Future situation

The ED is facing two future changes that alter the patient inflow. First, the ED becomes part of an integrated emergency post, and second, the other emergency department of HagaZiekenhuis located at the Sportlaan is going to be closed for adult emergency care (Prins, 2011). Both changes are planned for May 2012 and influence the patients input and output flow of the ED. In order to define valuable recommendations, we investigate the influence of these future changes on the throughput process of the ED in this section. In Subsection 2.6.1, we analyze the emergency post, and in Subsection 2.6.2, we discuss the closure of ED Sportlaan for adult emergency care.

2.6.1 Integrated Emergency Post

In the integrated emergency post, the ED is going to cooperate with a general practitioner post (GP post) and the AADU. The ED and GP post will be located alongside each other, with the AADU on the floor above them. The entrance, registration desk and waiting rooms are shared. An ED nurse triages all patients using the MTS (see Subsection 2.2.3), and the MTS indicates whether a patient must be assigned to the GP post or the ED. Referred patients are always assigned to the ED, but in case the patient is a self referral, the patient can be assigned to the GP post.

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Forecast changes in patient volume

From Subsection 2.2.4, we know that 49.6% of all patients attending the ED are self referring patients. When a large part of this input flow deflects towards the GP post, demand towards ED resources declines, likely resulting in waiting times decreasing when capacity levels remain unchanged. To forecast the changing patient volume of the ED, we use a retrospective analysis (SAP, 2010) based on triage codes and two documents that both indicate whether a patient with a specific triage code can be treated by a GP or must be treated at the ED. The first document is the MTS

complain acuity matrix (KUM MTS), which is created in England by ED physicians and ED nurses, and

provides per triage code whether the patient can be seen by a GP. The second document is an internal document of HagaZiekenhuis, in which per MTS category specialists have determined whether a patient with a specific triage indication can be seen by a GP or must be treated at the ED (KUM HAGA). In our forecast, we also include an estimation that 11% of the patients who are initially seen by a GP are secondarily referred to the ED. This percentage is copied from a study performed in the LUMC (Prins, 2011), a hospital with an urban patient population like HagaZiekenhuis.

The results of our forecast differ a lot between the KUM MTS and the KUM HAGA. Based on the KUM MTS the expected patient volumes attending the ED decrease with 7.1%, while based on the KUM HAGA the expected decrease is 35.6%. To place these percentages in perspective, at the LUMC 33% of the patients attending the ED are referred to the GP (LUMC, 2008, p25), and including 11% send back, results in a production loss of approximately 30%, indicating that the 35.6% is well plausible. We provide an overview of our findings specified towards the largest four specialties in Table 2.14.

General surgery Cardiology Internal medicine Neurology SAP, 2010 21,834 5,556 4,559 2,733 Forecast KUM MTS Difference 19,449 -10.9% 5,469 -1.6% 4,398 -3.5% 2,659 -2.7% Forecast KUM HAGA

Difference 10,016 -54.1% 5,223 -6.0% 4,146 -9.1% 2,430 -11.1%

Table 2.14: Forecast ED patient volume changes by opening GP post.

Different number of treatment rooms available

In the emergency post, the composition of treatment rooms changes slightly, as two low care beds will be changed towards two medium care beds (Twynstra Gudde, 2008). There will also be an additional fast track room, but the exact way of usage is not yet defined.

Acute assessment and diagnostic unit

The AADU becomes 26 beds instead of the current 16 beds, and patients of all specialties can be admitted on the AADU. In the new situation, patients can only stay for maximum 4 hours at the ED. Once these hours are passed and no treatment plan is established upon the patient, the patient will be transferred to the AADU.

2.6.2 Closure of the ED Sportlaan for adult emergency care

The second change the ED is facing in 2012 is the closure of the ED Sportlaan for adult emergency care. Once closed, the patients have to go to the ED Leyweg or to an ED of one of the competing hospitals in The Hague. De Groot (2010) executed already a research towards the expected changes

69 in patients flows based on patient postal codes, and estimates that 45% of the patients are likely to go to a competing hospital. Using the data of 2010, when 8,675 adults attended the ED Sportlaan (SAP, 2010; included all patients ≥ 16 years old), we estimate that the number of patients attending the ED increases with 4,770 patients (55%). Additionally, including that 75% of the patients in 2010 were self referrals, combined with our finding in the previous subsection that 7.1% to 35.6% of all patients are likely send to the GP (note that approximately 50% are self referrals on the ED Leyweg), we estimate that the patient volume at the ED Leyweg increases with 2,223 to 4,263 patients a year, equal to 6.1 to 11.7 patients a day.

2.6.3 Conclusions ‘future situation’

we predict a decrease in 7% to 36% patient volume, when the IEP is opened.

the patient volume at the ED Leyweg increases when the ED Sportlaan is closed for adult emergency care, with approximately 6 to 12 patients a day.