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PREDICTING CRITICAL CARE NEEDS DURING A PANDEMIC
GILLIAN ANDERSON AND FRANCES SNEDDON
NHS LANARKSHIRE IS THE THIRD LARGEST HEALTH BOARD IN SCOTLAND, serving a population of 655,000 across rural and urban communities in Lanarkshire. Its 12,000-strong team of staff work in communities, health centres, clinics and offices in the region and at three district general hospitals.
When COVID-19 emerged, it posed huge questions for healthcare organisations globally. How much capacity would be needed to care for those who became infected? Would there be enough ventilators and
other equipment to care for patients appropriately? And so much more.
At NHS Lanarkshire, advice from both UK and Scottish governments had suggested that the major NHS Trusts (in England and Wales) and Health Boards (in Scotland) prepare for the worst-case scenario of a fivefold increase in demand for critical care in the Spring 2020 peak of the COVID-19 pandemic. This left NHS Lanarkshire with the challenge of trying to predict, at very short notice, the critical care resources they would actually require over the coming weeks and months.
SIMULATION TO PREDICT CRITICAL CARE NEEDS Time was of the essence for decisionmaking and preparations required for the potential demand surges. Working in close collaboration with NHS Lanarkshire, the University of Strathclyde Business School health systems experts used Simul8 modelling software to predict critical care needs at the start of the COVID-19 pandemic.
NHS Lanarkshire was able to reshape centrally produced forecasts and make informed and accurate decisions based on local circumstances. This was done by creating a digital simulation that accurately replicated the expected flow of COVID-19 patients through the critical care department, using sophisticated modelling software from Simul8. Contrary to earlier government advice, the model highlighted that the Health Board had already made sufficient additions to its capacity to be able to manage the projected surge in critical care needs brought on by the pandemic. This meant the costly adaptations to resourcing needs that would have otherwise been wasteful were avoided, as well as providing front line staff and capacity planners with peace of mind.
Dr Nicola Irvine, consultant physician, doctoral researcher and one of the team leads in this successful collaboration: ‘Once the executive team at Lanarkshire had set their key question – which was what will be your critical care need and do we currently have the resource and the capability to meet that? – the fact that we were able to give them the answer within two weeks, and roughly seven to ten days before the COVID-19 peak started, was vital in helping them manage this pandemic’. CREATING THE SIMULATION Simul8 digital simulation software was used to create the model for this advanced new planning approach. ‘As its name suggests’, said Chandrava Sinha from the Department of Management Science at the University of Strathclyde, who worked with Nicola Irvine and Gillian Anderson in building the simulation model, ‘digital models are approximate representations of any real-life system. They are basically mathematical or statistical models created using a computer which tries to best mimic and present a real life scenario or a proposed scenario, and to then answer various “what if” questions to help decision-makers make a very well informed decision’.
A crucial element of the modelling process for NHS Lanarkshire was the use of data that the team were able to build into the simulation. To cut through any conflicting evidence and to make the model as accurate to local needs as possible the team drew on a range of data sets. This included very localised community data, such as population profiling, as well as national trends that were being received from central government. It also included wider international data from countries such as Italy and Spain where the pandemic wave was a few weeks ahead. This approach allowed the team to create a model that was as accurate as possible to local needs.
Chandrava added: ‘This data all fed into the model and then gave us the maximum utilisation of beds across all different categories on a week-by-week basis for the whole first wave of the
pandemic’.
COLLABORATING FOR SUCCESS Dr Irvine emphasises the need for a ‘triumvirate of executive expertise, clinical expertise and modelling expertise’ in building and implementing a successful model such as this one.
The clinician understands the behaviours of the organisation at floor level; the modeller is able to interpret that nuanced dynamic environment and to simplify and abstract data into a model that can be usefully predictive; and an executive team will have the overview needed to ask the
© Pordee_Aomboon/Shutterstock
most pertinent questions, and then the authority to act on the predictions of the model.
We were able to constantly update our simulation using data from the local hospitals and authorities, as well as from wider resources such as the intensive care audit and information from the European Centre for Disease Control
‘Validation is also a key part of any modelling process’, says Dr Irvine. ‘You want to make sure that you’ve captured the process that you are modelling, the environment, the disease, the activity etc. Crucial to this was the daily information that we were receiving from the hospital’s management team. We were able to constantly update our simulation using data from the local hospitals and authorities, as well as from wider resources such as the intensive care audit and information from
the European Centre for Disease Control’.
IDENTIFYING THE WIDER IMPACT In modelling for COVID-related planning, the research team realised that it was not just critical care that would be affected by the pandemic, but other areas of healthcare services would see knock-on effects too. ‘We were aware that other patients with emergency medical problems were presenting in smaller volumes’, said Dr Irvine, ‘but the turnaround time for testing the number of people who were presenting with suspected COVID – two days – was causing bottlenecks in the emergency department. This had potential to disrupt emergency care and other areas of urgent care, such in acute medical units’.
Further insights were also generated via the model in predicting that even while cases in the community were reducing, there were also some potential issues about infection being transmitted within the hospital that would need mitigating as well. the turnaround time for testing the number of people who were presenting with suspected COVID – two days – was causing bottlenecks in the emergency department
Dr Irvine: ‘Simul8 modelling meant that we could say “here is the likely impact from COVID-19, but your other inpatient resources are predicted to be impacted too and you need to have a plan in place for this”’.
WIDER ADOPTION OF SIMULATION The University of Strathclyde research team is led by Professor Robert Van Der Meer and includes Dr Nicola Irvine, Gillian Anderson, Chandrava Sinha and Holly McCabe as healthcare modelling specialists. The success of the Simul8 model in assisting NHS Lanarkshire at the beginning of the pandemic means that Holly and Gillian are now developing the model to support the development of an Early Warning System for the next stage in the COVID-19 pandemic.
Professor Van Der Meer said: ‘The Strathclyde model really demonstrates the value of simulation for critical decision-making. The approach provides evidence for those factors that are unknown and does so by generating an extremely localised picture of the situation. It is from here that you can make confident decisions where the risk has been mitigated significantly’.
‘We are grateful for the fantastic working relationship that our team has developed with NHS Lanarkshire, which really has been pivotal in the success of this initial project. Together
we are now looking ahead at further applications of our simulation tool to support the Health Board. This includes the next possible peak and how to manage resources under the added pressures during the winter months’.
As for wider applications, Dr Irvine is now a strong advocate for the use of digital simulation not just in critical care but throughout health services. ‘To be honest, I struggle to think of any applications in healthcare where simulation modelling wouldn’t be useful’, she said.As a clinician, these models allow you to create a virtual, experimental laboratory where you can see the patient, staffing and efficiency outcomes when testing different systems. To deliver this as a real-life trial would be cumbersome and it would take a long time, which would receive a lot of opposition. To instead be able to deliver the trial in a virtual environment and get a very clear picture of the outcomes without the associated risk or costs makes it a lot easier to achieve buy-in, and this makes digital simulation truly invaluable.
Gillian Anderson is a Research Associate at Strathclyde University who has been supporting health related modelling with the Scottish Government Modernising Patient Pathways Programme since 2014. She has led several projects and was responsible for driving the use of DES in the NHS in Scotland as part of a Whole Systems Patient Flow approach to care.
Frances Sneddon is the CTO of Simul8 Corporation. With over 20 years ORMS experience, her mission is to create simulation software that is so intuitive, fast and effective that anyone can use it to make critical decisions and deliver serious impact across their organisation. Born and raised in North Lanarkshire, Frances took particular interest in this project and was delighted Simul8 could help her local area.
OPERATIONAL RESEARCH IN A TIME OF CRISIS
Nicola Morrill
TO WRITE ABOUT THE IMPACT that Operational Research (O.R.) can have, does have and could have…… where to start? Perhaps at the beginning. O.R. as a term was originally used in Britain during World War II to refer to scientific research done to integrate new radar technologies into Royal Air Force tactics. The term expanded to include the provision of support to military officers in developing and planning combat operations. It is a discipline that has grown out of providing support in times of crisis and is well versed in supporting emergency response. It also has a key role to play in supporting medium- and long-term planning.
SO, WHAT EXACTLY IS O.R.? The million-dollar question! Formally, it is defined as a scientific approach to the solution of problems in the management of complex systems, which enables decisionmakers to make better decisions.
It is about real-world applications, supporting improved decision-making. A lifelong learning discipline, if that is possible. The O.R. toolset and its links with other disciplines have evolved over time and continue to do so. This is primarily in response to the changing nature of challenges; more complex, dynamic and interconnected. The current COVID-19 situation and climate change are prime examples of this.
So, what is O.R. again? The definition has proved difficult to pin down. I like to focus on what it can achieve, how it can help, rather than the specific tools it uses. A mix of science and art used to help ‘clients’ see the wood from the trees.
If you have a knotty issue, chances are O.R. can help you in some way.
QUESTIONS O.R. CAN HELP ANSWER, ILLUSTRATED THROUGH ITS SUPPORT TO COVID-19 CHALLENGES To give you a flavour of the nature of some of the questions O.R. can help with, it feels apt, given the origins of O.R. and the current global situation, to share some examples of how O.R. is helping with challenges presented by COVID-19.
This is by no means exhaustive and was identified via an Internet search. Here are some of the areas, in the open domain, where O.R. has and is providing support:
What is the best way to reorganise dialysis companies and reduce disruption to 650 sufferers receiving treatment at The Wessex Kidney Centre? (see https://bit. ly/DialysisServices) How many ICU beds and surge capacity will be needed to meet demand as case numbers rise? (see https://bit. ly/ICUSimul8) What areas of the UK are most vulnerable to the effects of COVID-19? (see https://bit.ly/vulnerabilityindex) What potential resourcing requirements may be needed to meet incoming demand and continue to provide high-quality end-of-life care? (see https://bit.ly/endoflifecaremodelling) What is the demand for an independent food bank likely to be? How do we best meet that demand? (see https://bit.ly/Foodbanksbays) How can the local authority maximise the involvement of their new volunteer workforce? (see https://bit. ly/Covidvolunteers) What is the impact on patient experience of a combination of specific nursing innovations? (‘COVID-NURSE’) (see https://bit.ly/Covidnursingcare) What might the mental health effects of COVID-19 be? (see https://bit.ly/ORSupportingNHS) Should Yale limit the number of people gathering for events and, if so, what would constitute a safe size? (see https://bit.ly/EDKaplan) What are the public behaviours and attitudes related to COVID-19? (see https://www.scrubcovid19.org/) What is my supply chain exposure? What shortages should I anticipate? What are my resource requirements? (see https://bit.ly/AMMSSupplyChain)
This is just a snapshot of the support being provided by O.R. experts covering operational to strategic; across business, government, charity, international development; and immediate and near term in outlook.
MAP OF UK TO SHOW POSTULATED VULNERABILITY AREAS (https://github.com/britishredcrosssociety/covid19-vulnerability)
O.R. also has a role to play with strategic decisionmaking and, in particular, exploring and de-risking the longer-term future.
Over time, when it is appropriate to do so, there will be much more, I am sure, that O.R. will be able to say about how it contributed to the current situation and a richer set of questions O.R. helped with will emerge. There are special issues of the Journal of the Operational Research Society and the European Journal of Operational Research aimed at doing just this.
WHO DOES O.R.? I believe what binds those engaged in doing O.R. is a collective enjoyment of ‘solving’ puzzles, tricks and messes. Noting that not all challenges can actually be solved! Coupled with the positive impact that O.R. can make; the practical, real-world help.
We are found in large companies, Small-Medium Enterprises, one-person companies, universities, central government, local government, charities. Slightly unhelpfully, often not with the title ‘O.R.’!
Typically, we have a quantitative background, though some ‘specialise’ into more qualitative areas of O.R., such as problem structuring.
WHO USES O.R.? Admittedly I am slightly biased here, but all organisations, no matter their size, will have a question that O.R. can help with. If you’re not using it, you should be!
So, what challenge do you have that O.R. could help with? If you are a decision-maker within an organisation, what questions about your medium and long term might you need support with? Do you need help defining the question you need help with?
WANT TO LEARN MORE? This is the first ‘column’ from me in Impact. My background is O.R. and while undertaking general management roles I was struck by how this really helped me. I am keen to broaden awareness of the use of O.R. within such roles – it is such a powerful discipline – and I’d like to use this ‘column’ to do just that.
If you have a particular challenge and you wonder how O.R. has or could help let me know. If you are an academic or practitioner and think there is a bit of O.R. that would benefit from having a light shone on it, let me know. I’ll use your thoughts for inspiration for the next ‘column’.
In the meantime, I’ll leave you with a quote I like from Russ Ackoff: ‘Managers are not confronted with problems that are independent of each other, but with dynamic situations that consist of complex systems of changing problems that interact with each other. I call such situations messes. Problems are extracted from messes by analysis. Managers do not solve problems, they manage messes’.
Thanks for reading and see you in the next issue!
Nicola Morrill is a Systems Thinking Consultant at Dstl, a certified coach and the current Diversity Champion of the O.R. Society. She writes in a private capacity - all views expressed are her own and all examples are available in the open domain. You can contact her on Nicola.impact@gmail.com.
