literature available at the time of writing. System-wide inefficiencies begin to emerge when experts perform decision-making for all patients referred. Impact upon patient health is unclear. The ESDM strategy has the potential to realise safer in-patient care and generate local efficiencies in hospitals that face frequent moments of overcrowding, but not in systems that maintain urgent care bed occupancy levels below 100%. Improving currently available decision-support tools to harness the decision-making of experts may deliver efficiency gains at lesser cost. Further research into the health impact of admission avoidance and overcrowding in urgent care areas outside of the ED is warranted before cost-effectiveness may be explored.
Advisor / supervisor
  • Meer, R. van der (Robert)
  • Megiddo, Itamar
Resource Type
DOI
Date Created
  • 2023

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