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Patient flow management in biological events: a scoping review

BMC Health Services Research volume 24, Article number: 1177 (2024) Cite this article

Abstract

Introduction

Biological Events affect large populations depending on transmission potential and propagation. A recent example of a biological event spreading globally is the COVID-19 pandemic, which has had severe effects on the economy, society, and even politics,in addition to its broad occurrence and fatalities.

The aim of this scoping review was to look into patient flow management techniques and approaches used globally in biological incidents.

Methods

The current investigation was conducted based on PRISMA-ScR: Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. All articles released until March 31, 2023, about research question were examined, regardless of the year of publication. The authors searched in databases including Scopus, Web of Science, PubMed, Google scholar search engine, Grey Literature and did hand searching. Papers with lack of the required information and all non-English language publications including those with only English abstracts were excluded. Data extraction checklist has been developed Based on the consensus of authors.the content of the papers based on data extraction, analyzed using content analysis.

Results

A total of 19,231 articles were retrieved in this study and after screening, 36 articles were eventually entered for final analysis. Eighty-four subcategories were identified,To facilitate more precise analysis and understanding, factors were categorised into seven categories: patient flow simulation models, risk communication management, integrated ICT system establishment, collaborative interdisciplinary and intersectoral approach, systematic patient management, promotion of health information technology models, modification of triage strategies, and optimal resource and capacity management.

Conclusion

Patient flow management during biological Events plays a crucial role in maintaining the performance of the healthcare system. When public health-threatening biological incidents occur, due to the high number of patients, it is essential to implement a holistic,and integrated approach from rapid identification to treatment and discharge of patients.

Peer Review reports

Introduction

Biological hazards are any type of incident in which one or more biological agents, such as viruses, bacteria, parasites, fungi, toxins, etc., cause harm to humans, animals, plants and the environment [1]. These agents have significant adverse effects on the economy, society,and even politics. They can infect a vast population and cause fatalities and diseases, depending on their capacity for transmission and proliferation [2,3,4]. Epidemics of deadly infectious diseases are increasing worldwide [4, 5]. In 2009, according to the estimations, the Hämagglutinin Neuraminidase (H1N1) pandemic caused about 150,000 to 580,000 deaths. Between the years 2002–2003, approximately 8,000 people died as a result of the Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV2), which spread to more than 30 nations on five continents [6, 7]. Middle East Respiratory Syndrome Coronavirus (MERS-CoV) was another infectious epidemic discovered in the Middle East in 2012 [6, 7] with a more than 30% mortality rate [7]. The Ebola pandemic is still a public health emergency with international significance. It emerged in Guinea in December 2013, causing 28,616 cases and more than 11,300 deaths, and ended in June 2016. This outbreak has been described as the deadliest recorded Ebola outbreak in history [8, 9].

On December 31, 2019, the spread of viral pneumonia was reported in Wuhan, China, which was caused by a new and genetically modified variant of the coronavirus family SARS-CoV2, named COVID-19 disease [10]. According to the World Health Organization (WHO), as of December 31, 2023, approximately 773,449,299 cases were confirmed and nearly 6,991,842 reported deaths worldwide [11], making it clear once again that the magnitude of the biological threat to human society is more evident than ever before.

In the event of a biological disaster, hospitals and the health system are crucial institutions that manage, treat, and care for the impacted population. The state of the healthcare system’s preparedness is crucial in this regard [12]. Managing affected people following epidemics is very difficult. It requires performing a complex and coordinated set of tasks, including implementing a holistic and integrated approach of rapid identification of the infected people locally, real-time monitoring, patient flow management, infection prevention and control services [13], etc. The lack of understanding of how to manage the flow of patients in the COVID-19 pandemic—despite experiences from previous incidents—has caused a great deal of harm to people and health organizations [14]. As COVID-19 spreads and the number of afflicted individuals rises, healthcare systems globally are collapsing [15]. Even in nations previously commended for meeting the gold standard for preparedness, the COVID-19 pandemic revealed severe deficiencies in the public health system [16, 17]. It led to extensive inequalities, uncontrolled costs, unsatisfactory quality of health services, restricted access to services, and marginalization of public health in the United States [14]. These shed light on the current state of global health disability and how to address the urgent and systemic problems brought on by biological occurrences [18].

Traditional healthcare systems’ approaches to disaster planning and prevention emphasised ingrained issues such poor patient management, a severe lack of personal protective equipment, difficulty identifying viral outbreaks in advance, and health care personnel’ fatigue [15].

On the other hand, the risk management of biological incidents is a national priority of societies. It has been recognized as part of the Sendai Framework and has been considered globally under international health regulations [19]. Therefore, it is essential to comprehend the procedure for controlling patient flow in biological occurrences that pose a signicant risk to public health and safety. The term “patient flow” describes how patients travel through healthcare institutions. The procedure includes providing patients with the medical attention, tangible resources, and internal mechanisms required to manage them from admission to release, guaranteeing their return to their homes and communities while upholding the standard of care. Both the cost of the therapy and its quality are factors that affect patient satisfaction [20, 21]. The impacted society and healthcare systems may bear a heavy financial, social, and psychological cost due to these catastrophes. To control and respond appropriately to the epidemics caused by biological factors, identifying strategies for patient management in Biological Emergencies and disasters in the world in current conditions and similar situations in the future is very important.

Thus, the purpose of this study was to find patterns and strategies for patient management against biological events as well as to examine patient flow management techniques in biological events methodically.

Methods

To learn more about patient flow management techniques and their models and strategies in biological events, a comprehensive scoping review was carried out. The review procedure was monitored and results were reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. This review was conducted based on Arksey and O’Malley’s scoping review methodology [22], This Framework conducted in five stages: 1) specify the research question, 2) identify relevant literature, 3) select studies, 4) map out the data, 5) summarize, synthesize, and for reporting the results. used the PRISMA2020 flowchart to show how to reach the final number of articles.

Eligibility criteria

The works on biological events management OR patient flow in biological events that were released until the end of March 2023 in English-language journals were the main subject of this review. Additionally, papers that satisfied the following requirements were considered for examination. (1). Articles with keywords and subjects about controlling patient flow during Epidemics and pandemics following biological events and also regional biological events. published in English; (3) published through March 2023; (4) full-text articles in English; and (5) Survey, assess and analyze or evaluate related papers analysis of biological events (epidemics, pandemics, infectious diseases, CBRN incidents, and emerging and re-emerging communicable diseases, as well as patient management) and (6) Any primary research articles, including randomized controlled trials, quasi-experimental studies, cohort studies, case–control studies, cross-sectional studies, case reports, qualitative studies and descriptive studies were eligible and all related documents which has been released with trustable organizations, such as WHO, CDC and Ministry of Health of Iran’s policies.

Among the exclusion standards were Research that only included an abstract in English and the article’s full text is written in a language other than English, Articles that examined deliberate biological incidents, such as bioterrorists, as well as those that dealt with management and policy-making regarding the entire epidemic were disqualified from the analysis.

Information sources and search

A search was conducted using using Scopus, Web of Science, PubMed databases, and Google Scholar search engine.Authors searched Grey Literature and did hand searching in valid websites, CDC, WHO and Ministry of Health of Iran’s policies. The search entered studies up to the end of March 2023. The search terms were utilized “Biological”, “CBRN”, “Biohazard Release,” “Mass Casualty Incidents”, “Pandemics,” “Epidemics,” “Communicable Disease,” “Outbreak,” “Disaster,” “Emergencies,” “Accidental Release”, “Infectious Diseases”, “Emerging Communicable Diseases”, “Emerging Infectious Disease”, “Reemerging Communicable Disease”, “Disease Outbreak”, “COVID-19”, “SARS-CoV-2”,“Ebola”, “SARS”,“MERS” “patient flow”, “patient management”, “Patient care management”. The National Library of Medicine’s MeSH (Medical Subject Headings) was utilized to derive synonyms for these keywords. The method used keyword combinations and Boolean operators based on the restricted text choices available in each database. For further research, references from pertinent excluded publications and included papers were reviewed. For instance, (Table 1) provides the complete PubMed,Scopus, WOS and google scholar search strategy.

Table 1 Electronic search strategy in Pub Med, Scopus, WOS and google scholar
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Selection of sources of evidence

Z.H. and M.S., two impartial reviewers, evaluated abstracts and titles to determine their eligibility. Complete copies of the article were retrieved, and both reviewers considered it eligible when they thought the abstract or title may be helpful. By engaging in these activities, we were able to preserve the study’s rigor and locate the most pertinent publications. Arbitration was used to resolve differences in opinion on relevance.

Data charting process

Duplicate titles were removed from the search results when loaded into the Mendeley program. A selection of papers was sent for abstract reading and subsequently cross-referenced with the inclusion criteria. Out of these, the most pertinent papers were chosen for independent full-text reading by two researchers (Z. H., SH.A.), an epidemiologist (M.S.), and an expert who confirmed the results (H. R. Kh) and (M.F). Studies were excluded for a variety of reasons such as the paper’s themes were not related about patient flow management, were not analysed biological events, Full text were irrelevance, Outcome was not patient flow /lack of the required information and Language was not E/N where the researchers couldn’t agree, a third researcher’s opinion was sought. In an iterative approach, the two reviewers plotted the data independently, talked about the findings, and updated the data charting form regularly.

Data items

Data on the first author, publication date, kind of biological event, study paradigm, study design/methodology/methods, sample size, and key outcomes were extracted from the selected papers using a checklist. The research team developed a comprehensive checklist that included items covering all aspects of the manuscript, such as the title, abstract, introduction, methods, results, and discussion, Based on the research question and the consensus among the authors, a draft checklist was created to record key information from each source. The authors evaluated 3–5 papers to find the most important components about data extraction’s theme. This information included details like the author, reference, and findings relevant to the review questions. The authors selected specific data points, such as the first author, year of publication, origin or country of the study, population and sample size (if applicable), methodology, type of biological event, outcomes, and key findings related to the scoping review questions. all contents of papers has been analyzed using content analysis. Once this form has been completed, the findings reviewed, summarised, and eventually reported.

Synthesis of results

In this study, the Graneheim & Lundman content analysis approach was utilised to analyse the data following data extraction from identified publications [23]. In summary, the principal investigator) evaluated the discussion, conclusion, and results sections multiple times after choosing the final articles. Subsequently, In the second step, the text was divided into semantic units that were summarized and shortened. the primary codes were retrieved from the parts that contained words, terminology, and phrases used to define or explain the concept’s features. These sections were classified as semantic units. Subcategories and primary categories were recovered in the next stage by comparing and classifying these codes. the codes that indicated a single topic were placed in a same category and finally main categories and sub categories were formed, And if the data does not match to the concepts, a new concept was generated.

Results

Selection of sources of evidence

The goal of this study was to comprehensively examine patient flow management techniques during biological events, spot trends, and develop patient management plans in the case of a biological event. in the first search using the keywords23297 articles found. All of the found articles were then added to the Mendeley database. for evaluation after duplicate articles were eliminated 19,231 articles were included. then 18,293 articles were eliminated from the study after it was determined from the titles and abstracts that they did not match the inclusion requirements. In total 938 papers were chosen for full-text review After examining the complete texts, the remaining 902 articles were disregarded from the final analysis because of topic disproportion. Eventually, the references were examined and 36 articles were entered into the final analysis (Fig. 1).

Fig. 1
figure 1

PRISMA flow diagram of the literature search and study selection process

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Characteristics of sources of evidence

Table 2 displays the data associated with the evaluated studies according to the type of biological event, study paradigm, study design, sample size, primary outcomes, and first author and publication date (Table 2).

Table 2 General Characteristics of the studied articles that were eligible for the review
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Synthesis of results

Among the 36 selected articles, 31 studies investigated the management of the patients flow and infected cases in the COVID-19 pandemic and the focus of the rest of the five articles was on managing patients in other biological events such as MERS, influenza, measles, Infectious disease.

Of the total studies presented’ seven studies (19.4%) were conducted in the United States (Fig. 2). In terms of publication year, 33% of articles were published in 2022. 50% of the articles employed quantitative paradigm, 33.3% qualitative paradigm and 16.7% were conducted by using Mixed Method.

Fig. 2
figure 2

Distribution of studies by country names

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A Graneheim and Landman conceptual data analysis approach (2003) was used to analyse the texts of all 36 collected articles qualitatively. Based on the articles’ findings, elements influencing patient flow management in biological accidents were determined. Eighty-four main categories and subcategories were determined by combining pertinent studies. To facilitate a more thorough examination and comprehension, the elements have been divided into seven groups:

Patient flow simulation models, risk communication management, integrated ICT system establishment, promotion of health information technology models, modification of triage strategies, optimal resource and capacity management, and systematic patient management are some examples of collaborative, interdisciplinary, and intersectoral approaches. The parameters that were categorized and taken from literature about patient flow management in biological incidents are displayed in Table 3.

Table 3 Categories and subcategories of patient flow management in biological events based on thematic analysis
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Systematic management of patients

Workers in the health care system are typically the first to diagnose and respond to an outbreak; therefore, emergency department (ED) workers may receive the most common indications of a new and highly infectious disease. Failure to detect index cases and delay in managing an outbreak can pose a global health risk [60] and put the health workers at risk. Thus, in three areas of primary care, hospital, and community level, the following measures are recommended. The COVID-19 pandemic has brought attention to the significance of a holistic and integrated approach, real-time monitoring, and active patient flow [13].

At the primary care system

An Outbreak of infectious diseases is a global security threat [61]. in this regard, for systematic management of the patients, the following steps are recommended: early identification of the threat [30, 55], intelligent screening [35], monitoring patients [49], visiting patients and strengthening home health care to determine the severity of the disease [35, 55] Public–Private Sector participation in quarantine [49]. rapid laboratory diagnosis [13, 33, 49], launching outpatient testing centers [58] and isolation of suspected and infected patients [33].

In regards to hospitality

Using MEWS [42], – Higher EWS scores predict a greater chance of a medical crisis and the need for quicker and more intensive care interventions; lower EWS scores indicate a decreased likelihood of such interventions. Examples of high-risk patients include those who require active patient flow management [13], capable command systems [53], timely monitoring [13], prompt treatment [33, 35], and the establishment of mobile outpatient clinics [48].

The interdisciplinary and intersectoral joint approaches

At the community level

Activation of intermediate care facilities and convalescence centers for hospitalization of patients with mild symptoms [24, 35, 50, 51], follow-up after discharge [35], and not leaving the patient after returning to home and community.

Interdisciplinary and intersectoral joint approach

It can be classified into: revising clinical and multidisciplinary approaches and inter-organizational cooperation and coordination.

Revision of clinical and interdisciplinary approaches

Sustainable intersectoral and interdisciplinary collaboration is beneficial the creation of a new clinical approach and the reorganization of clinical and operational processes [27]. With close interdisciplinary and intersectoral approaches [26, 59] and the development of multidisciplinary teams [30], it is possible to provide practical context for patient flow, resource management and improved communication culture and to manage patient flow and adapt to the challenges of new day-to-day care [58].

Inter-organizational coordination

In emergency management, coordination between medical staff, hospital and inter-hospital units, and local services is essential. The necessity of encouraging multispecialty and multidisciplinary integration is highlighted by the scheduling of regular problem-solving meetings, establishing emergency management plans or routine practice procedures for staff, and strengthening healthcare professionals in emergencies situations [45].

Employing patient flow simulation systems and models

Using simulation and predictive models, a dynamic understanding of patient flow is necessary to enhance the overall performance of hospitals.

Simulation models

Simulation is the best tool for identifying and allocating the necessary capacity to satisfy demand quickly and minimize delays to get this understanding. Furthermore, compared to most conventional statistical techniques, simulation is a workable substitute [25] that requires more time and money [62]. Generally speaking, the two primary goals of simulation models employed in several studies to examine healthcare delivery systems are (a) improving patient conditions in various wards and (b) allocating money to enhance services. Improving patient outcomes and reducing waiting times are the first goals of optimising patient hospitalisation. The second goal is to make efficient use of resources and figure out how much human and physical resources are needed to deliver high-quality care.

Predictive models

Predicting future trends and difficulties and making necessary preparations, particularly at the administrative and command levels, are crucial for the second phase [63]. Proposing suitable policies can be aided by developing several models and precise scenarios for forecasting future infections. By accounting for the number of nurses, doctors, beds, and other resources, anticipating the number of people who may contract an infection in the future might aid in estimating the strain on the healthcare system and making appropriate plans to avoid overload [21, 29]. As a result, agent-based modelling and other computer modelling and simulation can be helpful [28, 64,65,66,67].

Additionally, these models can be used to assess scenarios, interventions, operational hazards, and the cost-effectiveness of policies [28]. In this way, by anticipating the maximum and minimum number of beds required, an AI model assisted in managing patients in the emergency room during the COVID-19 epidemic. Additionally, it has aided in placing non-COVID-19 and suspected COVID-19 patients on the quick and conventional ED routes. According to the study’s findings, AI models can be a vital resource in helping to reduce resource loss and streamline ED operations [38].

Risk communications management

Responding to biological occurrences and the elements that lead to public health emergencies requires effective risk communication management [68]. It is regarded as essential to guaranteeing a thorough, open, and prompt flow of data and support to hospitals. In fact, prompt action and mitigation of catastrophic effects of disasters aid individuals in making wise decisions and building resilience [69].

Risk communication operations management

Promoting a communication culture [59], providing transparent information [55], and disclosing necessary real-time information [49].

Promotion of information systems

The use of ICT platforms [49] has been introduced as one of the influential factors in the management of structured risk communication.

Promoting health information technology models

Telehealth technologies are crucial in monitoring social distancing, decreasing human contact, and delaying the spread of viruses. They are perfect for managing communicable diseases. Through telemedicine-equipped booths, telehealth technologies provide remote care and evaluation [70].

Data and information management

The development of an integrated information technology system [13] can help to manage the flow of information and data [13, 55].

Providing telemedicine prerequisites

Expanding technology infrastructure [47] provides the possibility for identification and diagnosis of patients and suspicious people through online triage and virtual outpatient clinics. It is also possible to provide care to patients through equipped telemedicine [41] and telegarage [47] in medical centers. For non-infected people who have other diseases and need medical and hospital services, it is also possible to provide required daily care [71]. Providing physical space, technology infrastructure, equipment and workflow of employees are critical to operating the remote care system [47]. Furthermore, the use of telemedicine equipped booths for patients before entering triage as a screening process facilitates the flow of patients. It leads to rapid orientation of patients and reduced emergency burden [41].

Triage strategy modification

Dealing with an epidemic and biological incident is difficult for medical staff and emergency department specialists.

Creating special triage centers

Triage at the emergency room’s parking lot [37], mobile triage in cars [36], and triage tents [37], among other locations, is an essential tactic to lower the incidence among other inpatients and medical personnel. SARS-Cov2 patients were hard to diagnose during the COVID-19 pandemic because of the symptoms’ lack of specificity and ability to be confused with other bacterial or viral diseases. In addition, because no obvious risk indicators for transmission had been found in the early waves of the COVID-19 pandemic, determining the risk of contracting the virus grew increasingly challenging as the epidemic spread. Triage and working in particular areas outside of the classical emergency rooms allows the patient to be directed to the appropriate hospital unit, without the risk of spreading contamination to other non-infectious hospital areas [34].

Triage revision

A new two-tier triage center outside the hospital with two distinct zones—one for assessing suspected COVID-19 patients and the other for non-suspected patients—was established as one of the reforms that helped improve triage strategy during the COVID-19 pandemic [24, 34].

Optimal management of capacities and resources

Hospital emergency rooms (EDs) become the focus of healthcare personnel after mass casualties due to disasters or emergencies, and they rarely need to function above their intended capacity. Hospitals may lose the quality and safety of patient treatment during emergencies and disasters due to the large influx of patients, congestion, increased ED admissions, disruption of care flow, and inadequate resources. This is the results from inadequate preparation to boost patient care capacity, quality, and safety during emergencies and disasters [72].

A thorough explanation of capacity enhancement reads as follows: “the ability to acquire adequate staff, equipment, structures, and systems to provide adequate care to meet urgent needs following an influx of patients following a large-scale accident or disaster.” A hospital’s four areas of improvement are its staff or human resources, equipment and supplies, structure or physical space, and systems that include integrated management policies and processes [72].

Policies and processes

Preventive approaches [44], maintaining a holistic and integrated approach [13] from the time of identification to discharge and the use of innovative processes [41] during screening and triage led to improvements in the classical operational and clinical processes. Furthermore, cancellation of outpatient visits [26, 53], cancellation of elective surgeries [26, 54], classification of required resources [31, 32], simplification of discharge process of low-risk patients [25, 40, 53], reduction of hospitalization duration [33, 42, 47] in biological incidents have been useful in active management of patient flow.

Employees

Increasing staff or human resources is one of the most crucial components of the plan for expanding capacity. The kind of services each employee offers and the significance of realising their part in handling such situations are directly tied to how willing they are to respond to such instances. Transportation issues, the obligation of employees to care for others, ignorance of the risks involved or their part in responding to pandemics, and employees’ fear of infecting themselves or their families are some of the obstacles that prevent workers from taking part in pandemic response activities [68, 73, 74].

It has been recommended to provide mental health services for employees [57], reduce occupational burnout [57], train employees [26, 48], train specialised and skilled personnel [26, 43] and provide flexible work schedules [39, 46]. Additionally, it has been suggested to give incentives to effective employees [57], timely monitor their performance [13], train other disciplines [26] and utilise the potential of retired personnel [26].

Supplies and equipment

According to the reviewed studies, creating a safe working environment [26, 46], adequate and standard personal protective equipment [26, 48], timely infection control measures [39] and [13], have been introduced as the effective factors on the improvement of patient flow management.

Spaces

Reshaping the emergency department [26, 40, 48], adding graded waiting rooms [29, 52], adding treatment rooms [26, 29], setting up bed management dispatch [24, 40, 56], logistic restructuring, standardization of spaces [48],conversion of empty spaces into sections [47, 54], additional CT scan space in emergency room [26], addition of isolation rooms and special beds [13, 33, 56], hospital reconstruction [26] and standardization of hospital spaces based on the principles of modern hospital engineering are essential factors about optimal resource management.

Discussion

Based on the analysis of the selected articles, factors affecting patient flow management in biological incidents were identified. From the combination of relevant studies, eighty-four categories and primary sub-categories were extracted. For more detailed analysis and understanding, factors were classified into seven categories: systematic management of the affected patients, interdisciplinary and intersectoral joint approach, patient flow simulation models, risk communication management, establishment of integrated ICT system, promotion of health information technology models, triage strategy modification and optimal management of resources and capacities.

When patients arrive at the emergency department (ED) and cannot be admitted right away for a various reasons, such as a hospital bed shortage, poor patient flow is particularly noticeable [75]. Overcrowding in the ED can have negatively affect on patient satisfaction, critical intervention delays, and patient care delays [20, 76,77,78].

But in many cases, particularly in biological incidents, there is inadequate management of hospital beds, which leads to a delay in discharge and, ultimately, the release of hospital beds [25]. Poor patient flow has been linked to significant consequences during viral infection episodes, such as the coronavirus pandemic [79] and seasonal flu [80]. Thus, one of the most critical aspects of patient management in biological incidents typically linked to large numbers of victims—is the prediction and enhancement of patient flow.

Numerous investigations have been carried out about patient flow patterns and their handling in biological crises, particularly following the COVID-19 pandemic that caused medical facilities to fail in the majority of the world’s nations. This called for the conduct of numerous researches on patient flow and management in hospital EDs, which constituted the initial care-giving bottleneck for COVID-19 patients. In addition, several studies on infectious diseases like influenza, measles, and SARS have been conducted. Medical centers’ emergency departments (EDs) must continue to function as they will continue to be the first to respond to pandemics and other public health emergencies.

Reflecting these problems on the large biological incidents of the COVID-19 pandemic is an opportunity to identify ways to change policy, culture, and systems transformation to improve preparedness in the face of future public health emergencies [81].

Due to an abrupt or gradual inflow of patients, biological events can present difficulties for health centers and the healthcare system, as medical professionals must continue to operate and oversee day-to-day operations in their facilities. However, by efficiently and creatively planning ahead, some of the effects of such catastrophes may be mitigated. The research findings suggest that, in addition to education, the following measures should be considered: increasing resources, demand management, and lean thinking [82]. Corrective strategies include systematic patient management, an interdisciplinary and intersectoral approach, patient flow simulation models, risk communication management, the establishment of an integrated information and communication technology system, the promotion of health information technology models, the modification of triage strategies, and the optimal use of resources and capacities. The patient’s flow should be simplified as a process and the path of identification, transfer, acceptance, hospitalization in intensive care units and finally discharging and returning the patient to the community should be clear. Inter-sectoral and external coordination should be facilitated so that when it is necessary to review operational and clinical processes, this can be achieved through interdisciplinary cooperation.

Maximizing the care zone for critical patients can be achieved through creating an alternative care center for the patient, creating flexible plans that can accommodate essential care, and increasing adaptability to transform non-emergency units to emergency care zones to increase capacity [27, 82].

Besides the strategies as mentioned above, strategies, introduction and use of simulation models and machine learning prediction systems can have a statistically significant effect on improving the overall flow of patients [21, 28] This can be attained by presenting different patient flow scenarios and simulation models based on therapeutic spaces and disease type.

During the exceptional COVID-19 outbreak, standards and information were constantly evolving. Under these circumstances, effective and appropriate risk communication should be the main focus. This is especially noticeable during pandemics with high infection rates, serious consequences, little access to treatment, and a sharp increase in the number of cases. Poor risk communication and a lack of awareness of the risk might result in hoarding behavior, which can cause a shortage of medications and personal protective equipment. Maintaining a consistent media presence and using social media and other channels is one possible strategy to guarantee effective risk communication. Involving all parties involved, including community members, in biological occurrences is another crucial step [83].

Telemedicine became widely recognized as a vital tool during the COVID-19 pandemic, helping to enhance patient monitoring, prevent disease outbreaks, identify and treat sick individuals promptly, and, most critically, guarantee ongoing care for frail patients with underlying and chronic illnesses. Even though telemedicine was quite successful during COVID-19 and was adopted more widely in many nations, there were still large gaps in the field. Before telemedicine is widely used, the following important challenges must be resolved: (1) to effectively regulate telemedicine, health care operators must be authorised, patient privacy must be protected, and appropriate policies must be established. Additionally, practical guidelines for the routine clinical use of telemedicine in various contexts must be established and disseminated. Third, telemedicine integration with traditional healthcare services must be increased. Fourth, healthcare professionals and patients must be made more aware of and willing to use telemedicine. Finally, inequalities caused by technological, infrastructure, and economic barriers must be overcome. In the near future, remote patient management will be a vital tool for healthcare systems globally, enhancing both patient care and quality [84] if all these prerequisites are fulfilled.

The capacity of the emergency department automatically doubles when it is located next to other hospital units, when waiting rooms are added, and when the emergency department’s capacity is increased. Alternative care facilities, albeit with distinct access and departure doors, can be thought of nearby the EDs to maximize their capacity during these occurrences.

Additional suggestions made for improving capacity in healthcare facilities include the following: 1) creating cohort and dedicated intensive care units for patients who have experienced similar biological incidents; 2) developing suitable procedures for pre triage, diagnosis, and isolation of suspected and confirmed cases of the disease; and 3) providing training to all employees on how to operate in the dedicated intensive care unit, how to use personal protective equipment, and how to manage patients. to work on all the principles of capacity enhancement, including space definition, supply provision, personnel recruitment, and temporary training of specialized protocols for complete isolation of spaces, staff, and patients to manage resources at the time of biological incidents, hospitals also needed to collaborate across multidisciplinary and intersectoral domains [85]. Healthcare professionals and hospital administrators must participate on multiple levels and in numerous disciplines in order to reconstruct the entire hospital emergency department admissions process and focus all efforts on achieving a single objective. Daily updates and discussions may be necessary for routine processes and procedures.

Strengths and limitations

Broad search and systematic investigation on patient flow management, which is one of the main challenges of the health sector in the face of biological events.

the exclusion of non-English literature may result in the omission of relevant literature, that caused a shortage of resources available during the scoping review and We did not investigate the social and cultural conditions affecting the health system in the management of patient flow in biological events.

Conclusions

The performance of the health care system is crucially dependent on patient flow management during biological incidents, as demonstrated by this review study. Even in a pandemic, health treatment needs to be prompt, effective, safe, and focused on the patient’s needs. Managing the flow of patients is difficult when health centers are overcrowded, particularly during epidemics and pandemics. identifying influencing factors of patient flow special in Biological Events, could help healthcare providers to understand and construct targeted interventions. Our review found that patient flow management in biological events is influenced by patient flow simulation models, risk communication management, integrated ICT system establishment, collaborative interdisciplinary and intersectoral approach, systematic patient management, promotion of health information technology models, modification of triage strategies, and optimal resource and capacity management.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Data availability

Data will be provided in supplementary files (physical file from the output of Mendeley software).

Abbreviations

ICT:

Information and Communication Technology

CBRN:

Chemical, Biological, Radiological, Nuclear

CDC:

Centers for Disease Control

MERS:

Middle East Respiratory Syndrome

SARS:

Severe Acute Respiratory Syndrome

H1N1:

Hämagglutinin Neuraminidase

WHO:

World Health Organization

MEWS:

Modified Early Warning Score

ED:

Emergency Department

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Acknowledgements

The authors would like to thank Health in Emergency and Disaster Research Center personnel of University of Social Welfare and Rehabilitation Sciences for their support in the literature search process.

Patient and public involvement

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Article Summary

Subheading: Patient Flow Management in Biological Events.

Broad search strategy developed after a preliminary search of the current evidence base and Investigation the management of affected people and patient flow in Biological Events.

Not considering patient flow management in intentional biological incidents such as bioterrorism.

The researcher had limited or lack of access to the full text of some of the articles related to the subject that caused a shortage of resources available during the systematic review.

Funding

The authors have not declared a specific grant for this research from any funding.

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Authors and Affiliations

  1. Health in Emergency and Disaster Research Center, Social Health Research Institute, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

    Zoya Hadinejad, Mehrdad Farrokhi, Mohammad Saatchi, Shokoufeh Ahmadi & Hamidreza Khankeh

  2. Department of Biostatistics and Epidemiology, University of Social Welfare and Rehabilitation Science, Tehran, Iran

    Mohammad Saatchi

  3. QUEST Center for Responsible Research, Berlin Institute of Health at Charité, Berlin, Germany

    Hamidreza Khankeh

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  1. Zoya Hadinejad
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  2. Mehrdad Farrokhi
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  3. Mohammad Saatchi
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  4. Shokoufeh Ahmadi
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  5. Hamidreza Khankeh
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Contributions

Conceptualisation, data collection, analysis, writing of the manuscript; (Z.H) and (SH.A), confirming analysis, writing of the manuscript;(M.S). conceptualisation, data collection, analysis, writing and editing of the manuscript and revisions the results (H. R. Kh) and (M.F). All authors read and approved the final manuscript.

Corresponding author

Correspondence to Hamidreza Khankeh.

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Hadinejad, Z., Farrokhi, M., Saatchi, M. et al. Patient flow management in biological events: a scoping review. BMC Health Serv Res 24, 1177 (2024). https://doi.org/10.1186/s12913-024-11502-1

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BMC Health Services Research

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