Journal of Engineering and Development, Vol. 18, No.

2, March 2014, ISSN 1813- 7822

Simulation Models Of Emergency Department In Hospital

Asst. Lecturer. Basim Khudair Abbas

mathematic science
E-mail baasim_math@yahoo.com
Al _Mustansiriyah University, Bagdad_ Iraq

Abstract:

This paper gives the Emergency Department (ED) room patient flow using a medium
size hospital as a case-study model .The purpose of this paper was to determine the flow of
patients through the Emergency case and Elective surgical to identify the data elements
required to complete a quantitative analysis of waiting time issues. As this paper devote to
building and validation of a simulation model using the discrete event simulation for
modeling, analysis, and visualization. The basic model will be extended to simulate the
effects of different operating strategies on patient waiting time in the ED.
Keywords : patients, Emergency Departments (ED), CPR (Cardio Pulmonary
Resuscitation), Emergency Severity Index (ESI), Elective surgical.

‫ﻣﺣﺎﻛﺎة ﻟﻧﻣذﺟﺔ ﻋﻣل ﻗﺳم اﻟطوارئ ﻓﻲ اﻟﻣﺳﺗﺷﻔﯾﺎت‬

‫ ﺑﺎﺳﻢ ﺧﻀﯿﺮ ﻋﺒﺎس‬.‫م‬.‫م‬
‫ ﻛﻠﯿﺔ اﻟﻌﻠﻮم – ﻗﺴﻢ ﻋﻠﻮم اﻟﺤﺎﺳﻮب‬-‫اﻟﺠﺎﻣﻌﺔ اﻟﻤﺴﺘﻨﺼﺮﯾﺔ‬

:‫اﻟﺧﻼﺻﺔ‬

‫ وﻛﻤﺎ أن‬.‫أن اﻟﻐﺮض ﻣﻦ ھﺬه اﻟﺪراﺳﺔ ھﻲ ﻣﻌﺮﻓﺔ ﻣﺪى ﺗﺪﻓﻖ اﻟﻤﺮﺿﻰ إﻟﻰ ﻗﺴﻢ اﻟﻄﻮارئ ﺑﻤﺴﺘﺸﻔﻰ ﻣﺘﻮﺳﻄﺔ اﻟﺤﺠﻢ‬
‫ھﺬه اﻟﺪراﺳﺔ ﺗﮭﺪف إﻟﻰ ﻣﻌﺮﻓﺔ اﻟﺤﺎﻻت اﻟﺠﺮاﺣﯿﺔ اﻟﻄﺎرﺋﺔ واﻟﻤﺴﺘﻘﺮة ﻣﻦ ﺧﻼل ﺗﺤﺪﯾﺪ اﻟﺒﯿﺎﻧﺎت اﻟﻀﺮورﯾﺔ اﻟﺘﻲ ﻧﺤﺘﺎﺟﮭﺎ‬
‫ وﻗﺪ اﺗﺒﻌﻨﺎ ﻓﻲ ھﺬا اﻟﺒﺤﺚ طﺮﯾﻘﺔ ﻟﻨﻤﺬﺟﺔ ﻋﻤﻞ اﻟﻤﺴﺘﺸﻔﻰ ﺑﺎﺳﺘﺨﺪام ﻧﻈﺎم‬.‫ﻋﻦ اﻟﻤﺮﯾﺾ ﻟﺘﺤﺪﯾﺪ ﺣﺎﻟﺘﮫ وﻟﺘﻘﻠﯿﻞ ﻣﺪة اﻧﺘﻈﺎره‬
‫ وأﯾﻀﺎ ﻗﺪ ﺗﻢ ﺗﻄﺒﯿﻖ ﻋﺪة ﺳﺘﺮاﺗﯿﺠﯿﺎت ﻟﺘﻘﻠﯿﻞ وﻗﺖ اﻧﺘﻈﺎر اﻟﻤﺮﯾﺾ ﻓﻲ ﻗﺴﻢ‬.‫اﻷﺣﺪاث اﻟﻤﻨﻔﺼﻠﺔ ‘ ﻟﺘﺤﻠﯿﻞ وﺗﻘﯿﯿﻢ ﻋﻤﻞ اﻟﻨﻈﺎم‬
.‫اﻟﻄﻮارئ‬
1. Introduction

Healthcare delivery can be very expensive and is often subject to delays that can be costly
as well as dangerous to patient health. In our view both the problems of cost and delay might
be addressed by devising superior approaches for evaluating the utilization of resources. The
resources used in delivering health care include both equipment, such as beds, radiographic

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imaging equipment, and operating suites and people, such as doctors and nurses. All of these
resources are very costly. Accordingly these resources tend to be allocated sparingly in most
health care settings. This can lead to a lack of sufficient resources that can be at least partly to
blame for delays in delivering health care. Adding resources of only one type (e.g. more
doctors) is rarely sufficient to reduce delays, however, as patient care typically requires the
use of many types of additional resources (e.g. beds, nurses, and equipment)[1].
An Emergency Department (ED) is a medical treatment facility, specializing in acute
care of patients who present without prior appointment, either by their own means or by
ambulance. Due to the unplanned nature of patient attendance, the department must provide
initial treatment for a broad spectrum of illnesses and injuries, some of which may be life-
threatening and require immediate attention. The ED of a hospital is a complex unit where the
fight between life and death is always a hair’s breadth away, requiring a high degree of
coordination among human and material elements. One of the common areas of concern in
any ED is the reduction of waiting time or length of stay of patient[2]. In some cases, the
patients may require treatment in a traditional ED room, but many can be discharged without
using a room. The discharge process is followed by checkout which includes complete
registration and insurance verification or payment is called (Elective case)[3].
The aim of this paper is simulation model designed to assess the effect on emergency
department (ED) to reduce the interval of admitted patient departure from the ED and take the
necessary care.

2. Related Works

In 2010 Yariv Marmor discussed the concept of the (ED) of a modern hospital is a
highly complex system. Indeed, it gives rise to numerous managerial challenges from the
Service Engineering area, spanning the full spectrum of operational, clinical and _financial
perspectives, over varying horizons: operational few hours or days ahead, tactical - weeks or a
few months ahead, or strategically - months to years ahead. Since realistic ED models are
often intractable analytically, one resorts to simulation for an appropriate framework to
address these challenges, which is what we do here[4].
In 2008 Erik M. W. Kolb discussed the concept of medical care issue in the United
States and other developed nations. One major cause of ED crowding are holding patients
waiting in the Emergency Room (ER) for inpatient unit admission where they block critical
ED resources. With input data from a hospital in Massachusetts/ USA, we tested five patient
buffer concepts which aim at relieving pressure of the ER. The buffers are also assumed to
improve patient and staff satisfaction through their design tailored to needs in patient flow[5].
3. System Description
The ED of the hospital operates round the clock and receives an average of 58 patients
daily. The ED is of thirty-bed capacity. The ED currently has twenty-eight nurses, fifteen
physicians. There are two 12-hour shifts for physicians starting at 06:00 and 18:00 and three

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shifts for nurses starting at 06:00, 13:00, and 18:00 in the ED of a governmental hospital. The
patients are classified as per the Emergency Severity Index (ESI) standard in the triage. Triage
codes assigned by triage nurses are critical to achieve a correct dispatch of patients (giving the
right priority based on patient condition).

3.1 Acknowledging with the Proposal System

The proposal system is to simulate ED work in government hospital model. A regular

patient enters the system at waiting room, picks a number and remains in the waiting area.
When his number is called the patient is assessed by a triage nurse who screens for critical
apparent symptoms (high blood pressure, fever, etc.) then the examination rooms are used to
treat patients arriving from triage room. There are eight general examination rooms, four are
equipped to deliver specific care such as orthopedics, hand surgery, infections treatment, and
ophthalmology; otherwise If the patient's condition deteriorated will enter into a emergency
room to take care of the required. On the other hand, if patient is required entered to Cardio
Pulmonary Resuscitation (CPR), so that he can be resuscitated and he transferred to the
emergency department for immediate care after stabilizing the patient's condition will be
transferred to other lobby until improved discharge from the hospital or death. Figure(1)
summarize the patient flow through the ED by a flow chart.

Fig .(1) Flow chart of proposed patient conditions

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3.2 Methodology

The methodology of simulation models applied in the Emergency Department (ED)

represent the patients flow to take care by the following steps:

1. Generate pseudo random number using function RND ( ).

2. Transform this number in to random variable exponentially distributed to represent the
inter arrival time:
1
Inter arrival= − log (random number)
λ
3. Generate another pseudo random number
4. Transform this number to random variable exponentially distributed to represent the
service time in examination room and in emerge time:

1
service time = − log (random number)
µ1
1
emerge time = − log (random number)
µ2
5. Calculate arrival time, waiting time, idle time and depart time

• arrival time (patients) =inter arrival time (previous patients)+ arrival time (current
patients )
• Idle time= arrival time - depart time (if arrival>depart of previous patients)
• Wait time = depart time - arrival time (if depart > arrival of previous patients).
• Depart time= arrival time + service time + wait time +exam time + emerge time

4. Results and discussion.

By means of the created simulation model, with preliminary assigned for the two
scenarios, each scenarios have number of patients the incoming flow, intensity of the
incoming flow (arrival rate), if the patients is Elective condition then enter to the several
phases until take care then leave from the hospital is simulated the operation of the system
“Emergency Department ”.
Scenario 1 – simulation of the “ED” as Elective Case model having Poisson incoming
flow about the patients with an average inter-arrival time. Figure (2) shows a sample of the
program tabular results to simulation model of elective surgical when λ = 0.6 and µ = 0.3 ,
and not required to count the time in emergency department, the results are display as
graphical scheme that represent the leave time in Figure(3).

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Fig .(2) Tabular results of Elective Case

Fig .(3) graphical results of Elective Case model

Scenario 2 – simulation of the system “ED” as Elective Case with Emergency model
having Poisson incoming flow with an average inter-arrival time of the patient flow and
emergency time as exponential distributed. Figure (4) shows a sample of the program tabular
results to simulation model, when λ = 0.4 , µ = 0.02, µ1 = 0.3, µ 2 = 0.09 . If the patient's
condition worsened, it is necessary to transfer to the emergency room therefore required to
count time in the emergency department and display the results of leave time as graphical
scheme in Figure(5). In the tabular results represent the elective surgical by value of (1) but if
the patient required transfer to the ED represent by value (0).

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Fig .(4)Tabular results of Elective Case with Emergency model

Fig .(5) graphical results of Elective Case with Emergency model

Scenario 3 – simulation of the system “ED” as emergency model having Poisson

incoming flow with an average inter-arrival time of patients as exponential distributed.
Figure (6) shows a sample of the program tabular results to simulation model, when
λ = 0.3 and µ1 = 0.6 . Display the results of leave time as graphical scheme in Figure (7).
In the tabular results represent the emergency case by value of (1) but if the patient death
represent by value (0).

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Fig. (6)Tabular results Emergency model

Fig. (7) graphical results of Emergency model

5. Conclusions:
The simulation model gives the patients flow through an illustrative emergency
department in hospital by a following special features:

• The queuing models enhance a new dimension in computer simulations which take to
consideration the waiting time reduced. Via applying several models queuing , the
minimum waiting time will obtained.

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• The priority discipline is measure of urgency or importance, when the patients arrival to
hospital by ambulance before other patients because it's urgent, therefore waiting time in
this state is smaller than without.
• The elective case with emergency model is measuring service time ; the average of depart
from (92.4) is greater than average depart from case of elective without emergency (76.2).
• ED represent an important department in hospital because the patients required a special
health to access a best case without any delay.

Reference:

1. M. S. Raunak, L. J. Osterweil, A. Wise, L. A. Clarke, “Simulating Patient Flow

through an Emergency Department Using Process-Driven Discrete Event
Simulation”, University of Massachusetts Amherst {raunak, ljo, wise, clarke} @
cs.umass . edu,
2. Hamidreza Eskandari, Mohammadali Riyahifard, “Improving The Emergency
Department Performance Using Simulation and MCDM Methods”, Tarbiat
Modares University, 2011.
3. D. J. Medeiros, Eric Swenson, Christopher DeFlitch, “Improving Patient Flow in a
Hospital Emergency Department” Industrial and Manufacturing Engineering
Department of Emergency Medicine Penn State University, 2008.
4. Yariv Marmor, “Emergency-Departments Simulation in Support of Service
Engineering:Staffing, Design, and Real-Time Tracking”, Shvat, 5770 Haifa
February 2010.
5. Erik M. W. Kolb, Jordan Peck, “Reducing Emergency Department Overcrowding
Five Patient Buffer Concepts in Comparison”, RWTH Aachen University
Massachusetts Institute of Technology Aachen, 52074, GERMANY Cambridge, MA
02139, U.S.A., 2008.

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