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Operations Throughput As a Determinant of Golden-Hour in Mass-Gathering Medicine

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Operations Throughput As a Determinant of Golden-Hour in Mass-Gathering Medicine International Journal of Medicine and Medical Research 2017, Volume 3, Issue 1, p. 53–59 copyright © 2017, TSMU, All Rights Reserved DOI 10.11603/IJMMR.2413-6077.2017.1.7804 OPERATIONS THROUGHPUT AS A DETERMINANT OF GOLDEN-HOUR IN MASS-GATHERING MEDICINE I. D. Khan1, B. Asima2, S. A. Khan2 ARMY COLLEGE OF MEDICAL SCIENCES AND BASE HOSPITAL, NEW DELHI, INDIA1 RESIDENT NUCLEAR MEDICINE, ARMY HOSPITAL RESEARCH AND REFERRAL, NEW DELHI, INDIA2 Background. Golden-hour, a time-tested concept for trauma-care, involves a systems approach encompassing healthcare, logistics, geographical, environmental and temporal variables. Golden-hour paradigm in mass- gathering-medicine such as the Hajj-pilgrimage entwines along healthcare availability, accessibility, efficiency and interoperability; expanding from the patient-centric to public-health centric approach. The realm of mass- gathering-medicine invokes an opportunity for incorporating operations-throughput as a determinant of golden- hour for overall capacity-building and interoperability. Methods. Golden-hour was evaluated during the Indian-Medical-Mission operations for Hajj-2016; which established, operated and coordinated a strategic network of round-the-clock medical operations. Throughput was evaluated as deliverables/time, against established Standard-Operating-Procedures for various clinical, investigation, drug-dispensing and patient-transfer algorithms. Patient encounter-time, waiting-time, turnaround- time were assessed throughout echeloned healthcare under a patient-centric healthcare-delivery model. Dynamic evaluation was carried out to cater for variation and heterogeneity. Results. Massive surge of 394 013 patients comprising 225 103 males (57.1%) and 168 910 females (42.9%) overwhelmed the throughput capacities of outpatient attendance, pharmacy, laboratory, imaging, ambulance, referrals and documentation. There was a delay in attendance, suspicion, diagnosis and isolation of patients with communicable infections. The situational-analysis of operations-throughput highlights wasted turnaround-time due to mobilization of medical-team, diverting critical healthcare resources away from emergency situations. Conclusions. Time being a crucial factor in the complexity of medical-care, operations-throughput remains an important determinant towards interoperability of bottlenecks, thereby being a determinant of golden-hour in mass-gathering-medicine. Early transportation of a patient to definitive-care reduces treatment initiation-time, notwithstanding logistics of communication, evacuation, terrain and weather being deterministic in outcome. Golden-hour needs to be emphasized under a population-based approach targeting the clientele towards administering first-aid and reaching out to hospital within the golden-hour. KEy wORDS: golden-hour; operations throughput; mass-gathering medicine; turnaround-time; definitive-care; population-based approach. Introduction trauma, environment, occupation, lifestyle, Golden-hour, a hitherto time-tested concept substance-abuse and disasters [1, 2]. Hajj pil- for trauma-care, has been found useful across grimage is a 5-day outdoor unbounded peace- the entire ambit of emergency health-systems. ful mass-gathering involving a moving assem- Golden-hour involves a systems approach blage of over 3.5 million pilgrims from 200 encompassing healthcare, logistics, geogra- countries, engaged in prayers, supplications phical, environmental and temporal variables. and strenuous rituals in densities of 9 people/ Mass-Gathering-Medicine applies to situa- m2 or more, in harsh desert climate of Saudi- tions where a mass-gathering overwhelms Arabia. Mass-Gathering-Medicine at Hajj is accessibility, interoperability and public-safety challenged by issues of healthcare availability, response to medical-emergencies. Mass-Gath- accessibility, infection control, rapid-diagnosis, ering-Medicine involves higher rates of morbid- on-site treatment, referral, evacuation, and ity and mortality attributable to infections, response to disasters and public-health emer- Corresponding author: Inam Danish Khan gencies [3, 4]. Clinical Microbiology and Infectious Diseases, Army College of The realm of Mass-Gathering-Medicine in- Medical Sciences and Base Hospital, New Delhi 110010, India vokes an opportunity for incorporating opera- Phone number: +91 9836569777 tions-throughput as a determinant of golden- E-mail: [email protected] AND EPIDEMIOLOGY PUBLIC HEALTH ISSN 2413-6077. IJMMR 2017 Vol. 3 Issue 1 I. D. Khan et al. 53 hour for overall capacity-building and interop- waiting time due to resource limitations attrib- erability. This prospective study explored the utable to health-system, while excluding wait- perspective of golden-hour across the spec- ing-time attributable to patient or otherwise trum of Mass-Gathering-Medicine. such as delayed reporting, traffic-conditions and post-attendance time for decisions or Methods other personal reasons. Turnaround-time was The perspective of golden-hour as a deter- defined as time taken to complete a task incor- minant of operations-throughput was evalu- porating both operation and waiting-time, as ated during the Indian Medical Mission opera- applicable. Communication-time/reporting- tions for Hajj-2016, which established, operated time/accessibility-time or patient-rescue time and coordinated a strategic network of round- was defined as time taken for health-intelli- the-clock medical operations in Mecca, Medina gence to reach the doctor. Visit-time was de- and Jeddah during Hajj-2016 pilgrimage from fined as time taken for visit by medical team to 01 Aug to 30 Oct 2016. The mission framework reach the patient through ambulance/foot. comprised of (a) Mobile medical task-forces Doctor-patient interaction on-site was defined detailed for strategic mass-gathering locations as time taken for elicitation of relevant history such as mosques, religious places, bus-stops, and administration of first-aid, if any. The train-stations and along the pilgrimage assem- turnaround-time for healthcare personnel was blage during the five critical days of hajj, to compared between site visits and that with cater for 5000-100000 pilgrims per congrega- patient being brought to healthcare facility. tion. (b) 18 Static-clinics having basic first-aid health emergency was defined as any condition capabilities catered for 6000-9000 pilgrims/ threatening the life or limb of a patient. Initia- clinic residing in over 400 buildings in Mecca tion of definitive-care was the end/start point and Medina (c) One mobile referral tent-clinic of defining upstream (pre-hospital) and down- with 35 tent-clinics having medical attendance stream (hospital-care) processes, being prior facilities only, catered for 3000-4000 pilgrims in and after respectively. Dynamic evaluation was over 5000 tents in Mina and Arafat, as well as carried out to cater for variation and heteroge- 1,40,000 unsheltered pilgrims in Muzdalifah. (d) neity. Two strategically sited 40-bedded secondary- care referral facilities for critical-care, internal- Results medicine, general and orthopaedic surgery, A total of 394 013 patients comprising 225 gynaecology, paediatrics, psychiatry, dermatol- 103 males (57.1%), and 168 910 females ogy, isolation, lab-medicine and radiology (e) (42.9%) were attended by a team of 144 doc- Tertiary-care patient transfers coordinated with tors including 50 specialists, 146 paramedics 28 Saudi Arabian hospitals. and 74 ancillary staff. The patient distribution Golden-hour as a determinant of operations in mobile medical task-forces, static-clinics and throughput was evaluated across the spectrum tent-clinics was 13473, 374475 and 5135 pa- of Mass-Gathering-Medicine, through evalua- tients. Out of 930 secondary-care and 523 tion of throughput in terms of deliverables/per tertiary-care referrals, 585 and 495 patients unit time, against established Standard-Oper- were institutionalized respectively. Total sec- ating-Procedures for various clinical, investiga- ondary-care bed days were 4626, average bed tion, drug-dispensing, patient-transfer, admin- occupancy being 77.78% for one month istrative and patient-safety algorithms. around Hajj and 32% otherwise. Pooled unad- The average range of patient encounter- justed average length of stay of all patients time, waiting-time, turnaround-time were as- was three days. 1505 minor surgical and 770 sessed throughout various echelons of health- orthopaedic procedures were performed. 7850 care under a patient-centric healthcare delivery laboratory, 2074 imaging and 1159 electrocar- model. Even low-acuity patients were attended diograms were carried out. round-the-clock. Subjective assessment of Massive surge of patients overwhelmed the communication-time, visit-time and doctor- throughput capacities of outpatient attend- patient interaction on-site was done. Encoun- ance, pharmacy, laboratory, imaging, ambu- ter-time was defined as time taken by the lance, referrals and documentation. There was patient for a healthcare operation such as out- delay in attendance, suspicion, diagnosis and patient attendance, investigation, drug-dispen- isolation of patients with communicable infec- sing, minor-procedures and ambulance trans- tions. Average encounter-time, waiting-time fers. waiting-time was defined as pre-operation and operation turnaround-time for patients, PUBLIC HEALTH AND EPIDEMIOLOGY PUBLIC HEALTH 54 I. D. Khan et al. ISSN 2413-6077. IJMMR 2017 Vol. 3 Issue 1 procedures, investigations and ambulance Discussion operations is
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