Modeling Cardiovascular Patient Pathways in an Accident and Emergency Department from a System Dynamic Perspective Using a Patient Oriented Modeling Approach Hannah Rønhovde Thesis Submitted to the Department of Geography In Partial Fulfillment of the Requirements for the Degree of Masters in System Dynamics System Dynamics Group Department of Geography University of Bergen February, 2017 Abstract This thesis provides a detailed overview of a system dynamics model that focuses on the accident and emergency department and the clinical pathways of cardiovascular patients at Haukeland University hospital. A patient-oriented approach was chosen and sub- models representing patient attributes and accident and emergency resources were developed based on this approach. The simulation model illustrates accident and emergency processes and patient attributes in a disaggregated system. In addition to System Dynamics, other modeling concepts facilitated the modeling process. This included object-based and discrete event modeling concepts where object -based modeling concepts were used to create interactive objects, and stock and flow structures were constructed to be discrete in time and space. As such, the model is considered a hybrid model. The model serves as a network of resources aiding the patient in the most appropriate direction in order to place him or her in the right location at the right time. The patient-oriented modeling approach has proven useful, as it has enabled a systematic observation on the emergence of various cardiovascular pathways based on patient attributes incorporated in the model. The use of objects to represent attributes and AED processes, make this model a unique take on System Dynamics. The attributes arising from the model were built on predetermined values in the form of graphical functions, enabling scenario testing to capture the resources the patient claimed in the AED. To this end, a successful simulation model has been created that permits a detailed observation of clinical pathways for cardiovascular patients. Keywords: system dynamics, clinical pathways, accident and emergency department, cardiovascular patient, patient attributes, object-based modeling, hospital simulation, discrete event simulation. II Acknowledgements First, I want to give my sincere gratitude to my thesis advisor Professor Pål Davidsen at University of Bergen. Prof. Pål has been an encouraging and great advisor to work with, who suggested I should take on the project with Haukeland University Hospital. He has shown engagement and immense knowledge throughout the project, and I am grateful for all the help and assistance throughout my master’s thesis. I admire the passion he has for system dynamics and its potential as a useful tool in the healthcare sector. I want to give a big thanks to Kjersti, whose creativity and hard work has helped us get ashore on this project. Thank you to Johannes Kolnes at Haukeland for providing us with useful and valuable information to help us along the way, for taking his time to write up long responses over e-mail in regard to the emergency department and the diagnostic processes, and for taking the time to meet with us on several occasions this past year. This would not have been possible without him. Finally, I want to thank my family, Matt and my friends for helping me survive this master’s thesis journey. You have been supporting me through all the frustration and stress, you have listened to me talking about equations, loops and stock and flows while continued to provide me with encouragement and pride. Thank you. Hannah III Table of Contents ABSTRACT ............................................................................................................................................... II ACKNOWLEDGEMENTS ........................................................................................................................ III TABLE OF CONTENTS .......................................................................................................................... IV LIST OF TABLES .................................................................................................................................... VI LIST OF FIGURES ................................................................................................................................. VII EQUATIONS ............................................................................................................................................ IX TABLE OF ACRONYMS .......................................................................................................................... X CHAPTER 1 .............................................................................................................................................. 1 INTRODUCTION ....................................................................................................................................... 1 1.1 HEALTHCARE IN NORWAY .............................................................................................................. 1 1.2 HAUKELAND UNIVERSITY HOSPITAL AND MOTIVATION FOR RESEARCH ........................................................... 3 1.3 THE ACCIDENT AND EMERGENCY DEPARTMENT AT HUS ................................................................................. 4 1.4 METHOD .............................................................................................................................................................. 7 1.5 PROBLEM DEFINITION AND RESEARCH OBJECTIVE ......................................................................................... 12 CHAPTER 2 LITERATURE REVIEW .................................................................................................... 16 2.1 SYSTEM DYNAMICS .................................................................................................................................... 16 2.2 APPLICATION OF SYSTEM DYNAMIC MODELS .................................................................................................. 17 2.3 DISCRETE EVENT SIMULATION ......................................................................................................................... 20 2.4 OBJECT-BASED MODELING .............................................................................................................................. 22 2.5 PATIENT-CENTERED CARE ............................................................................................................................... 24 CHAPTER 3 MODEL DEVELOPMENT AND PROCESS STRUCTURE ............................................. 26 3.1 GENERAL OVERVIEW OF THE AED .................................................................................................................. 26 3.2 FORMULATION OF EQUATIONS ......................................................................................................................... 28 3.3 PATIENT ARRIVAL AT AED ............................................................................................................................... 29 3.4 TRIAGE AND SATS ........................................................................................................................................... 29 3.5 CLINICAL ASSESSMENT SECTOR ...................................................................................................................... 32 3.6 CATH LAB, EVALUATION FOR PLACEMENT, ECHOCARDIOGRAM ..................................................................... 36 3.7 DIAGNOSTIC IMAGING ....................................................................................................................................... 38 3.8 EVALUATION FOR PATIENT PLACEMENT .......................................................................................................... 41 3.9 UNDERLYING MECHANISMS .............................................................................................................................. 45 3.10 SIMPLIFIED PROCESSES AND ACTIVITY TIME STRUCTURES ......................................................................... 46 3.11 PLACEMENT OF PATIENT ................................................................................................................................ 49 3.12 DEVELOPMENTS ............................................................................................................................................. 50 3.13 ELECTROCARDIOGRAM DEVELOPMENT AND EVALUATION ............................................................................ 51 3.14 UNDERLYING MECHANISMS IN TRIAGE .......................................................................................................... 55 3.15 LAB TEST AND DEVELOPMENTS ..................................................................................................................... 58 3.16 CLINICAL SIGNS AND SYMPTOMS – PATIENT ATTRIBUTES ............................................................................ 63 IV 3.17 RISK FACTORS AND EVALUATION .................................................................................................................. 66 3.18 NUMBER GENERATORS .................................................................................................................................. 67 3.19 MODEL VALIDATION AND VERIFICATION......................................................................................................... 70 3.20 SENSITIVITY ANALYSIS ................................................................................................................................... 70 CHAPTER 4 SCENARIO TESTING ...................................................................................................... 74 4.1 INTRODUCTION .................................................................................................................................................. 74 4.2 ACUTE CORONARY SYNDROME: VARIATIONS ................................................................................................. 75 4.2.1 Scenario 1: Acute coronary syndrome- STEMI ................................................................................. 77 4.2.2 Scenario 2: Acute Coronary Syndrome- NSTEMI ............................................................................. 78 4.2.3 SCENARIO 3: ACS- NSTEMI WITH ARRHYTHMIAS .................................................................................... 80 4.2.4 Scenario 5: ACS- No Chest Pain at Arrival: cTnT Positive .............................................................. 81 4.2.6 Scenario 6: ACS- No Chest Pain and Normal Troponin Levels ...................................................... 83 4.3 CARDIOGENIC SHOCK ...................................................................................................................................... 83 4.3.1 Scenario 7: ACS- Cardiogenic Shock ................................................................................................. 84 4.3.2 Scenario 8: Cardiogenic Shock - Unstable Arrhythmia .................................................................... 86 4.4 AV- BLOCKS (ATRIOVENTRICULAR HEART BLOCKS) ....................................................................................... 87 4.4.1 Scenario 9: AV-Block II.......................................................................................................................... 87 4.4.2 Scenario 10: AV-Block III resulting in unconsciousness, or seizure ............................................... 88 4.4.3 Scenario 11: AV-Block III resulting in respiratory arrest in which resuscitation is initiated. ........ 89 4.5 SCENARIO 12: ATRIAL FIBRILLATION AND ATRIAL FLUTTER ............................................................................ 90 4.6 SCENARIO 13: VENTRICULAR FIBRILLATION .................................................................................................... 92 4.7 SCENARIO 14: VENTRICULAR TACHYCARDIA ................................................................................................... 93 CHAPTER 5 RESEARCH OUTCOME AND CONCLUSION ................................................................. 95 5.1 RESEARCH OUTCOMES .................................................................................................................................... 95 5.2 RESEARCH LIMITATIONS AND BOUNDARIES ..................................................................................................... 97 5.3 THE AED AND HOSPITAL AS A COLLABORATIVE ORGANIZATION ........................ ERROR! BOOKMARK NOT DEFINED. 5.4 IDEAS FOR FUTURE RESEARCH ....................................................................................................................... 98 5.5 CONCLUSION .................................................................................................................................................. 101 BIBLIOGRAPHY ................................................................................................................................... 103 A APPENDIX .................................................................................................................................... 110 B MODEL EQUATIONS AND DOCUMENTATION ............... ERROR! BOOKMARK NOT DEFINED. V LIST OF TABLES Table 1 Random Number Generators Used in Aiding Patient Attribute Combinations and Developments ........................................................................................................................................... 10 Table 2 a Meta Comparison of DES and SD (Jovanovski, Minovski, Voessner & Lichtenegger (2012) ......................................................................................................................................................... 22 Table 3 Comparison of DES, SD and OBM (Adapted from the Meta-Comparison by Jovanoski), (2012). ........................................................................................................................................................ 24 Table 4 Overview of AED processes ................................................................................................... 27 Table 5. Adult Triage Early Warning Signs (TEWS) .......................................................................... 30 Table 6 Clinically Priority List Indicating Level of Urgency Assigned in Triage ............................. 32 Table 7 Possible ACS Outcomes from Clinical Assessment .......................................................... 36 Table 8 Diagnose and Patient Placement Destination ..................................................................... 44 Table 9 Sub-models in Simulation Model ........................................................................................... 46 Table 10 Simplified Process and Assessment Time Structures ...................................................... 47 Table 11 Patient Attribute- Developments .......................................................................................... 51 Table 12 Electrocardiogram Developments Classification in Triage .............................................. 52 Table 13 Electrocardiogram Developments ........................................................................................ 54 Table 14 Blood Tests. ............................................................................................................................. 59 Table 15 Clinical Signs and Symptoms ................................................................................................ 64 Table 16 Risk Factors ............................................................................................................................. 67 Table 17 Acute Coronary Syndrome Variations .................................................................................. 76 Table 18 Patient AED Time for a NSTEMI patient ............................................................................. 79 VI LIST OF FIGURES Figure 1. Flowchart of the clinical pathway for cardiovascular patients adapted from Helse Bergen .......................................................................................................................................................... 7 Figure 2. Stock and flow structure indicating triage completion. ...................................................... 10 Figure 3. Simple stock and flow structure. .......................................................................................... 17 Figure 4. Example of a causal loop diagram (Brailsford, 2008). ...................................................... 17 Figure 5. Overview of the AED and the various processes for cardiovascular patients. The flowchart shows the relationship between sub-models and the main AED model process flow. 27 Figure 6. Triage sector showing vital parameters and ECG evaluation. ........................................ 31 Figure 7. Example of structure in the clinical assessment sub-model. ........................................... 34 Figure 8. Structure demonstrating patient type prioritization. ........................................................... 38 Figure 9. Echocardiogram structure, including the result generator. .............................................. 39 Figure 10. Imaging evaluation: Combining the results from echocardiogram. ............................ 40 Figure 11 . Placement evaluation at the end of the AED process. .................................................. 41 Figure 12. Structure indicating possible placement decisions. ........................................................ 42 Figure 13. Placement decision overview. ............................................................................................ 44 Figure 14. Registration of the number of diagnoses suspected when the patient departs the AED. ........................................................................................................................................................... 45 Figure 15. Activity time structure of the clinical assessment including waiting time, assessment and evaluation. ......................................................................................................................................... 48 Figure 16. Graph showing that lab test processing is initiated shortly after triage starts and the evaluation is ready about an hour after patient arrival. ...................................................................... 48 Figure 17. Lab test process. .................................................................................................................. 49 Figure 18. Placements that will be chosen based on the patient’s status. ..................................... 50 Figure 19. Graph illustration the ECG development possibilities. ................................................... 52 Figure 20. Examples of ECG developments structure. ..................................................................... 54 Figure 21. ECG readings structure. ...................................................................................................... 55 Figure 22. Triage Assessment Time Structure. .................................................................................. 56 Figure 23. Patient Flow indicating location of sub-models in grey (adapted from Vanderby, 2009) .......................................................................................................................................................... 56 Figure 24. Triage Urgency evaluation structure. ................................................................................ 57 Figure 25. Lab Test Developments structure. ..................................................................................... 59 Figure 26. Lab test evaluation of arterial blood gas structure. ......................................................... 61 Figure 27. Lab test structure of the cTnT lab process structure. ..................................................... 61 Figure 28. Lab test combination structures used in evaluation for patient placement, in combination with other diagnostic results. ............................................................................................ 62 Figure 29. Stock and flow structures showing of clinical signs and symptoms development. .... 65 Figure 30. Cardiogenic Shock Symptom manually activated when the modeler wants to observed cardiogenic shock. .................................................................................................................. 66 Figure 31. Structure showing risk factor structures and combination. ............................................ 67 Figure 32. The purple variable called Lab Test Development Options originates in the random generator sector. ...................................................................................................................................... 68 Figure 33. Sub-model showing number generators used in the model. ......................................... 69 VII Figure 34. Example of stock and flow structures, where the inflows contain numerical ranges linked to a random number generator. .................................................................................................. 71 Figure 35. Graph showing all ECG developments, where the variables containing developments have all been modified to be above the 0.70 threshold. .................................................................... 72 Figure 36. Graph indicating ECG STEMI results. .............................................................................. 73 Figure 37. Graph showing ACS runs when all STEMI developments were changed to > 0.70. . 73 Figure 38. Example showing how the graphical functions are presented: AED processes are modeled discretely. .................................................................................................................................. 74 Figure 39. ACS Classification. Cardiac Markers, usually Troponin determines the patients ACS diagnose. In the general AED however, the patient is placed based on the current chest pain indication. .................................................................................................................................................. 75 Figure 40. Graph showing STEMI patient and its clinical pathway in the AED. ............................ 77 Figure 41. Graph showing NSTEMI diagnostic process. .................................................................. 78 Figure 42. Activity Time Structures indicating the time spent for various procedures. The total time when looking at the activity time structures are approximately 87 minutes. .......................... 80 Figure 43. Graph showing NSTEMI Arrhythmias AED Placement Process. ................................. 80 Figure 44. Graph showing acute coronary syndrome suspected patient without chest pain at arrival. ........................................................................................................................................................ 81 Figure 45. Lab Test Availability and Placement Evaluation Comparison. ...................................... 82 Figure 46. Graph showing a patient arriving with no ongoing chest pain, no significant ECG findings, and normal cTnT levels but appears unstable. .................................................................... 83 Figure 47. Graph showing cardiogenic shock & NSTEMI. ................................................................ 84 Figure 48. Graph showing arterial blood gas observed during the clinical assessment evaluation of cardiogenic shock, indicating metabolic acidosis. .......................................................................... 85 Figure 49. Graph showing the diagnostic process for cardiogenic shock with discovered Ventricular Tachycardia. ......................................................................................................................... 86 Figure 50. Scenario 9: Graph showing AV-Block II patient. ............................................................. 87 Figure 51. Graph showing AV-Block II resulting in Asystole unconsciousness or seizure. ......... 88 Figure 52. Av- Block III Patient admitted to the cardiac care unit. ................................................... 88 Figure 53. Graph showing AV-Block resulting in respiratory arrest. ............................................... 89 Figure 54. Graph showing AV-Block III patient requiring resuscitation. ......................................... 89 Figure 55. Graph showing risk evaluation for AFib/Atrial Flutter. .................................................... 90 Figure 56. Graph showing Atrial Fibrillation/Flutter patient and its pathway. ................................. 91 Figure 57. Antiplatelet therapy given to AFib/Atrial flutter patients. ................................................. 91 Figure 58. Graph showing risk score evaluation and treatment based on evaluation. ................. 92 Figure 59 Graph showing Ventricular Fibrillation patient and its pathway. .................................... 92 Figure 60. Graph showing ventricular tachycardia patient and its pathway. .................................. 93 VIII EQUATIONS Equation 1: ACS Suspicion Evaluation ................................................................................................. 34 Equation 2: ACS Symptom and ECG evaluation. ............................................................................... 35 Equation 4: ECG Development STEMI ................................................................................................. 57 Equation 5: ECG Development NSTEMI/UA ....................................................................................... 57 Equation 6: Troponin (cTnT) Developments ........................................................................................ 60 Equation 7: NT ProBNP Developments ................................................................................................ 60 Equation 8: Cardiac Marker Evaluation Equation ............................................................................... 62 Equation 9: Electrolyte Equation ............................................................................................................ 62 Equation 10: Cardiac Markers (2) .......................................................................................................... 63 Equation 11: Number Generator for Lab Test Developments ........................................................... 68 IX Table of acronyms AED Accident and Emergency Department AFib Atrial Fibrillation ABM Agent-Based Modeling AGB Arterial Blood Gas cTnT Troponin DES Discrete Event Simulation ECG Electrocardiogram HUS Haukeland University Hospital MAS Multi-Agent System MOS Multi-Object System MIO Medisinsk Intensiv overvåking/Medical intensive care unit NSTEMI non-ST Segment Elevation Myocardial Infarction OBM Object-Based Modeling OR Operational Research SD System Dynamics STEMI ST-Segment Elevation Myocardial Infarction TEWS Triage Early Warning Score UA Unstable Angina UMO Utgreiingsmottak (referred to as diagnostic unit in the study) X