Suggestions to prevent collapsing and deaths?

[Zenstrive]

The last three insurances give quests that seems to be impossible to crack. You basically need to keep everyone alive, which is frustating.

Does anyone have suggestions on how to prevent deaths? I have made like 400+ staffed hospitals with amples ICUs and HDUs and hospitalizations, running in red, and still have deaths occuring.

So what's the general consensus of preventing deaths? Tons of TC and emergency staffs?

[vonMoo]

It is possible to decrease collapse frequency and avoid all/most deaths. The key is to optimise design and use player control for critical patients. Sometimes events send a huge number of the most critical cases at the wrong time, which can be problematic though. Here are some ideas.


Hospital design suggestions

These are mainly about ensuring rapid movement of critical patients between key rooms.

Have a single cluster of several CT rooms, maybe 2 with space for a 3rd, that are dedicated to hospitalised patients. These should ideally have a short path to the TC and the ICU. CT is the single most important diagnostic that can't be done in the TC or ICU for critical patients.

To obtain short paths I use a single central elevator. The TC, ICU, labs and radiology for hospitalised patients are all fairly close to the elevator, but can be spaced across many floors. So I then put all the radiology rooms for clinic patients in one place with a single waiting room.

I place nurses stations between the rooms/wards they are serving and the elevator.

Angiography rooms for hospitalised patients should ideally be on the same floor as the cardiology wards, with a short path to the TC and ICU as mentioned above. And check the queues for angiography for clinic patients, cardio clinic patients can be quite prone to nasty collapses if they have to wait for too long. Have enough cardiography rooms within the cardio department too, and consider some dedicated to clinic patients and some to hospital patients.


Staffing, ambulances and beds

The TC can be quite staff intensive if you are running many ambulances with events, and will similarly need many beds. I would recommend not running more than 3 ambulances unless you need to for objectives or you just really want to. With 3 ambulances running I might have 4 or 5 doctors dedicated to the TC for the day shift, and 3 at night. Have a separate doctor or two dedicated to observation patients so that your trauma docs are ready to go. It's also helpful to have a common room near to the emergency department on call room and nurses stations. There should be a surplus of nurses and stretchers and dedicating most to transport and a few to stabilisation really helps. Patients might have to wait for a CT room to free up, but shouldn't have to wait for a transport nurse apart from in exceptional circumstances.

TC and ICU doctors should be anaesthesiologists wherever possible, they have a flat bonus to their chance of saving a patient suffering a life threatening collapse.

Having enough capacity in the TC for ambulances, collapses in the clinic and events can be tough. 1 bed for each ambulance is a good starting point, plus extras for the other collapses. You might get a huge influx of patients for some event, on top of a bunch of collapses from dehydration etc. in the clinic. In a large hospital with 3 working ambulances and 4 insurance companies I might have 12 TC beds, obviously planning for this from the start and adding them as needed. I can use this extra capacity when the TC is quiet to warehouse less serious ambulance cases if the relevant department lacks beds (patients with diagnoses like methanol poisoning, spleen contusions, etc. can all be fully treated in the TC and held there under player control until they are sent home).

Having enough clinic capacity also helps, having clinic patients collapse because they've been waiting all day really strains the system. I have enough offices to have cleared out the normal morning rush in emergency by 1400 to 1500, so that patients arriving after that will be seen immediately. This also helps during events, of course.

In a busy hospital you may need 3 ICU doctors. Again, these should be anaesthesiologists if possible, and dedicated to working in the ICU; if you want to roll with anaesthesiologists for surgery working out of the ICU department, keep these separate and dedicated to their own jobs). The nursing situation is similar to the TC, but you will probably end up needing a few less. For the way I use ICU, which I write about below, I find I need between 12 to 16 beds; again I build these up over time.


Surgical facilities and staff

With all departments open and 4 insurance companies it's probably necessary to have 2 ORs and 2 full teams for GS, cardio, neuro and traumatology, day and night. Earlier in the game with only one specialised department it might be necessary to have more teams and ORs; if a hospital has 50 patients going to specialist departments then with one department open they will all go there, with 2 departments, each will receive 25, etc. Running with more ambulance will also increase surgical demand. Some neuro trauma cases need surgery within 2 to 4 hours, cardio and traumatology are similar, so having some excess capacity is essential to avoid deaths.

Have dedicated surgical teams. The surgeons should only be assigned to the surgery role, the assistant to assist at surgery, the anaesthesiologists to the surgical role, the two surgical nurses to their surgical role. Have enough nurses and stretchers so the team and OR aren't left waiting for patient transfer. Consider dedicated on-call rooms and nurses stations for these staff near to the ORs, with small common rooms and rest rooms nearby.

If you find that you have too much surgical capacity in one department as you open new departments, it's easy to fix. It's possible to transfer surgical staff to other departments. Resetting their department specific skill may or may not even be necessary, I haven't tested this but I reset it anyway. The thing that's important are the surgical specific skills. And since ORs are shared rooms it's not necessary to transfer ownership by rezoning them, although I do this as well. This works best if you can put all ORs on one floor, with small dedicated on call rooms, nurses stations, common rooms and rest rooms for each department (I put the ICU department on this floor too).


Using player control to get critical cases what they need in a timely fashion

One major reason why the sickest ambulance patients die is that the TC sends them to the relevant HDU as soon as there's a firm diagnosis. This often misses hidden critical symptoms that rapidly lead to life threatening collapses. Another issue is that these patients will often collapse if sent to a normal departmental HDU, as departments are busy and these patients can't be treated as quickly as they need to be. They then end up having more time wasted by being transferred to ICU. This problem is easy to fix though, by transferring the most critical cases directly from the TC to ICU.

The aim here is to diagnose and treat as many dangerous high hazard symptoms before the patient goes to surgery, and to ensure really ill go straight to ICU, where they would most likely end up anyway, and bypass the departmental HDU.

Be aware of the range of hidden high hazard symptoms that a patient might have, and how to diagnose them. You can use the link in this steam guide to find an easy to use reference, I highly recommend it as it's up to date, easy to use and comprehensive:

https://steamcommunity.com/sharedfiles/filedetails/?id=2078560014

Here's the direct link to the guide:

https://encyclopediaofdiagnoses.wordpress.com/

You can use the possible diagnoses window on the patient card too, and it is useful for getting an overview, but the guide above is good for finding alternative diagnostic methods. So for example, using the patient card you might see that a cardio case could have a dangerous hidden symptom (such as irregular heartbeat) that's detected by ECG, but the guide shows that it can also be detected by heart monitoring which can be done at the bedside in the TC or ICU.

The guide also shows collapse times for high hazard symptoms, and what they collapse to. Knowing these is powerful; if you don't run a CT to rule out skull fracture in the penetrating head trauma case it will cause them to collapse within 2 to 4 hours.


Here's what I do with ambulance arrivals:

1) Set them to player control when the ambulance arrives. They can't be transferred anywhere then,

2) Queue any treatments that can be performed in the TC for high hazard symptoms that are already detected.

3) Look at the possible diagnoses. If the diagnosis isn't already firm then usually a physical exam can narrow things down. Make use of exams such as blood pressure monitoring, heart monitoring, FAST, urgent echo, etc. wherever relevant; these can be done in the TC and can allow high hazard symptoms to be found and often directly treated.

4) You might by now know that you have a firm diagnosis with all the high hazard stuff discovered and treated and will be fine going to the relevant department (contusions, poisonings, etc). Or the patient might need a simple operation for a high hazard symptom that's not so critical, most of the general surgery and orthopaedic cases fit here. In which case it's usually best to set the patient back to AI control and let the game transfer and treat them. Similarly you may have narrowed the diagnosis to a small range of similar, less dangerous conditions, such as a range of leg fractures. Again, here it's best to let the AI handle things.

5) But if the diagnosis is still unknown and potentially very dangerous, or there may still be hidden dangerous high hazard symptoms then keep control of the patient. Consider if it's worth immediately transferring the patient to ICU; for example if the TC is very busy and you know this patient has some very serious symptoms then it might be worth the transfer.

6) Even with a diagnosis, you'll need to run further procedures to find any bad high hazard symptoms. Neurology cases such as traumatic brain injury, and some traumatology and cardio cases are the usual suspects here. What you want to prevent is the patient going to surgery if you haven't ruled out another hidden symptom that will cause collapse in an hour or two. Many traumatology cases and some neuro cases can have multiple high hazard symptoms that can lead quickly to collapse and death and also require different sugeries. It's best to find all of these, or rule them out, before going to the OR because surgeries on critical patients are usually performed back to back, without the patient leaving the room. This saves lives as no time is wasted transferring back and forth from OR. I've written in detail about this for neuro cases in this thread:

https://steamcommunity.com/app/868360/discussions/0/2789369598126994431/

If a patient needs multiple surgeries for serious symptoms, or needs surgery for a symptom that can cause collapse within a few hours, it's always best to send them straight from the TC to ICU. ICU do a better job of managing collapses than departments (if the doctors are anaesthesiologists, are less busy so can get diagnostics and treatments done quickly, and are very effective at prioritising their patients fore life saving surgery.

7) If you've now got a patient in ICU with all serious high hazard symptoms discovered or ruled out, then it's best to release control back to the AI, but consider keeping their card open for monitoring,


Avoiding inappropriate ICU admissions

If a patient collapses with a known diagnosis they get automatically transferred to ICU. This is usually appropriate, but you may not want the diagnosed case of bacterial gastroenteritis who collapses in the waiting room to be transferred to ICU for rehydration and antibiotics. By setting them to player control and un-selecting their diagnosis, you can cause the patient to go to the TC instead, where you can queue the treatments. Preventing ICU staff from transporting, stabilising, diagnosing and treating non-critical cases saves their time for the patients who have just collapsed from heart failure or those who need 3 operations.


Consider micromanaging wards and HDUs at night

Due to the way patient distribution works, with only one or two department open the wards get very busy. Then at night the AI doctors like to run many tests to look for hidden symptoms that may not be necessary, for example searching for symptoms that are already ruled out or those that are not important to find. This tends to make treatments and necessary diagnostics take much longer, and transfer to surgery is impacted. It's especially bad when it delays patients who are waiting for post surgical exams to detect complications. Consider clicking through ward patients at night and cancelling unneeded diagnostics; for exampl the patient doesn't need a blood pressure test if it was already performed in the clinic, and they don't need an X-ray if the symptom it would discover is already implied by the diagnosis. This becomes much less necessary as you open more departments.

[cybercat_cyberdog]

Oftenly, they died because an untreated symptom, usually it'is a hidden one. Change precision for diagnoses and check your patients on critical condition. They must not have hidden symptom at all.

[Galadral]

"Have a single cluster of several CT rooms, maybe 2 with space for a 3rd, that are dedicated to hospitalised patients."

Nice solution! But how can I dedicate CTs only to hospitalised patients? I wish, I could :-)

[vonMoo]

Galadral eredeti hozzászólása:

"Have a single cluster of several CT rooms, maybe 2 with space for a 3rd, that are dedicated to hospitalised patients."

Nice solution! But how can I dedicate CTs only to hospitalised patients? I wish, I could :-)

This is done on the staff card. In the bottom left corner of the radiologist's card there are some check boxes for clinic and hospitalised patients. Uncheck clinic patients and you're good to go.

[Galadral]

Brilliant! Thanks a lot.