Section 3.1 gave an overview of the paths a patient can go through at the NIP. These paths consist of several sub processes, each with a specific duration. The duration of a number of the sub processes is dependent on certain factors, for example the staff member that performs the task. In this section, we describe the various sub processes and we determine the duration of these sub processes.
Figure 4 shows all the possible paths through a NIP, with the process steps. Some of these processes need further explanation. Consultation at the GP post is generally carried out by a GP. However, three weekends a month a nurse practitioner (NP) is present at the post. A NP treats patients with specific characteristics. Consultation by a GP takes on average less time than consultation by a NP (ten versus fifteen minutes).
Only a GP can visit a patient at home. During the execution of this task, the GP is not present at the GP post. To arrive at the patients’ home, the GP uses a car with a specialized chauffeur. Generally, there is one car available, only on Saturday and Sunday between 12 pm and 18 pm there are two cars available.
An ED consult consists of three steps: anamnesis, diagnostics, and treatment. For these sub-steps there are several options. In the remainder of this section we describe these options. An overview is given in Figure 18. The first step, anamnesis, can be performed by an ED nurse, an ED doctor, or by a resident. The residenthelps all labeled patients. Labeled patients are all patients who are referred to a given specialism by, for example, a GP or a (external) specialist. These patients will be helped by a resident of that specialization. All unlabeled patients are first seen by an ED doctor. Unlabeled patients are patients who are not referred to a given specialism and includes all self-referrals at the ED and all patients who are brought to the ED by ambulance, helicopter, or by the police. The time anamnesis takes does not depend on the staff member that performs this process.
The next step is diagnosis. At the ED, various types of diagnostic tests can be requested/ performed. The most common diagnostic tests are X-ray, lab research, and computed tomography (CT). Other diagnostic tests are ultrasound, or electrocardiography (ECG). In the design of the new hospital, one can perform or request the diagnostic test in the following ways:
Two devices for making X-rays are available, one at each trauma room. In first instance, these devices are used for the (multi-) trauma patients at the ED. However, when it is quiet this resource can also be used for non-trauma patients that enter the ED. If this device is not available, these patients are send to the ED/X-ray department, adjacent to the ED. Making x- rays is performed by a diagnostic employee.
Lab research can be requested by a resident or by a medical specialist. In most cases, a diagnostic employee from the laboratory department comes to the ED to carry out the research.
One device for making ultrasounds is available at the ED. This device can be used at every room, because in every room a dedicated connector is available.
A patient can undergo a CT scan at the ED. A CT device is available in the diagnostic room, situated between the two trauma rooms. For this diagnostic test, a diagnostic employee comes to the ED.
33
ECG equipment is not available at the ED. If a patient needs an ECG, this can be requested at the cardiac technician, or at the after-hours team leader. A diagnostic employee from the cardiac department is then send to the ED to perform the ECG.
The probability that a certain diagnostic test is requested depends on the treatment group of the patient, and is independent from the probability that other types of diagnostic tests are requested. Furthermore, the amount of diagnostic tests that is requested of a certain type is dependent on the treatment group. The probabilities and the average number of requests of a certain diagnostic test per treatment group are given in Appendix J.
The third step of an ED consult is treatment. In most cases, the patient is first treated by a resident.
However, in some cases a medical specialist is called for further diagnosis and/or treatment of the patient. We assume that the probability that a medical specialist is called is dependent on the urgency of the patient. We assume that the duration of treatment is dependent on two variables: the treatment group and the treating doctor. The chance on calling a medical specialist is given in Appendix I, the duration of treatment is given in Appendix K.
Figure 18 Processes ED
3.5.1 Sub processes vs. resource availability
In previous sections, we made a distinction between several rooms, personnel, and processes. Not every process can be performed in every room, and not every process can be performed by all types
Consult ED X-ray Lab Ultrasound CT scan ECG research Review time Resident ED doctor ED nurse Resident Triage Departure Anamnesis Diagnostics Treatment ED doctor Medical specialist
34 of personnel. Table 20 gives an overview of what tasks may be performed by whom and where, and what extra resource is needed.
Table 20
Processes vs. personnel and rooms
What Task Personnel Room Resource
Processes GP post
Telephonic triage GP assistant Call center -
Physical triage GP assistant Triage room GP post - Consultation GP; nurse practitioner Consultation room;
treatment room
-
Visit GP - Car GP post
Processes ED
Triage Triage nurse Triage room ED -
Anamnesis ED nurse
ED nurse Trauma room; acute
room; treatment room - Anamnesis
resident
ED doctor; resident; medical specialist
Trauma room; acute room; treatment room
-
Plaster ED nurse Plaster room -
Treatment ED doctor; resident; medical specialist
Trauma room; acute room; treatment room
- Diagnostics
ED
Lab research Diagnostic employee Trauma room; acute room; treatment room
- Ultrasound Diagnostic employee Trauma room; acute
room; treatment room
Ultrasound equipment
X-ray Diagnostic employee Trauma room; X-ray
department
X-ray equipment
CT scan Diagnostic employee Diagnostic room CT
ECG Diagnostic employee Trauma room; acute
room; treatment room ECG Review lab research ED doctor; resident; medical specialist - - Review ultrasound ED doctor; resident; medical specialist - -
Review X-ray ED doctor; resident; medical specialist
- -
Review CT scan ED doctor; resident; medical specialist
- -