Hospital Beds Research Articles

Diagnosing an overcrowded emergency department from its Electronic Health Records

Emergency department overcrowding is a complex problem that persists globally. Data of visits constitute an opportunity to understand its dynamics. However, the gap between the collected information and the real-life clinical processes, and the lack of a whole-system perspective, still constitute a relevant limitation. An analytical pipeline was developed to analyse one-year of production data following the patients that came from the ED (n = 49,938) at Uppsala University Hospital (Uppsala, Sweden) by involving clinical experts in all the steps of the analysis. The key internal issues to the ED were the high volume of generic or non-specific diagnoses from non-urgent visits, and the delayed decision regarding hospital admission caused by several imaging assessments and lack of hospital beds. Furthermore, the external pressure of high frequent re-visits of geriatric, psychiatric, and patients with unspecified diagnoses dramatically contributed to the overcrowding. Our work demonstrates that through analysis of production data of the ED patient flow and participation of clinical experts in the pipeline, it was possible to identify systemic issues and directions for solutions. A critical factor was to take a whole systems perspective, as it opened the scope to the boundary effects of inflow and outflow in the whole healthcare system.

An analysis of order utilization and overall costs secondary to an extended length of stay in hospitalized patients pending discharge to long term care facilities during the peak of Omicron

During the covid pandemic there was an influx of patients admitted to hospitals worldwide. This resulted in a presumptive overuse of resources, increased utilization costs, and decrease in hospital bed availability. This study focuses on patients admitted with a positive covid test, who required transfer to a long-term health facility after the acuity of their symptoms no longer required hospitalization but necessitated an extended length of stay due to acceptance into these facilities. Such facilities included: alternative living facility, skilled nursing facility, psychiatric institutions, or hospice. Wherein these facilities required a negative Covid PCR test or required a certain time frame to have elapsed after a positive test prior to accepting or recovering a patient. This study utilized patient records from Keralty Hospital, with admission during the 2022 peak of Omicron (January 31, 2022- February 13, 2022). Patient inclusion criteria was if they had a positive covid test on admission and experienced an extended length of stay over 2 days pending discharge to a long-term care facility. A quantitative/qualitative analysis was conducted of all orders placed subsequent to the first discharge order, and the number of additional days spent at the hospital. Correlations regarding total bed cost, and total overall, were then calculated using single tailed p values utilizing Prism 9 GraphPad software. Our research findings indicate there was a significant correlation between the number of extended hospitalization days and total bed costs but no correlation in the total overall costs or initial length of stay for each patient.

Socio-Economic Impact of COVID-19 Pandemic Among Lower Income Group of People in Pakistan

Objective: To determine the Socio-economic Impact of COVID-19 Pandemic among lower income group of people in Lahore, Pakistan Material and Methods: An analytical cross-sectional study design was used for conducting this research from April 2021 to September 2021 in Lahore and a self-structured questionnaire with multiple variables was filled by 274 participants. Non- Probability type of convenience sampling technique was used for data collection after informed consent. This paper was structured into two sections: The initial part addressed the socio-economic challenges experienced by impoverished individuals amidst the coronavirus pandemic. The subsequent section assessed the current state of Pakistan's healthcare system. Chi-square test was used for qualitative data analysis and p-value <0.05 was taken as significant. Results: Most of the participants (65.7%) in this survey were males and had an income of up to Rs.20,000/ month (70.1%).Out of total, 254 (92.7%) respondents had profound impact of Covid-19 on their lives economically. Majority of them 152(55.5%) visited public places while 133(48.5%) avoided social gatherings like marriages, funerals, religious events etc. during pandemic. More than half of the participants agreed that hospital beds and oxygen were neither available nor it was affordable during their stay at hospital. A significant association was found between family income of respondents and financial crisis faced by respondents when sick with covid-19(p-value=0.05), monthly income suffered due to lockdown or decrease in economy (p-value=0.04) and loan was taken to fulfill their household needs during pandemic (p-value=0.00). Conclusion: The study showed that 254 (92.7%) respondents had profound impact of Covid-19 on their lives economically. A significant association was found between family income of respondents and financial crisis faced by respondents when sick with covid-19, monthly income suffered due to lockdown or decreases in economy and loan taken to fulfill their household needs during pandemic.

Direct Medical Cost for Acute Ischemic Stroke Patients in Vietnam

Ischemic stroke is one of the leading causes of global disease burden. Vietnam, among other low- and middle-income countries, bears nearly 90% of the ischemic stroke burden. This study was a cost-of-illness study conducted from the healthcare system perspective to estimate the direct medical costs and associated factors for acute ischemic stroke patients at Bach Mai Hospital, a major hospital in Hanoi, Vietnam. A total of 500 eligible patients with acute ischemic stroke at the Neurology Department of Bach Mai Hospital from July 2021 to December 2021 were included. Patient characteristics and treatment information were collected via medical records and patient interviews. The majority of the patients were men (65.8%), with a mean age of 65.3 years. The average direct medical cost per patient was 10.5 ± 7.3 million Vietnam Dong (~454.2 ± 313.8 US dollars). The cost of hospital beds accounted for most of the total cost (34.6%), followed by medications and infusion fluid costs (27%) and diagnostic imaging (12.6%). Factors significantly associated with higher direct medical costs were the duration of stay, stroke severity, complications, number of comorbidities, and intravenous thrombolysis treatment. The study highlighted the need for a reduction in the duration of hospital stay and an improvement in onset-to-hospital arrival time.

Analyzing the Capacity of the Healthcare System in Gaza to Address Gaza Residents Needs

The present humanitarian crisis in Gaza has resulted in the devastation of medical facilities and health infrastructure. As of January 2024, the World Health Organization reports that 78% of primary care clinics funded by the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA, 2024) have ceased operations, and hospitals’ bed capacity throughout Gaza has decreased by more than 59% (World Health Organization, 2024). Direct military attacks on medical facilities as well as the blockade of medical supplies and humanitarian aid pose the largest obstacles to greater healthcare attainment in Gaza (IRC, 2024). Over the course of the conflict, there has been a surge in the number of people suffering from war injuries, which now totals 71,377 (Shurafa, 2024). The rise in the number of patients who require access to medical services in combination with the limited hospital functionality in the Gaza Strip is putting a massive strain on their already limited healthcare system; before the over 6 month long duration of direct military attacks by the Israeli Defence Forces (IDF) on hospitals in Gaza, data indicated a maximum ratio of 1.55 hospital beds per 1000 individuals across the entire region of the Gaza Strip, while the ratio in the US is around 2.35 hospital beds per 1000 individuals (Taylor, 2024). The already poor living conditions of the demographic–most of whom are housed in temporary structures in severe weather conditions with a lack of access to food and water for sustenance or hygiene–signify a need for a more robust healthcare system. However, triage conditions prioritize treatment of the most severe war injuries, which has forced hospitals to abandon previously established vaccination projects and disease surveillance programs, leaving the remaining population to suffer from preventable diseases such as chickenpox, upper respiratory infections, scabies, and Hepatitis A (Soni, 2024). Individuals who do receive medical care face higher levels of infection due to a lack of adequate sanitation, waste management measures, and basic hygiene supplies (The Economist, 2024).

Identification of a Patient Suitable for CAR-T Cell Therapy in the Outpatient Setting: A Vodcast and Case Example.

Chimeric antigen receptor T cell (CAR-T) therapies targeting the CD19 antigen have been associated with high and durable response rates in patients with diffuse large B cell lymphoma (DLBCL). CAR-T cell therapies are commonly administered in the inpatient setting due to the average onset of cytokine release syndrome within the first 3days post infusion, but there has been growing interest in delivering CAR-T cell therapies in the outpatient setting to overcome frequent hospital bed shortages and the high cost of inpatient care. Although this approach could improve access whilst catering to patient preference, it requires a multidisciplinary approach as well as careful patient selection. Herein, Dr. Foley and Dr. Kuruvilla discuss the case of a patient presenting with the ideal profile for CAR-T cell therapy referral whilst also determining the key attributes for eligibility from a clinician's perspective. Solutions for successful outpatient management include proper education, caregiver support, and early referral to ensure a timely infusion. In conclusion, outpatient administration of CAR-T cell therapy in patients with DLBCLs should be assessed on a case-by-case basis.A vodcast feature is available for this article.

Modelling COVID-19 Vaccination in the UK: Impact of the Autumn 2022 and Spring 2023 Booster Campaigns.

The delivery of COVID-19 vaccines was successful in reducing hospitalizations and mortality. However, emergence of the Omicron variant resulted in increased virus transmissibility. Consequently, booster vaccination programs were initiated to decrease the risk of severe disease and death among vulnerable members of the population. This study aimed to estimate the effects of the booster program and alternative vaccination strategies on morbidity and mortality due to COVID-19 in the UK. A Susceptible-Exposed-Infectious-Recovered (SEIR) model was used to assess the impact of several vaccination strategies on severe outcomes associated with COVID-19, including hospitalizations, mortality, National Health Service (NHS) capacity quantified by hospital general ward and intensive care unit (ICU) bed days, and patient productivity. The model accounted for age-, risk- and immunity-based stratification of the UK population. Outcomes were evaluated over a 48-week time horizon from September 2022 to August 2023 considering the actual UK autumn 2022/spring 2023 booster campaigns and six counterfactual strategies. The model estimated that the autumn 2022/spring 2023 booster campaign resulted in a reduction of 18,921hospitalizations and 1463 deaths, compared with a no booster scenario. Utilization of hospital bed days due to COVID-19 decreased after the autumn 2022/spring 2023 booster campaign. Expanding the booster eligibility criteria and improving uptake improved all outcomes, including averting twice as many ICU admissions, preventing more than 20% additional deaths, and a sevenfold reduction in long COVID, compared with the autumn 2022/spring 2023 booster campaign. The number of productive days lost was reduced by fivefold indicating that vaccinating a wider population has a beneficial impact on the morbidities associated with COVID-19. Our modelling demonstrates that the autumn 2022/spring 2023 booster campaign reduced COVID-19-associated morbidity and mortality. Booster campaigns with alternative eligibility criteria warrant consideration in the UK, given their potential to further reduce morbidity and mortality as future variants emerge.

An SEIHR model with age group and social contact for analysis of Fuzhou COVID-19 large wave

BackgroundThe structure of age groups and social contacts of the total population influenced infection scales and hospital-bed requirements, especially influenced severe infections and deaths during the global prevalence of COVID-19. Before the end of the year 2022, Chinese government implemented the national vaccination and had built the herd immunity cross the country, and announced Twenty Measures (November 11) and Ten New Measures (December 7) for further modifications of dynamic zero-COVID polity on the Chinese mainland. With the nation-wide vaccination and modified measures background, Fuzhou COVID-19 large wave (November 19, 2022–February 9, 2023) led by Omicron BA.5.2 variant was recorded and prevailed for three months in Fujian Province. MethodsA multi-age groups susceptible-exposed-infected-hospitalized-recovered (SEIHR) COVID-19 model with social contacts was proposed in this study. The main object was to evaluate the impacts of age groups and social contacts of the total population. The idea of Least Squares method was governed to perform the data fittings of four age groups against the surveillance data from Fujian Provincial Center for Disease Control and Prevention (Fujian CDC). The next generation matrix method was used to compute basic reproduction number for the total population and for the specific age group. The tendencies of effective reproduction number of four age groups were plotted by using the Epiestim R package and the SEIHR model for in-depth discussions. The sensitivity analysis by using sensitivity index and partial rank correlation coefficients values (PRCC values) were operated to reveal the differences of age groups against the main parameters. ResultsThe main epidemiological features such as basic reproduction number, effective reproduction number and sensitivity analysis were extensively discussed for multi-age groups SEIHR model in this study. Firstly, by using of the next generation matrix method, basic reproduction number R0 of the total population was estimated as 1.57 using parameter values of four age groups of Fuzhou COVID-19 large wave. Given age group k, the values of R0k (age group k to age group k), the values of R0k (an infected of age group k to the total population) and the values of R^0k (an infected of the total population to age group k) were also estimated, in which the explorations of the impacts of age groups revealed that the relationship R0k>R0k>R^0k was valid. Then, the fluctuating tendencies of effective reproduction number Rt were demonstrated by using two approaches (the surveillance data and the SEIHR model) for Fuzhou COVID-19 large wave, during which high-risk group (G4 group) mainly contributed the infection scale due to high susceptibility to infection and high risks to basic diseases. Further, the sensitivity analysis using two approaches (the sensitivity index and the PRCC values) revealed that susceptibility to infection of age groups played the vital roles, while the numerical simulation showed that infection scale varied with the changes of social contacts of age groups. The results of this study claimed that the high-risk group out of the total population was concerned by the local government with the highest susceptibility to infection against COVID-19. ConclusionsThis study verified that the partition structure of age groups of the total population, the susceptibility to infection of age groups, the social contacts among age groups were the important contributors of infection scale. The less social contacts and adequate hospital beds for high-risk group were profitable to control the spread of COVID-19. To avoid the emergence of medical runs against new variant in the future, the policymakers from local government were suggested to decline social contacts when hospital beds were limited.

Outpatient parenteral antibiotic treatment for infective endocarditis: A retrospective observational evaluation

BackgroundInfective endocarditis (IE) requires long courses of intravenous (IV) antibiotics. Outpatient parenteral antibiotic therapy (OPAT) saves resources, improves the patient experience and allows care in their preferred place; however, questions remain about safety when treating IE patients. This study evaluates OPAT management of IE patients in our region between 2006 and 2019. MethodsThis is a retrospective observational evaluation and description of outcomes and adherence to suitability criteria, according to British Society for Antimicrobial Chemotherapy (BSAC) guidelines. ResultsWe identified five models of OPAT delivery. The number of patients treated expanded significantly over time. Of 101 patients, six (6%) suffered poor outcomes, but each patient had contributing factors outside of the primary infection. Median OPAT duration was 12 days and 1,489 hospital bed days were saved. ConclusionsIn a setting where there was good adherence to BSAC criteria, treating IE patients using OPAT services was safe. Complications observed were likely independent of treatment location. Significant bed days were saved.

Impact of an ICU bed capacity optimisation method on the average length of stay and average cost of hospitalisation following implementation of China’s open policy with respect to COVID-19: a difference-in-differences analysis based on information management system data from a tertiary hospital in southwest China

ObjectivesFollowing the implementation of China’s open policy with respect to COVID-19 on 7 December 2022, the influx of patients with infectious diseases has surged rapidly, necessitating hospitals to adopt temporary...

An Adaptive Research Approach to COVID-19 Forecasting for Regional Health Systems in England

A team of researchers worked with public health officials and clinical decision makers to create real-time models to help predict COVID-19 cases and hospital bed needs in the East of England. These models used up-to-date data and allowed officials to explore different scenarios and make informed plans. The models have also been applied in other countries and can be a valuable tool in future epidemics.

Change in the Proportion of Death at Home during the COVID-19 Pandemic and Its Associated Factors in the Municipality Level: A Nationwide Study in Japan.

The coronavirus disease 2019 (COVID-19) pandemic may have led to an increase in home deaths due to hospital bed shortage and hospital visitation restrictions. This study aimed to examine changes in the proportion of home deaths before and after the COVID-19 pandemic and identify associated factors. We used publicly available nationwide data to describe the proportion of home deaths among total deaths from 2015 to 2021. Furthermore, we used municipal-level data to examine the factors associated with the increase in the proportion of home deaths from 2019 to 2021. The dependent variable was the absolute change in the proportion of home deaths from 2019 to 2021. The independent variables included each municipality's 2019 home death percentage, medical and long-term care (LTC) resources divided by the population of older people, population density, and cumulative number of COVID-19 cases. A multivariable linear regression analysis was conducted after the standardization of each variable. The proportions of home deaths in 2015, 2019, and 2021 were 12.7%, 13.6%, and 17.2%, respectively, indicating a sharp increase in home death rate after the COVID-19 pandemic. In the multivariable linear regression analysis that included 1,696 municipalities, conventional home care support clinics and hospitals (HCSCs) (coefficient [95% confidence intervals (CIs)], 0.19 [0.01-0.37]), enhanced HCSCs (0.53 [0.34-0.71]), home-visiting nurses (0.26 [0.06-0.46]), population density (0.44 [0.21-0.67]), and cumulative COVID-19 cases (0.49 [0.27-0.70]) were positively associated with the increase in home deaths, whereas beds of LTC welfare facilities (-0.55 [-0.74--0.37]) and the proportion of home deaths in 2019 (-1.24 [-1.44--1.05]) were negatively associated with the increase. During the COVID-19 pandemic, home deaths significantly increased, particularly in densely populated areas with high cumulative COVID-19 cases. HCSCs, especially enhanced HCSCs, are crucial for meeting the demand for home-based end-of-life care.

Antimicrobial prescribing in acute pancreatitis: Too much for too many?

BackgroundAcute pancreatitis (AP) is an inflammatory condition of the pancreas that varies widely in both clinical presentation and severity. Current international guidelines do not recommend the use of prophylactic antimicrobials in AP. AimTo review the compliance of antimicrobial prescribing in AP with international guidelines. MethodWe conducted a retrospective review of patients admitted with AP between 1st January 2021 and 31st December 2021, in Beaumont Hospital, Dublin, Ireland. For each case identified, the 2012 Revised Atlanta Criteria for AP were then applied on review of medical, laboratory and radiology records. ResultsThere were 98 patients, 52 % male (n = 51) with a median age of 53 years (range 18–88) who met the Revised Atlanta Criteria accounting for 1,032 hospital bed days inclusive of 82 critical care bed days. Gallstones were the most common aetiology; 48 % (n = 47). Antimicrobials were prescribed for 55 (56 %) patients with AP. Of those, only 38 % (n = 21) met the American Gastroenterological Association criteria for antimicrobials. The most common classes of antimicrobials prescribed were beta-lactams and carbapenems. Procalcitonin testing was conducted on just one patient (1 %). There were no cases of inpatient or 90-day mortality. ConclusionsOur findings are consistent with previously published reports of low mortality in mild acute AP and an excessive prescription of antimicrobials, highlighting this as an area for a targeted antimicrobial stewardship (AMS) intervention, including an increased use of procalcitonin as a biomarker.

Incidents et accidents médicamenteux en établissement de santé : une analyse descriptive au sein d’un CHU mère-enfant de 2018 à 2022

The safety of care provided is based on an analysis of medication incidents and accidents. The primary objective was to describe medication-related incidents and accidents (I&A) within a university-affiliated hospital. This retrospective descriptive study was based on data from a 500-bed mother-child university-affiliated hospital. All I&As declared between April 1, 2018, and March 31, 2022, were considered. The analysis included all medication-related I&As that occurred during an admission or in an outpatient setting. Some variables were recoded manually. Descriptive statistical analyses were performed. A total of 23 284 I&As were considered, including 7578 medication-related I&As. Daily averages of 15.9 ± 14.0 I&As and 5.2 ± 0.3 medication-related I&As were reported. There were 22.4 medication-related I&As/1000 inpatient days. The majority of medication-related I&As occurred in surgery (20%, 1530/7578), oncology (19%, 1405/7578), and pediatrics (16%, 1200/7578). Most were associated with incorrect dosing (21%, 1575/7578); infiltration, extravasation, or removed lines (19%, 1405/7578); and omissions (16%, 1205/7578). Physical consequences were reported in 15% (1158/7578) of the medication-related I&As. Conversely, psychological consequences were reported in less than 1% (44/7578) of medication-related I&As. This study provides a comprehensive descriptive profile over a 4-year period. Most of the reported I&As did not lead to consequences for patients. The sharing of ratios promotes comparative analysis with other facilities and can contribute to discussions about risk reduction. A culture of reporting events is present within this health care facility.

Impact on Hospital Resource Utilization of Endoluminal Bypass Using the Viabahn Endoprosthesis with Heparin Bioactive Surface Compared With Surgical Femoropopliteal Bypass.

To assess the impact of heparin-bonded endoprosthesis compared with femoropopliteal bypass on key hospital resources and revenues up to 1-year follow-up. A 2-arm scenario resource consumption data analysis was modeled based on a multicentre prospective randomized controlled trial. Six centers in the Netherlands. A total of 100 patients were assigned to 2 arms (50 each arm). The first arm evaluated endovascular treatment using the heparin-bonded Viabahn endoprosthesis and the second the femoropopliteal bypass. Resource consumption rates were compared between arms. Resource consumption rates, including hospital stay for bypass procedure, operating room time, type of anesthesia, number of used (endo)grafts, use of different types of bed locations (vascular ward, medium or intensive care), readmission for wound infections, and reinterventions over a period of 12 months. Endovascular repair used fewer hospital resources, with an overall difference of €149.983. Hospital stay was 118 days less (261 vs 379), including 21 fewer days in medium/intensive care (5 vs 26) and 50 fewer operating room hours (100 vs 150). Fewer patients required general anesthesia (31 vs 39), and there were less surgical site infections (3 vs 12). In the surgical bypass group, there were 18 fewer days of hospital stay related to reinterventions (80 vs 62), and the cost of the devices was €309.996, cheaper. The total monetary difference was € 160.013, in favor of the femoropopliteal bypass (€3.200, per patient). Endovascular repair of the superficial femoral artery reduces the use of valuable hospital resources. Its major limitation is the cost of the devices, which should be balanced against the reduction in peri-procedural morbidity and faster recovery. In the context of shortage of hospital beds, it offers capacity benefits, allowing for the treatment of more patients overall. These benefits may outweigh the fewer reinterventions in the surgical bypass group. The SuperB Trial was registered in clinicaltrials.gov; NCT-ID: NCT01220245. Modeling is a useful technique to predict the impact of treatment modalities on hospital resources and revenue. This study uses real-world data from the SuperB Trial to compare two treatment strategies of superficial femoral artery disease, reflecting actual clinical practice and patient outcomes. The analysis focused on direct costs associated with hospital resources and device usage without considering indirect costs or long-term cost-effectiveness. The analysis showed that endovascular repair reduces the use of valuable hospital resources. Its major limitation is device costs, which should be balanced against the reduction in peri-procedural morbidity and faster recovery. In the context of shortage of hospital beds, it offers capacity benefits, allowing for the treatment of more patients overall.

Low Cost Motorized Patient BED with Voice Control

In recent years, there has been a growing interest in integrating advanced technologies into healthcare settings to improve patient care and enhance medical infrastructure. One such innovation is the motorized voice-controlled hospital bed, which represents a significant advancement in patient comfort, mobility, and overall healthcare management. This paper presents the design, development, and implementation of a motorized voice- controlled hospital bed aimed at revolutionizing patient care in medical facilities. The motorized voice-controlled hospital bed incorporates cutting- edge technology, including voice recognition systems, motorized actuators, and wireless connectivity. Through voice commands, patients can effortlessly adjust the bed's position, including height, tilt, and backrest angle, enhancing their comfort and facilitating activities such as eating, reading, and watching television. Moreover, healthcare providers can remotely monitor and adjust bed settings, ensuring optimal patient positioning and reducing the risk of complications such as pressure ulcers. Key features of the motorized voice-controlled hospital bed include an intuitive voice interface, customization positioning options, safety mechanisms to prevent unintended movements, and seamless integration with existing healthcare infrastructure. Additionally, the bed's design prioritizes patient safety, infection control, and ease of maintenance, adhering to stringent healthcare standards and regulations.

The development of a delirium and dementia outreach team in a district general hospital

The structure of NHS services nationally means that there is enormous variation in the availability and content of specialist dementia and delirium services to patients in acute hospitals. The Dementia Action Alliance estimate that over 25% of beds in acute hospitals are occupied by people with dementia and their stays are longer with difficulties discharging in a timely way. 42% of unplanned admissions are people over 70 with dementia and there are high re-admission rates. The NIHR report by Gwernan-Jones et al. (2020) emphasises the need for a transformation of organisational and ward culture to improve the experience of people with dementia in hospital. For Warwick Hospital, a district general in the South Warwickshire NHS Foundation Trust (SWFT) there is enormous pressure for beds and an emphasis on flow through the hospital, including a need to reduce acute admissions and shorten length of stay. A pilot project was developed to seek to review the current data on patients with dementia in hospital, consider the assessment and interventions for delirium and advise on interventions that could both improve patient care and influence discharge. The initial findings for the project are shared alongside a review of the psychology role and challenges faced.

Predicting pressure injury risk in hospitalised patients using machine learning with electronic health records: a US multilevel cohort study

ObjectiveTo predict the risk of hospital-acquired pressure injury using machine learning compared with standard care.DesignWe obtained electronic health records (EHRs) to structure a multilevel cohort of hospitalised patients at risk...

Equity in distribution of hospital beds in Tehran province

Equity in distribution of hospital beds in Tehran province

Empiètement, rejet ou tempérance : l’adolescence en pédiatrie au risque de la surviolence

ContextThe work of the clinical psychologist in pediatric hospitals aims to promote the subjective appropriation of the experience by the child, by ensuring a feeling of continuity and security. It is particularly important to ensure the quality of the relation between subject, entourage, and caregivers. However, a certain amount of violence exists in the relation between caregiver and patient. We suggest that beyond the violence of caregiving itself, there is an “over-violence” (Tomkiewicz, 1991) which risks undermining the patient's feeling of security. ObjectivesWe believe that this over-violence arises when caregivers are confronted with intolerable experiences in the face of the vital risk incurred by the patient. This article aims to examine the emergence of this over-violence and its modes of expression. MethodThis work is based on several situations encountered in different pediatric wards, based on three cases of adolescent patients who put their caregivers in difficulty and required the intervention of hospital psychologists to understand the issues at hand. ResultsThrough these different clinical cases we identify two mechanisms of over-violence. First, encroachment, in the form of excessive control of patients’ behavior, which echoes the control that exists over the bodies of sick children. second, rejection, as an attempt to evacuate that which is violent, despite the needs of the patient, sometimes justified by the imperative of freeing hospital beds for other patients. We also identify the effects of a paradoxical over-violence in the oscillation between these two poles. DiscussionFaced with potential death and the anxiety it arouses, caregivers confronted with violent affects deploy unconscious defense mechanisms that can undermine the professional-patient relationship and can produce over-violence in care. Faced with this phenomenon, reflecting together as a team allows for the regulation of affects and promotes temperance in the professional-patient relationship. Psychologists practicing in somatic hospitals are instrumental in the setting up and maintaining of spaces for regulation or analysis of professional practice in services in which psychological care is not the primary task.