QUESTIONS FOR LEUVEN CASE (B)

Transcription

1 Brandeis University The Heller School for Social Policy & Management QUESTIONS FOR LEUVEN CASE (B) Jon Chilingerian, Ph.D Managing Clinics, Care Processes and the Physics of Patient Flow September 20, 2013 On July 31st, 2001 in the middle of the summer holiday, in a period of less than 15 hours 3 multi-organ donors were offered to Leuven Medical center. A multi-organ donor donates simultaneously liver, heart, 2 kidneys, lungs, and pancreas. One donor thus initiates several simultaneous transplantations on different organ recipients, needing many of the available OR and SICU resources. The sudden donor organ excess was the result of holiday closings in other European transplant centers. 1

2 The first donor became available late at night, and all organs were accepted for transplantation (a liver, a lung, and two kidney transplants). Early the next morning, a second multi-organ donor became available. A liver and kidney transplant were done; the heart and lungs were refused because of acute capacity shortage both in the OR and SICU. In the early afternoon, yet another multi-organ donor became available; all organs were refused because of capacity problems. The refusals caused enormous uproar amongst the treating physicians, as one of the potential recipients was a young child who had been on the liver transplant list for two years, who had missed a transplant twice before, and was now in bad condition. I What am I to do as a medical doctor, responsible for a patient who has an adequate donor liver available? These are my options: 1. Refuse the donor liver offer with as a consequence a very high risk of mortality during the waiting time for another organ. Furthermore, you can imagine what the consequences are for a refusal for a liver from the university hospital in Antwerp because of capacity problems in our center. 2. Continue anyway and have the patient admitted to MICU, where experience with immediate post-transplantation care is absent. 3. Send the patient with the allocated liver to another transplant center, where they do have places available in SICU. 2

3 to Clinical Director from Chair of Cardiac Surgery - Monday 9 July, 3 of the 6 planned operations were postponed - Tuesday 10 July, all 4 scheduled surgeries (of which 2 from Monday) were postponed to 12/7 (psychological urgencies could not be operated on 11/7 because it is a national holiday) - Thursday 12 July, only 3 of the 4 already delayed patients were operated - Friday 13 July, 5 patients were scheduled (all of them already postponed at least once); only one operation was done - Today we finally operated on a patient who was scheduled last Thursday!! Surgical Patient Flow Flow of ER Patients 14.3% Flow of Transplant Patients.7% 20% Flow of Elective Patients 85% OR 80% SICU 100% General Beds Average daily discharge Capacity 307 hrs/day 56 beds 1782 beds Utilization 238 hrs 55 beds 1427 beds Variability +/- 103 surgical hrs. +/- 4.1 beds +/- 189 beds 3

4 Questions What is the real problem? Who is responsible? Look at Table 2-where is the bottleneck? Analyze exhibits 7-10, 11,17,18,19, 20 Solutions? Develop an action plan What is the real problem 4

5 Analyze exhibits 7-10, 11,17,18,19, 21 Solutions? 5

6 Action Plan 6

7 There are 110 beds and 100 are utilized on average, with a standard deviation of 10. The z score is 1 which is.3413 of the total area to the right of the mean. So, on any given day, there is a 16% chance that there will be no bed capacity available. Z = Z = Average Occupied Beds.1587 Bed Capacity z-score table z II \ ;.1950 / " Chilingerian I

8 Calculating the Likelihood of a SICU Bottleneck There are 56 SICU beds and 55 are utilized on average, with a standard deviation of 4.1 days. The z score is which is.2439 of the total area to the right of the mean. So, on any given day, there is a 41% chance that there will be no SICU bed capacity available. Z = Z = Average Occupied SICU Beds SICU Bed Capacity What are the root problems? 8

9 Cardiac Surgery activities as influenced by ICU capacity (2001) April May June N beds N cardiac surgeries postponed N patients refused

10 Conclusion: More Beds In 2002, Bart, the Chair of the SICU requested 20 new SICU beds at a cost of 3 million. Though an analysis revealed a 40% chance of a bottleneck on any given day, the clinical leaders were reluctant to add capacity because of an anomaly in the information. More Beds? When the Chair of Internal Medicine proposed the MICU (medical intensive care unit) as a buffer, the chair of the SICU had quipped, You are messing up my strategy to obtain more beds. I do not need your MICU beds, let me handle this! 10