Along with the aging of the population, eye diseases have increased by 15% to 34% in Germany over the last 15 years (1, 2). As the result, the number of patients seeking ophthalmology emergency care has risen. In the absence of sufficient capacity expansion, this causes a longer duration of consultations (including waiting time) in university hospital outpatient departments. To provide adequate care to a large number of patients, process optimization is vital. We therefore assessed the time spent by outpatients in the Department of Ophthalmology at the Medical Center—University of Freiburg and identified potential opportunities for improvement.
Acknowledgments
Translated from the original German by Ralf Thoene, MD.
Footnotes
Conflict of interest statement
The authors declare no conflict of interest.
Methods
After receiving a positive opinion of the ethics committee (No. 21–1710-retro), an exploratory approach was used to retrieve all timestamps from electronic medical records in an anonymized manner. Timestamps were placed in the patient management system either manually by staff or automatically upon completion of an examination, depending on the ward/examination. Data points from 34 859 patient visits between 1 January 2018 and 31 December 2019 were extracted from selected outpatient clinics (table 1) and unscheduled visits. Outpatient surgical procedures as well as specialty and private consultations were not included, because they did not use digital timestamps and thus could not be analyzed. Over the study period, a total of 108 200 outpatient clinic visits occurred and 36 491 outpatient surgical procedures were performed.
Table 1. Overview of median time to eye test, time to first physician contact, and median duration of consultations in the outpatient clinics with more than 1000 patient visits during the period studied.
| Clinic | n |
Median time
to eye test [min] IQR) |
Median time
to first physician contact [min] IQR) |
Median
duration [min] (IQR) |
Number of
examinations (IQR) |
| Unscheduled visits | 19 133 | 34 (19–74) | 100 (61–158) | 122 (46–208) | 5 (3–6) |
| Cornea and conjunctiva | 3198 | 40 (28–57) | 114 (77–155) | 174 (135–227) | 9 (8–10) |
| Glaucoma | 2253 | 31 (23–42) | 142 (105–183) | 192 (148–241) | 11 (10–12) |
| Eyelid | 1962 | 32 (22–44) | 101 (69–147) | 170 (123–227) | 8 (7–9) |
| Retina | 6255 | 29 (19–43) | 92 (65–131) | 158 (108–224) | 9 (9–10) |
IQR denotes the interquartile range. Not shown are the uveitis clinic, the general clinic, the inpatient cataract clinic, and the Descemet Membrane Endothelial Keratoplasty (DMEK) clinic (2058 patient visits in total). The examinations include both equipment-based and non-equipment-based examination steps.
The start of the appointment, registration, start and end of all examination steps, and check-out were recorded. Examinations included eye test, tonometry, optical coherence tomography, corneal topography, and perimetry. Other data collected included the number of examinations, the type of outpatient clinic, the day of the week, the time of day, the age and sex of the patients, and the staffing (number of physicians and healthcare professionals) at the time of the visit. Multiple linear regression analysis was used to examine the influence of these latter factors on duration of consultations. For this purpose, estimates were calculated In addition, we determined the median and interquartile range of time between registration and eye test, registration and first physician contact, and the median duration of consultations at the outpatient clinic.
Results
A total of 34 859 patient visits were analyzed (52% female; median patient age, 63 years; interquartile range, 46–76). The median time between registration and eye test was 33 minutes (interquartile range, 20–55), and the median time between registration and first physician contact was 102 minutes (interquartile range, 67–150). The median duration of consultations was 149 minutes (interquartile range, 81–220; details [Table 1]).
Early arrival, morning appointments, a high number of examinations, a high number of patient visits on the day of the visit, utilization of unscheduled consultations, and appointments on Tuesday (compared to Monday) were all associated with a longer duration of consultations (table 2). Higher medical staffing levels, late afternoon and evening visits, and Thursdays, as well as the outpatient clinics “Descemet Membrane Endothelial Keratoplasty (DMEK),” ”Uveitis,” “Glaucoma,” “Retina,” and “Cornea and Conjunctiva” all resulted in significantly shorter durations. Age and sex had no influence on the duration of consultations.
Table 2. Presentation of a selection of important factors influencing the duration of consultations at the outpatient clinic.
| Factors |
Estimate [min]
(Standard error) |
| Unscheduled visits | 24.00 (4.50) |
| Number of examinations | 22.58 (0.35) |
|
Visit in the morning 8 am to 10 am 10 am to 12 pm |
37.84 (1.73) 44.38 (1.87) |
| Early arrival | 0.10 (0.02) |
|
Visit in the afternoon and evening
2 pm to 4 pm 4 pm to 9 pm |
–45.67 (2.73) –39.94 (3.35) |
| Number of medical staff | –0.60 (0.28) |
Higher scores make a longer duration of consultation more likely.
Monday (day of the week), midnight to 8 am (time of day) and the general clinic (clinics) were chosen as references. This is a selection of factors. For outpatient clinics that were associated with shorter duration of consultations and an assessment of the influence of the days of the week, please refer to the text. Late arrival, age, sex, number of physicians, presentation on a Wednesday or Friday, and visit to the inpatient cataract or eyelid clinic had no relevant impact. The p-value for the factor “number of medical staff” is 0.035, and the p-value for the remaining factors presented in the table is <0.001.
Discussion
In our analysis, patients who arrived too early stayed longer at the outpatient clinic. Our findings confirm study results from Saudi-Arabia and the United States (3, 4). For this reason, patients should not be asked to arrive much earlier. Arriving too early prolongs the time when patients are only waiting and no examinations are performed due to the fact that the examination capacities are usually still occupied by the previous patients. In the same way, if examination capacities are limited both in terms of space and number of staff, it seems logical that on days with particularly high numbers of patient visits, the duration of consultations will be longer for the individual patient.
The longer duration on Tuesdays could be related to the fact that many patients with uveitic symptoms are referred unscheduled on this day of the week. These patients require additional time compared to less complex conditions and thus may have led to a longer duration of consultations.
Furthermore, an increased number of examinations also resulted in a long consultation duration. Thus, in the future appointments should be scheduled in such a way that staffing levels are sufficiently high when a large number of examinations is expected, because the more medical staff worked at the time of the appointments, the shorter the duration of consultations was. Thus, staffing levels adjusted to patient load could reduce the duration of consultations. By contrast, limited space and equipment resources translate into a cap on maximum patient capacity. Staffing should be kept dynamically adapted over the course of the day to what is appropriate, taking into account all available resources. The fact that the duration of consultations is shorter after noon, when there are fewer appointments overall, could also be the result of a lower patient load in the presence of with higher staffing levels.
Utilization of unscheduled appointments is associated with a longer duration of consultations compared to scheduled appointments, a finding that can be explained by the less predictable patient flow. In the case of unscheduled appointments, there is rather a risk of not having adequate staff resources available. Unscheduled patients in particular, whose treatment is considered less urgent, may have to wait significantly longer.
Our findings point to numerous opportunities to reduce the duration of consultations. The scheduling of appointments needs to be aligned with the projected duration of consultations. Another approach would be to make a longer duration of consultations more acceptable by providing information about the expected waiting time. (5). In conclusion, staggering of appointments according to the number of examinations and permanent optimization of staffing levels at peak times should be implemented to improve patient flow.
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