医院多服务台时两种等待队列的性能分析

目的利用排队论的相关知识，对医院中多服务台时两种排队模型进行分析比较。方法从医院信息系统（HIS）中提取有关排队数据，计算出平均到达率和平均服务率，运用排队论的数学模型，借助M／M／1模型和M／M／C模型的算法及有关辅助程序，得到评价指标。结果医院多服务台时，单一共享等待队列的性能显著优于多个独自的等待队列。结论在医院安排排队方式时，尽量采用单一共享等待队列。     

Consequences of queuing for care at a public hospital emergency department

OBJECTIVE: To determine whether the length of a queue at a public hospital emergency department was associated with increased likelihood of patients' leaving without being seen by a physician and whether leaving adversely affected patients' health or affected their subsequent use of health care services. DESIGN: Observational cohort. Patients were surveyed during 1 week in July 1990 and received a follow-up survey 7 to 14 days later. The responses of patients who left without being seen by a physician were compared with those who were seen by a physician. SETTING: Emergency department at San Francisco (Calif) General Hospital. PATIENTS: All English-, Spanish-, and Cantonese-speaking adults waiting for emergency care were eligible. Of 882 eligible individuals, 700 agreed to participate; 85% of enrolled subjects saw a physician and 15% left without being seen. Demographic characteristics of patients who were and who were not seen were not significantly different. MAIN OUTCOME MEASURES: Emergency department waiting time and changes in patients' self-reported health. RESULTS: Patients were more likely to leave as waiting times increased. At follow-up, patients who left without being seen were twice as likely as those who were seen to report that their pain or the seriousness of their problem was worse. Only 4% of patients who left required subsequent hospitalization, but 27% returned to an emergency department. CONCLUSION: Many patients can appropriately decide whether their problem is truly urgent and make alternative plans in the face of long waits, but the health of some patients may be jeopardized by long queues for emergency care.     

Coronary artery bypass graft surgery in Newfoundland and Labrador

BACKGROUND: Newfoundland and Labrador, like other health care jurisdictions, is faced with widening gaps between the demands for health care and a strained ability to supply the necessary resources. The authors carried out a study to determine the rates of appropriate and inappropriate coronary artery bypass grafting (CABG) in the province and the waiting times for this surgery. METHODS: This retrospective cohort study was performed in the tertiary care hospital that receives all referrals for coronary angiography and coronary artery revascularization for Newfoundland and Labrador. By reviewing the hospital records, the authors identified 2 groups of patients: those in whom critical coronary artery disease was diagnosed on the basis of coronary angiography and who were referred for CABG between Apr. 1, 1994, and Mar. 31, 1995, and those who actually underwent the procedure during that period. By applying specific criteria developed by the RAND Corporation, the authors determined the appropriateness and necessity of CABG in each case. They also compared waiting times for CABG with optimal waiting times; as determined by a consensus-based priority score. RESULTS: A total of 338 patients underwent CABG during the study period. The cases were characterized by multivessel disease and late-stage angina symptoms. Almost all of the patients had high appropriateness scores (7-9), and nearly 95% had high necessity scores (7-9). However, during the study period, the waiting list increased by about 20%, because a total of 391 patients were referred by the weekly cardiovascular surgery conference; the authors identified these and an additional 31 patients as having necessity scores of 7 or more. Only 7 (23%) of 31 patients for whom CABG was considered very urgent underwent surgery within the recommended 24 hours, and only 30 (24%) of the 122 patients for whom CABG was considered urgent underwent surgery within the recommended 72 hours. INTERPRETATION: These results provide evidence that the cardiac surgery program in Newfoundland and Labrador is performing CABG in patients for whom surgical revascularization is highly appropriate and necessary. Access to CABG is less than ideal, however, since the waiting list continues to expand, and many patients wait beyond the recommended time for surgery.     

浅谈医院门诊排队叫号系统在医院的实施

以河北工程大学附属医院皮肤科为例,针对医院皮肤科门诊患者流量大,存在排队管理中无序、医生诊室纷乱、病人的心理焦虑、医生看病环境差、医护人员工作强度大等问题,医院上线了门诊排队叫号系统,实行病人挂号直接到医生,病人在候诊大厅等待语音广播叫号等,改善了医院就医环境,提高了工作效率与医院为病人服务质量,使医院的管理更加规范化、数字化。     

Rates of cardiac catheterization, coronary angioplasty and open-heart surgery in adults in Canada.

OBJECTIVE: To determine the rates of and waiting lists for cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA) and open-heart surgery in adults in Canada between Apr. 1, 1988, and Mar. 31, 1989. DESIGN: Mail survey. PARTICIPANTS: The directors of all 48 adult cardiac catheterization laboratories and the chiefs of all 33 adult cardiovascular surgery programs in Canada. MAIN RESULTS: A total of 61,116 cardiac catheterization procedures were performed, a rate of 236 per 100,000 population. The mean waiting times for elective procedures were weighted to reflect more accurately the differences between centres in the number of patients awaiting the procedures. The mean wait for elective cardiac catheterization was 8.5 weeks. There were 10,097 PTCA procedures done, a rate of 39 per 100,000 population. The mean wait for elective PTCA was 11.0 weeks, the longest wait occurring in Quebec (15.4 weeks). A total of 16,240 open-heart procedures were performed, a rate of 63 per 100,000 population. The mean wait for elective open-heart surgery was 22.6 weeks, the longest wait occurring in Quebec and British Columbia (more than 32 weeks). The rates for all three procedures were much lower in Canada than in the United States. CONCLUSIONS: The results suggest that the cumulative wait for coronary angiography and PTCA or open-heart surgery may lead to major losses of productivity, delayed rehabilitation and reduced probability of return to previous levels of productivity. Regular collection of data such as ours should help to understand better the resources required for these specialized cardiac procedures.     

医院门诊电子排队管理系统的设计和应用

目的解决患者看病过程中的各种排队拥挤和混乱现象，做到人人平等、秩序井然，体现医院“以患者为中心”的服务宗旨。方法建立门诊电子排队系统，并应用于全院的挂号、就诊、收费、发药、检验、检查等，使整个医院有机结合起来。结果（1）改善了就医环境；（2）提高了医护人员的工作效率；（3）规范了就诊秩序；（4）为考核医生和管理决策提供依据。结论提高了医院的服务质量，改进了医院的服务形象，减少了患者的就诊等待时间。     

US ad uses lure of prompt treatment to entice Canadians needing joint replacement.

A Virginia hospital has used newspaper advertisements to solicit Ontario patients who are waiting for hip- or knee-replacement surgery. The ads promote the medical services of US orthopedic surgeons and call attention to exasperatingly long waiting lists for the same surgery in Canada. "Pain doesn't wait," they state. "Neither should you." The hospital says it has been receiving more than 100 calls a week inquiring about the procedure, which costs $15000 (US).     

Feasibility and safety of day care laparoscopic cholecystectomy in a developing country

Background: Although day care laparoscopic cholecystectomy (DCLC) has been shown to be safe in centres with adequate infrastructure for day care surgery, its feasibility and safety in developing countries has never been studied. Because of differences in the quality of health care delivery, western guidelines for day care surgery cannot be universally applied to developing countries. Patients and methods: Patients less than 65 years who were graded I and II on the American Society of Anesthesiologists physical status score, irrespective of their educational status, living within 20 km, and willing to make their own arrangements for a return to hospital in case of problems were selected for DCLC. Follow up was done by patients calling the hospital the morning after surgery. Results: 50% of the eligibility criteria were new; 313/383 patients were suitable for DCLC. The commonest cause for rejection was that the patient lived out of the defined area (50%). Altogether 92% were discharged within eight hours of surgery. The reasons for failure to discharge were the presence of abdominal drains in four (2%), nausea and vomiting in nine (3%), and conversion to open surgery in five (2%). Ten patients (3%) were readmitted; of these only two (<1%) had complications needing re-exploration. Analysis of results showed that the inclusion and discharge criteria were valid and that the readmission and complication rates as well as the ease and accuracy of follow up were comparable to published data. DCLC reduced waiting times and increased patient turnover and may have a positive impact on resident training. Conclusions: DCLC is safe, feasible, and has potential benefits for health care delivery in developing countries. Each surgical service needs to develop their own guidelines based on local patient demography.     

Reducing Bottlenecks to Improve the Efficiency of the Lung Cancer Care Delivery Process: A Process Engineering Modeling Approach to Patient-Centered Care

The process of lung cancer care from initial lesion detection to treatment is complex, involving multiple steps, each introducing the potential for substantial delays. Identifying the steps with the greatest delays enables a focused effort to improve the timeliness of care-delivery, without sacrificing quality. We retrospectively reviewed clinical events from initial detection, through histologic diagnosis, radiologic and invasive staging, and medical clearance, to surgery for all patients who had an attempted resection of a suspected lung cancer in a community healthcare system. We used a computer process modeling approach to evaluate delays in care delivery, in order to identify potential ‘bottlenecks’ in waiting time, the reduction of which could produce greater care efficiency. We also conducted ‘what-if’ analyses to predict the relative impact of simulated changes in the care delivery process to determine the most efficient pathways to surgery. The waiting time between radiologic lesion detection and diagnostic biopsy, and the waiting time from radiologic staging to surgery were the two most critical bottlenecks impeding efficient care delivery (more than 3 times larger compared to reducing other waiting times). Additionally, instituting surgical consultation prior to cardiac consultation for medical clearance and decreasing the waiting time between CT scans and diagnostic biopsies, were potentially the most impactful measures to reduce care delays before surgery. Rigorous computer simulation modeling, using clinical data, can provide useful information to identify areas for improving the efficiency of care delivery by process engineering, for patients who receive surgery for lung cancer.     

医院网络预约挂号系统的构建

医院门诊挂号排队一直是制约医院提高服务质量的问题,尤其是在一些医疗技术水平较高的大型综合性医院,门诊挂号排队更属于极其普遍的现象。在互联网迅猛发展的今天,网上挂号成为分流的重要途径。提出了医院网络预约挂号系统的构建方案,患者只需要利用互联网就能够实现提前预约挂号,减少排队挂号的等候时间,还能够掌握不同医生擅长的治疗方向。通过信息技术使医院可以为患者提供更优质、更便捷的服务,同时也有效提高了患者对医院的满意度。     

NHS waiting list have been a boon for private medicine in the UK.

Health care: public, private or both? In Great Britain, about 13% of the population is covered by private health insurance, and everyone else is served by the public health care system known as the National Health Service, or NHS. Caroline Richmond, who examined the impact of private medical practice in Britain, says people become private patients for one compelling reason: to avoid the NHS's notoriously long waiting lists for surgery. According to Professor Alan Maynard, a health care researcher, the mainstays of the private sector are the "three h's" --hips, hernias and hemorrhoids-- along with some elective surgery, particularly in gynecology and opthalmology. Another small sector focuses on fertility regulation and cosmetic surgery. Although the levels are not monitored closely, physician consultants are not permitted to earn more than 10% of their income from private practice.     

大型医院门诊候诊环节管理的实践探讨

分析大型医院门诊候诊现状,提示门诊候诊环节管理在优化门诊服务流程中起到重要作用。首都医科大学宣武医院本着公平透明、人员流向均衡、尊重关爱和安全至上的候诊管理原则,采取分诊叫号系统、排队叫号系统、导诊和咨询服务、多种形式温馨提示、分时段就诊和检查、提高门诊工作效率、便民服务、诊间健康宣教、志愿者服务、院内就诊急救系统等措施,及时分流,缩短等候时间,改善候诊感受,提高门诊整体服务水平。     

Contemporary English health care: what lessons can we learn from it?

Even though the United Kingdom has developed a reputation for lengthy patient queues, two-tier medicine and inadequate hospital facilities, its National Health Service (NHS) has some valuable attributes that are worth studying as Canada struggles to control its health care costs. Dr. Grant Thompson thinks the NHS focus on the GP as the entry point to health care and the resulting continuity of care, as well as a central medical record system, are successes that could be incorporated into Canada's medicare system.     

Cardiac transplantation in severely ill patients requiring intensive support in hospital

Sixty four patients were referred for cardiac transplantation from a single cardiac team at this hospital between October 1984 and December 1986. Of these patients, 33 were referred for urgent transplantation, all of whom required intensive treatment in hospital with intravenous infusions of cardiac drugs, intra-aortic balloon counterpulsation, peritoneal dialysis, ventilation, or any combination of these to sustain life. Of these 33 patients, six died while awaiting transplantation, one was removed from the waiting list for a transplant, and 26 received cardiac transplants. There were five deaths within 24 hours of operation and one death 10 days after the operation. Twenty of those who had surgery had a successful outcome of transplantation, but there was one late death 10 weeks postoperatively and a further death 31 months after surgery. Eighteen patients were alive and well 10 to 33 months (mean 19.4 months) after transplantation, with an overall survival rate after surgery of 69%. Provided that surgery can be performed before renal failure has progressed such that renal dialysis [corrected] is necessary, the results are excellent (surgical survival 85.5%) and, we believe, justify the expenditure and staffing requirements necessary to treat these terminally ill patients.     

临床护理路径在腹腔镜胆囊切除术患者中的应用

目的探讨临床护理路径（clinical nursing pathway,CNP）工作模式对腹腔镜胆囊切除术患者住院天数、住院费用及护理质量的影响。方法将120例患者随机分为两组,观察组60例应用护士版和患者版护理路径表格实施CNP模式,对照组60例按常规模式护理,对比观察两组候手术天数、术后首次排气时间、首次下床活动时间、首次入厕时间、首次进食时间、住院天数、住院费用以及健康知识掌握情况、护理满意度等指标。结果观察组候手术时间、术后首次排气时间、首次下床活动时间、首次入厕时间、首次进食时间和住院时间均显著短于对照组（P〈0.01）,观察组的住院费用显著少于对照组（P〈0.01）,出院前健康知识掌握得分显著高于对照组（P〈0.01）,护理满意度显著高于对照组（P〈0.01）。结论对腹腔镜胆囊切除术患者实施CNP,可提高护理工作的主动性,增进了患者的自护能力,提高患者健康知识掌握水平,密切护患关系,提高护理质量,最终达到减少住院天数、控制医疗费用的目的。     

Informed consent by children: the new reality.

Recent legislative changes in British Columbia and New Brunswick allow children to make their own decisions about health care, something that used to be the prerogative of their parents. In this article, Eike-Henner Kluge argues that the changes hold profound implications for physicians. He says they increase the responsibility placed on doctors, who must now consider whether a child is indeed competent, and whether the decision made by a competent child is indeed in the child's best interests.     

Process Modeling of Emergency Department Patient Flow: Effect of Patient Length of Stay on ED Diversion

A discreet event simulation methodology has been used to establish a quantitative relationship between Emergency Department (ED) performance characteristics, such as percent of time on ambulance diversion and the number of patients in queue in the waiting room, and the upper limits of patient length of stay (LOS). A simulation process model of ED patient flow has been developed that took into account a significant difference between LOS distributions of patients discharged home and patients admitted into the hospital. Using simulation model it has been identified that ED diversion could be negligible (less than ∼0.5%) if patients discharged home stay in ED not more than 5 h, and patients admitted into the hospital stay in ED not more than 6 h Using full factorial design of experiments with two factors and the model’s predicted percent diversion as a response function, other combinations of LOS upper limits have been determined that would result in low ED percent diversion as well. It has also been determined that if the number of patients exceeds 11 in queue in ED waiting room then the diversion percent is rapidly increasing.     

Queuing for coronary angiography during severe supply-demand mismatch in a US public hospital: analysis of a waiting list registry.

CONTEXT: Adverse cardiac events have been reported in patients waiting for either coronary surgery or angioplasty. However, data on the risk of adverse events while awaiting coronary angiography are limited, and none are available from a US population. OBJECTIVE: To quantify cardiac outcomes in patients waiting for elective coronary angiography. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of 381 adult outpatients (mean [SD] age, 55 [12] years; 64% male; 61% white) on a waiting list for coronary angiography at a US tertiary care public teaching hospital during 1993-1994. MAIN OUTCOME MEASURES: Rates of cardiac death, nonfatal myocardial infarction, and hospitalizations for unstable angina or heart failure as a function of amount of time spent on a waiting list. RESULTS: Sixty-six patients were dropped from the waiting list but were included in the study analysis. During a mean (SD) follow-up of 8.4 (6.5) months, cardiac death, myocardial infarction, and hospitalization occurred in 6 (1.6%), 4 (1.0%), and 26 (6.8%) patients, respectively. The probability of events was minimal in the first 2 weeks and increased steadily between 3 and 13 weeks. By Cox multivariate analysis, 2 variables independently identified an increased risk of adverse events: a strongly positive treadmill exercise electrocardiogram or positive stress imaging result at referral (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.22-4.16; P=.01) and the use of 2 to 3 anti-ischemic medications (OR, 1.98; 95% CI, 1.19-3.96; P=.04). Among 311 patients who ultimately underwent angiography, those with adverse events had a higher prevalence of coronary disease (96% vs 60%; P<.001), more frequently required revascularization (93% vs 53%; P<.001), and had longer hospital stays (mean [SD], 6.2 [4.3] vs 1.3 [0.7] days; P=.001). CONCLUSION: Our data suggest that in a cohort referred for coronary angiography, delaying the procedure places some patients at risk for death, myocardial infarction, unplanned hospitalization, a longer hospital stay, and, potentially, a poorer prognosis. Waits longer than 2 weeks should be avoided, and patients with strongly positive stress test results and those who require 2 to 3 anti-ischemic medications should be prioritized for early intervention.     

Victoria conference highlights differences in federal, provincial stands on health care issues

When Canada's health ministers met in Victoria recently, the number of issues debated were yet another sign of the many problems facing Canada's health care system. There were dis-agreements about the use of facility fees by private clinics, and concern about the huge impact federal cuts to transfer payments are going to have on provincial governments. British Columbia, for instance, faces 1996 federal cuts totalling $375 million — 5.8% of the province's health care budget. As well, ministers debated the merits of a report discussing alternatives to the fee-for-service method of paying physicians. Dr. Jack Armstrong, the president, said the CMA does not favour one particular remuneration system over another, but feels strongly that doctors should have the right to choose the system they want.     

Outcome of rationing access to open-heart surgery: effect of the wait for elective surgery on patient outcome.

OBJECTIVE: To assess the effect of the waiting period before elective open-heart surgery on patient outcomes. DESIGN: Retrospective analysis. SETTING: The Montreal Heart Institute, a referral centre in cardiology and cardiac surgery. PATIENTS: All 568 patients who underwent open-heart surgery on an elective basis or following urgent admission or interhospital transfer between October 1991 and February 1992. MAIN OUTCOME MEASURES: In-hospital death rate, incidence of postoperative complications, length of stay in the intensive care unit (ICU) and total length of hospital stay. RESULTS: A total of 206 patients (151 men and 55 women with an average age of 59.0 [standard error of the mean (SEM) 1] years) underwent elective surgery, and 362 patients (264 men and 98 women with an average age of 62.0 [SEM 1] years) underwent urgent surgery. The mean wait for elective surgery was 2.8 (SEM 0.2) months. There was no significant difference between the two groups in the in-hospital death rate (4% v. 4%), the average length of stay in the ICU (4.4 [SEM 0.2] days v. 5.8 [SEM 1] days) or the average total length of hospital stay (9.0 [SEM 0.4] days v. 9.1 [SEM 1] days). As would be expected, postoperative complications developed in significantly more patients in the urgent group (27%) than the elective group (18%) (p = 0.02). Eight patients were admitted on an urgent basis for surgery owing to worsening symptoms or acute myocardial infarction after a mean wait of 4.6 months. One patient died suddenly at home 1 month after medical investigation while awaiting repeat coronary artery bypass grafting. Among the 206 patients who underwent elective surgery there was no relation between waiting time and adverse clinical outcomes after surgery. CONCLUSIONS: The results suggest that the wait before elective open-heart surgery had no effect on patient outcome after surgery in our institution. A policy of a short waiting period before elective open-heart surgery for patients whose condition is stable is safe and acceptable only if rapid access to medical and surgical treatment is available should it become necessary.