Discrete-event Simulation and Optimization to Improve the Performance of a Healthcare System

Thesis (Ph.D.)--University of Washington, 2016-08

A university extension course in leprosy: telemedicine in the Amazon for primary healthcare

There is a high prevalence of leprosy in the Amazon region of Brazil. We have developed a distance education course in leprosy for training staff of the Family Health Teams (FHTs). The course was made available through a web portal. Tele-educational resources were mediated by professors and coordinators, and included the use of theoretical content available through the web, discussion lists, Internet chat, activity diaries, 3-D video animations (Virtual Human on Leprosy), classes in video streaming and case simulation. Sixty-five FHT staff members were enrolled. All of them completed the course and 47 participants received a certificate at the end of the course. At the end of the course, 48 course-evaluation questionnaires were answered. A total of 47 participants (98%) considered the course as excellent. The results demonstrate the feasibility of an interactive, tele-education model as an educational resource for staff in isolated regions. Improvements in diagnostic skills should increase diagnostic suspicion of leprosy and may contribute to early detection.

Impact of sensor nodes scaling and velocity on handover mechanisms for healthcare wireless sensor networks with mobility support

Health promotion in hospital environments can be improved using the most recent information and communication technologies. The Internet connectivity to small sensor nodes carried by patients allows remote access to their bio-signals. To promote these features the healthcare wireless sensor networks (HWSN) are used. In these networks mobility support is a key issue in order to keep patients under realtime monitoring even when they move around. To keep sensors connected to the network, they should change their access points of attachment when patients move to a new coverage area along an infirmary. This process, called handover, is responsible for continuous network connectivity to the sensors. This paper presents a detailed performance evaluation study considering three handover mechanisms for healthcare scenarios (Hand4MAC, RSSI-based, and Backbone-based). The study was performed by simulation using several scenarios with different number of sensors and different moving velocities of sensor nodes. The results show that Hand4MAC is the best solution to guarantee almost continuous connectivity to sensor nodes with less energy consumption.

A cross layer protocol based on mac and routing protocols for healthcare applications using Wireless Sensor Networks

Using Wireless Sensor Networks (WSNs) in healthcare systems has had a lot of attention in recent years. In much of this research tasks like sensor data processing, health states decision making and emergency message sending are done by a remote server. Many patients with lots of sensor data consume a great deal of communication resources, bring a burden to the remote server and delay the decision time and notification time. A healthcare application for elderly people using WSN has been simulated in this paper. A WSN designed for the proposed healthcare application needs efficient MAC and routing protocols to provide a guarantee for the reliability of the data delivered from the patients to the medical centre. Based on these requirements, A cross layer based on the modified versions of APTEEN and GinMAC has been designed and implemented, with new features, such as a mobility module and routes discovery algorithms have been added. Simulation results show that the proposed cross layer based protocol can conserve energy for nodes and provide the required performance such as life time of the network, delay and reliability for the proposed healthcare application.

MAC protocols and mobility management module for healthcare applications using Wireless Sensor Networks

Using Wireless Sensor Networks (WSNs) in healthcare systems has had a lot of attention in recent years. In much of this research tasks like sensor data processing, health states decision making and emergency message sending are done by a remote server. Many patients with lots of sensor data consume a great deal of communication resources, bring a burden to the remote server and delay the decision time and notification time. A healthcare application for elderly people using WSN has been simulated in this paper. A WSN designed for the proposed healthcare application needs efficient Medium Access Control (MAC) and routing protocols to provide a guarantee for the reliability of the data delivered from the patients to the medical centre. Based on these requirements, the GinMAC protocol including a mobility module has been chosen, to provide the required performance such as reliability for data delivery and energy saving. Simulation results show that this modification to GinMAC can offer the required performance for the proposed healthcare application.

MAC protocols and mobility management module for healthcare applications using wireless sensor networks

Using Wireless Sensor Networks (WSNs) in healthcare systems has had a lot of attention in recent years. In much of this research tasks like sensor data processing, health states decision making and emergency message sending are done by a remote server. Many patients with lots of sensor data consume a great deal of communication resources, bring a burden to the remote server and delay the decision time and notification time. A healthcare application for elderly people using WSN has been simulated in this paper. A WSN designed for the proposed healthcare application needs efficient MAC and routing protocols to provide a guarantee for the reliability of the data delivered from the patients to the medical centre. Based on these requirements, the GinMAC protocol including a mobility module has been chosen, to provide the required performance such as reliability for data delivery and energy saving. Simulation results show that this modification to GinMAC can offer the required performance for the proposed healthcare application.

A university extension course in leprosy: telemedicine in the Amazon for primary healthcare

There is a high prevalence of leprosy in the Amazon region of Brazil. We have developed a distance education course in leprosy for training staff of the Family Health Teams (FHTs). The course was made available through a web portal. Tele-educational resources were mediated by professors and coordinators, and included the use of theoretical content available through the web, discussion lists, Internet chat, activity diaries, 3-D video animations (Virtual Human on Leprosy), classes in video streaming and case simulation. Sixty-five FHT staff members were enrolled. All of them completed the course and 47 participants received a certificate at the end of the course. At the end of the course, 48 course-evaluation questionnaires were answered. A total of 47 participants (98%) considered the course as excellent. The results demonstrate the feasibility of an interactive, tele-education model as an educational resource for staff in isolated regions. Improvements in diagnostic skills should increase diagnostic suspicion of leprosy and may contribute to early detection.

Operational research applied to regional healthcare system

In this thesis we focus on optimization and simulation techniques applied to solve strategic, tactical and operational problems rising in the healthcare sector. At first we present three applications to Emilia-Romagna Public Health System (SSR) developed in collaboration with Agenzia Sanitaria e Sociale dell'Emilia-Romagna (ASSR), a regional center for innovation and improvement in health. Agenzia launched a strategic campaign aimed at introducing Operations Research techniques as decision making tools to support technological and organizational innovations. The three applications focus on forecast and fund allocation of medical specialty positions, breast screening program extension and operating theater planning. The case studies exploit the potential of combinatorial optimization, discrete event simulation and system dynamics techniques to solve resource constrained problem arising within Emilia-Romagna territory. We then present an application in collaboration with Dipartimento di Epidemiologia del Lazio that focuses on population demand of service allocation to regional emergency departments. Finally, a simulation-optimization approach, developed in collaboration with INESC TECH center of Porto, to evaluate matching policies for the kidney exchange problem is discussed.

Strategic Emergency department design: An approach to capacity planning in healthcare provision in overcrowded emergency rooms

Healthcare professionals and the public have increasing concerns about the ability of emergency departments to meet current demands. Increased demand for emergency services, mainly caused by a growing number of minor and moderate injuries has reached crisis proportions, especially in the United Kingdom. Numerous efforts have been made to explore the complex causes because it is becoming more and more important to provide adequate healthcare within tight budgets. Optimisation of patient pathways in the emergency department is therefore an important factor. This paper explores the possibilities offered by dynamic simulation tools to improve patient pathways using the emergency department of a busy university teaching hospital in Switzerland as an example.

Learning to manage complexity through simulation: students' challenges and possible strategies

Many have called for medical students to learn how to manage complexity in healthcare. This study examines the nuances of students' challenges in coping with a complex simulation learning activity, using concepts from complexity theory, and suggests strategies to help them better understand and manage complexity.Wearing video glasses, participants took part in a simulation ward-based exercise that incorporated characteristics of complexity. Video footage was used to elicit interviews, which were transcribed. Using complexity theory as a theoretical lens, an iterative approach was taken to identify the challenges that participants faced and possible coping strategies using both interview transcripts and video footage.Students' challenges in coping with clinical complexity included being: a) unprepared for 'diving in', b) caught in an escalating system, c) captured by the patient, and d) unable to assert boundaries of acceptable practice.Many characteristics of complexity can be recreated in a ward-based simulation learning activity, affording learners an embodied and immersive experience of these complexity challenges. Possible strategies for managing complexity themes include: a) taking time to size up the system, b) attuning to what emerges, c) reducing complexity, d) boundary practices, and e) working with uncertainty. This study signals pedagogical opportunities for recognizing and dealing with complexity.

Computer and laboratory simulation in the teaching of neonatal nursing: innovation and impact on learning

Objectives: to evaluate the cognitive learning of nursing students in neonatal clinical evaluation from a blended course with the use of computer and laboratory simulation; to compare the cognitive learning of students in a control and experimental group testing the laboratory simulation; and to assess the extracurricular blended course offered on the clinical assessment of preterm infants, according to the students. Method: a quasi-experimental study with 14 Portuguese students, containing pretest, midterm test and post-test. The technologies offered in the course were serious game e-Baby, instructional software of semiology and semiotechnique, and laboratory simulation. Data collection tools developed for this study were used for the course evaluation and characterization of the students. Nonparametric statistics were used: Mann-Whitney and Wilcoxon. Results: the use of validated digital technologies and laboratory simulation demonstrated a statistically significant difference (p = 0.001) in the learning of the participants. The course was evaluated as very satisfactory for them. The laboratory simulation alone did not represent a significant difference in the learning. Conclusions: the cognitive learning of participants increased significantly. The use of technology can be partly responsible for the course success, showing it to be an important teaching tool for innovation and motivation of learning in healthcare.

Cluster Analysis To Identify Elderly People's Profiles: A Healthcare Strategy Based On Frailty Characteristics.

The new social panorama resulting from aging of the Brazilian population is leading to significant transformations within healthcare. Through the cluster analysis strategy, it was sought to describe the specific care demands of the elderly population, using frailty components. Cross-sectional study based on reviewing medical records, conducted in the geriatric outpatient clinic, Hospital de Clínicas, Universidade Estadual de Campinas (Unicamp). Ninety-eight elderly users of this clinic were evaluated using cluster analysis and instruments for assessing their overall geriatric status and frailty characteristics. The variables that most strongly influenced the formation of clusters were age, functional capacities, cognitive capacity, presence of comorbidities and number of medications used. Three main groups of elderly people could be identified: one with good cognitive and functional performance but with high prevalence of comorbidities (mean age 77.9 years, cognitive impairment in 28.6% and mean of 7.4 comorbidities); a second with more advanced age, greater cognitive impairment and greater dependence (mean age 88.5 years old, cognitive impairment in 84.6% and mean of 7.1 comorbidities); and a third younger group with poor cognitive performance and greater number of comorbidities but functionally independent (mean age 78.5 years old, cognitive impairment in 89.6% and mean of 7.4 comorbidities). These data characterize the profile of this population and can be used as the basis for developing efficient strategies aimed at diminishing functional dependence, poor self-rated health and impaired quality of life.

[lay Agency And Healthcare: Producing Healthcare Maps].

This study aimed to characterize which regulatory logics (other than government regulation) result in healthcare output, using a two-stage qualitative study in two municipalities in the ABCD Paulista region in São Paulo State, Brazil. The first stage included interviews with strategic actors (managers and policymakers) and key health professionals. The second phase collected life histories from 18 individuals with high health-services utilization rates. An analysis of the researchers' involvement in the field allowed a better understanding of the narratives. Four regulatory systems were characterized (governmental, professional, clientelistic, and lay), indicating that regulation is a field in constant dispute, a social production. Users' action produces healthcare maps that reveal the existence of other possible health system arrangements, calling on us to test shared management of healthcare between health teams and users as a promising path to the urgent need to reinvent health.

The Environment Of Professional Practice And Burnout In Nurses In Primary Healthcare.

to assess how nurses perceive autonomy, control over the environment, the professional relationship between nurses and physicians and the organizational support and correlate them with burnout, satisfaction at work, quality of work and the intention to quit work in primary healthcare. cross-sectional and correlation study, using a sample of 198 nurses. The tools used were the Nursing Work Index Revised, Maslach Burnout Inventory and a form to characterize the nurses. To analyze the data, descriptive statistics were applied and Spearman's correlation coefficient was used. the nurses assessed that the environment is partially favorable for: autonomy, professional relationship and organizational support and that the control over this environment is limited. Significant correlations were evidenced between the Nursing Work Index Revised, Maslach Burnout Inventory and the variables: satisfaction at work, quality of care and the intent to quit the job. the nurses' perceptions regarding the environment of practice are correlated with burnout, satisfaction at work, quality of care and the intent to quit the job. This study provides support for the restructuring of work processes in the primary health care environment and for communication among the health service management, human resources and occupational health areas.