Inpatient Bed Capacity Research Articles

Hospital design planning: unscheduled trauma ER visits impacting inpatient space allocation

ABSTRACT Medical healthcare planners need to align outpatient and inpatient design factors that affect hospital space allocation. The Emergency Departments (ED) design must be congruent with the inpatient platform design to limit bottlenecking of patient admissions. However, limited research deciphers the impact of unscheduled ED admissions and the effects on inpatient bed capacity to ensure facility capability. The current study utilizes a case study by comparing the use of space planning criteria of the Department of Defense (DoD) with similar Private healthcare organization departmental metrics to inform space allocation. This study established the significance of unscheduled ED visits metric on inpatient space allocation. Bed capacity was calculated by outlining specific metrics; namely: population at risk, Average Daily Patient Load (ADPL), Average Length of Stay (ALOS), Average Annual Workload, Annual Admissions, and Occupancy Rate that are necessary for the right-sized inpatient hospital designs with a trauma mission. By analyzing existing research, identifying key metrics, highlighting capacity gaps, and showcasing real-world impacts via a case study pilot model. Valuable insights and benefits allow medical planners and administrators to assess and incorporate unscheduled visits as a key factor that influences appropriate hospital facility sizing and resource allocation.

Care Patterns and Barriers to Outpatient Care for Adults With AML Following Intensive Chemotherapy at NCCN Member Institutions.

Prolonged hospitalization following intensive (re)induction chemotherapy for acute myeloid leukemia (AML), while standard, is costly and resource intense, limits inpatient bed capacity, and negatively impacts quality of life. Early hospital discharge (EHD) following completion of chemotherapy has proven safe as an alternative at select institutions, but is not widely implemented. From February 2023 through May 2023, the NCCN Best Practices Committee conducted a survey evaluating AML hospitalization patterns, care models, and barriers to EHD at its 33 member institutions. A total of 30 (91%) institutions completed the survey; two-thirds treat >100 patients with AML annually and 45% treat more than half of these with intensive chemotherapy. In the (re)induction setting, 80% of institutions keep patients hospitalized until blood count recovery, whereas 20% aim to discharge patients after completion of chemotherapy if medically stable and logistically feasible. The predominant reasons for the perceived need for ongoing hospitalization were high risk of infection, treatment toxicities, and lack of nearby/accessible housing. There was no significant association between ability to practice EHD and annual AML volume or treatment intensity patterns (P=.60 and P=.11, respectively). In contrast, in the postremission setting, 87% of centers support patients following chemotherapy in the outpatient setting unless toxicities arise requiring readmission. Survey responses showed that 80% of centers were interested in exploring EHD after (re)induction but noted significant barriers, including accessible housing (71%), transportation (50%), high toxicity/infection rate (50%), high transfusion burden (50%), and limited bed availability for rehospitalization (50%). Hospitalization and care patterns following intensive AML therapy vary widely across major US cancer institutions. Although only 20% of surveyed centers practice EHD following intensive (re)induction chemotherapy, 87% do so following postremission therapy. Given the interest in exploring the EHD approach given potential advantages of EHD for both patients and health care systems, strategies to address identified medical and logistical barriers should be explored.

A data-driven newsvendor model for elective-emergency admission control under uncertain inpatient bed capacity.

Elective-emergency admission control referred to allocating available inpatient bed capacity between elective and emergency hospitalization demand. Existing approaches for admission control often excluded several complex factors when making decisions, such as uncertain bed capacity and unknown true probability distributions of patient arrivals and departures. We aimed to create a data-driven newsvendor framework to study the elective-emergency admission control problem to achieve bed operational efficiency and effectiveness. We developed a data-driven approach that utilized the newsvendor framework to formulate the admission control problem. We also created approximation algorithms to generate a pool of candidate admission control solutions. Past observations and relevant emergency demand and bed capacity features were modeled in a newsvendor framework. Using approximation algorithmic approaches (sample average approximation, separated estimation and optimization, linear programing-LP, and distribution-free model) allowed us to derive computationally efficient data-driven solutions with tight bounds on the expected in-sample and out-of-sample cost guaranteed. Tight generalization bounds on the expected out-of-sample cost of the feature-based model were derived with respect to the LP and quadratic programing (QP) algorithms, respectively. Results showed that the optimal feature-based model outperformed the optimal observation-based model with respect to the expected cost. In a setting where the unit overscheduled cost was higher than the unit under-scheduled cost, scheduling fewer elective patients would replace the benefit of incorporating related features in the model. The tighter the available bed capacity for elective patients, the bigger the difference of the schedule cost between the feature-based model and the observation-based model. The study provides a reference for the theoretical study on bed capacity allocation between elective and emergency patients under the condition of the unknown true probability distribution of bed capacity and emergency demand, and it also proves that the approximate optimal policy has good performance.

A forecasting tool for a hospital to plan inbound transfers of COVID-19 patients from other regions

BackgroundIn April 2021, the province of Ontario, Canada, was at the peak of its third wave of the COVID-19 pandemic. Intensive Care Unit (ICU) capacity in the Toronto metropolitan area was insufficient to handle local COVID patients. As a result, some patients from the Toronto metropolitan area were transferred to other regions.MethodsA spreadsheet-based Monte Carlo simulation tool was built to help a large tertiary hospital plan and make informed decisions about the number of transfer patients it could accept from other hospitals. The model was implemented in Microsoft Excel to enable it to be widely distributed and easily used. The model estimates the probability that each ward will be overcapacity and percentiles of utilization daily for a one-week planning horizon.ResultsThe model was used from May 2021 to February 2022 to support decisions about the ability to accept transfers from other hospitals. The model was also used to ensure adequate inpatient bed capacity and human resources in response to various COVID-related scenarios, such as changes in hospital admission rates, managing the impact of intra-hospital outbreaks and balancing the COVID response with planned hospital activity.ConclusionsCoordination between hospitals was necessary due to the high stress on the health care system. A simple planning tool can help to understand the impact of patient transfers on capacity utilization and improve the confidence of hospital leaders when making transfer decisions. The model was also helpful in investigating other operational scenarios and may be helpful when preparing for future outbreaks or public health emergencies.

The successful and safe conversion of joint arthroplasty to same-day surgery: A necessity after the COVID-19 pandemic.

A key strategy to address system pressures on hip and knee arthroplasty through the COVID-19 pandemic has been to shift procedures to the outpatient setting. This was a retrospective cohort and case-control study. Using the Discharge Abstract Database and the National Ambulatory Care Reporting System databases, we estimated the use of outpatient hip and knee arthroplasty in Ontario, Canada. After propensity-score matching, we estimated rates of 90-day readmission, 90-day emergency department (ED) visit, 1-year mortality, and 1-year infection or revision. 204,066 elective hip and 341,678 elective knee arthroplasties were performed from 2010-2022. Annual volumes of hip and knee arthroplasties increased steadily until 2020. Following the start of the COVID-19 pandemic (March 1, 2020) through December 31, 2022 there were 7,561 (95% CI 5,435 to 9,688) fewer hip and 20,777 (95% CI 17,382 to 24,172) fewer knee replacements performed than expected. Outpatient arthroplasties increased as a share of all surgeries from 1% pre-pandemic to 39% (hip) and 36% (knee) by 2022. Among inpatient arthroplasties, the tendency to discharge to home did not change since the start of the pandemic. During the COVID-19 era, patients receiving arthroplasty in the outpatient setting had a similar or lower risk of readmission than matched patients receiving inpatient arthroplasty [hip: RR 0.65 (0.56-0.76); knee: RR 0.86 (0.76-0.97)]; ED visits [hip: RR 0.78 (0.73-0.83); knee: RR 0.92 (0.88-0.96)]; and mortality, infection, or revision [hip: RR 0.65 (0.45-0.93); knee: 0.90 (0.64-1.26)]. Following the start of the COVID-19 pandemic in Ontario, the volume of outpatient hip and knee arthroplasties performed increased despite a reduction in overall arthroplasty volumes. This shift in surgical volumes from the inpatient to outpatient setting coincided with pressures on hospitals to retain inpatient bed capacity. Patients receiving arthroplasty in the outpatient setting had relatively similar outcomes to those receiving inpatient surgery after matching on known sociodemographic and clinical characteristics.

Hospital Development of a Hybrid Emergency Department—Inpatient Care Observation Unit

IntroductionThis project aimed to design and implement an emergency department-managed observation unit that improves inpatient bed and emergency department stretcher capacity, decreases observation patient length of stay, earns high patient satisfaction scores, and generates a positive fiscal impact on the organization. MethodsThis quality improvement project followed a 1-group, pre- and postprogram implementation design. ResultsIn the first year of operations, 40% of the total observation patients treated in this hospital were managed in the new observation unit. Emergency department observation unit length of stay across all patient complaints was half of the average length of stay for observation patients located on hospital inpatient units. In most cases, the emergency department observation unit was in the top 25 percentile of hospital Press Ganey inpatient satisfaction categories. The hospital estimates a contribution margin of three-quarters of a million dollars in the first year. DiscussionThis effective and efficient hybrid observation unit possessed specific aspects of inpatient and emergency department patient care models. Placing providers and nurses at the workstation for faster communication expedited care. Prioritizing all observation patient testing, transportation, phlebotomy, and intravenous (IV) services shortened disposition times. Emergency nurses transitioning to the observation unit were challenged to acquire inpatient care knowledge. Observation unit management struggled to maintain staffing while under an inpatient productivity model managed by the inpatient house supervisor. Reducing patient disposition time required clear communication between observation unit and inpatient staffing managers, between physician consultants and advanced practice nursing providers, and among nurses, patients, and providers. Observation units are 1 solution to decrease observation patient length of stay and improve emergency department capacity.

A Comprehensive Examination of Pediatric Behavioral Health Service Demand and Utilization in a Large, Academic Health System from 2019 to 2021.

Studies of the effects of COVID-19 on youth suggest a worsening in mental health globally. We performed a retrospective analysis of data from January 2019-November 2021 for all outpatient referrals, as well as outpatient, inpatient, and emergency department (ED) encounters for behavioral health (BH) reasons in children aged < 18 in a large academic health system in the United States. Mean weekly rates of outpatient psychiatry referrals, outpatient psychiatry visits, ED visits, and inpatient admissions for BH reasons were compared between pre-pandemic and pandemic periods. The average weekly rate of ambulatory referrals (8.0 ± 0.33 to 9.4 ± 0.31) and completed appointments (194.2 ± 0.72 to 213.1 ± 0.71) significantly increased during the pandemic, driven largely by teenagers. The weekly average of ED pediatric encounters for BH did not increase during the pandemic, although the percentage of all pediatric ED encounters that were for BH did increase from 2.6 to 4.1% (p < 0.001). Length of stay for pediatric BH ED patients increased from 1.59 ± 0.09 days pre-pandemic to 1.91 ± 0.11 days post-pandemic (p < 0.0001). Inpatient admissions for BH reasons overall decreased during the pandemic, due to a decrease in inpatient psychiatric bed capacity. However, the weekly percentage of inpatient hospitalizations for BH reasons that occurred on medical units increased during the pandemic (15.2% ± 2.8-24.6% ± 4.1% (p = 0.0006)). Taken together, our data suggest the COVID-19 pandemic had varying degrees of impact, depending on the setting of care.

Assessment and management of secondary bacterial infections complicating Mpox (Monkeypox) using a telemedicine service. A prospective cohort study.

During spring 2022, an outbreak of Monkeypox (mpox) emerged as an infection of concern in Europe. Due to the overlapping clinical features of mpox and bacterial infections, diagnosis of concomitant bacterial infection is challenging. In this prospective cohort study, we report the incidence, severity, and progression of patients with secondary bacterial infection complicating mpox infection. Data were collected via a bespoke mpox telemedicine service provided by Infection services at North Manchester General Hospital, UK. A diagnosis of secondary bacterial infection was based on the history (balanitis, surrounding erythema, purulent discharge and nasal ulceration) and review of patient-collected medical photography. Patient were reviewed face-to-face where necessary. Secondary bacterial infection was diagnosed in 15 of 129 (11.6%) patients with mpox. Three patients with secondary bacterial infection (3/129, 2.3%) required admission to hospital and one patient underwent surgical debridement. Median healing (thus, isolation) times were longer in those with bacterial infection. In this prospective cohort study of patients with mpox, secondary bacterial infection was infrequent and predominantly mild. The virtual ward and telemedicine follow up allowed for the prompt recognition of secondary bacterial infections and timely antibiotic administration. Due to concerns regarding nosocomial transmission, mild clinical course and limited inpatient bed capacity, we believe this model of outpatient management for mpox (Clade II B.1 lineage) could be replicated in other low risk populations where suitable home isolation facilities exist.

A Statewide Assessment of Pediatric Emergency Care Surge Capabilities

Pediatric surge planning is critical in the setting of decreasing pediatric inpatient capacity. We describe a statewide assessment of pediatric inpatient bed capacity, clinical care therapies, and subspecialty availability during standard and disaster operations in Massachusetts. To assess pediatric (<18 years old) inpatient bed capacity during standard operations, we used Massachusetts Department of Public Health data from May 2021. To assess pediatric disaster capacity, therapies, and subspecialty availability in standard and disaster operations, we performed a state-wide survey of Massachusetts hospital emergency management directors from May to August 2021. From the survey, we calculated additional pediatric inpatient bed capacity during a disaster and clinical therapy and subspecialty availability during standard and disaster operations. Of 64 Massachusetts acute care hospitals, 58 (91%) completed the survey. Of all licensed inpatient beds in Massachusetts (n = 11 670), 19% (n = 2159) are licensed pediatric beds. During a disaster, 171 pediatric beds could be added. During standard and disaster operations, respiratory therapies were available in 36% (n = 21) and 69% (n = 40) of hospitals, respectively, with high flow nasal cannula being most common. The only surgical subspecialist available in the majority of hospitals (>50%) during standard operations is general surgery (59%, n = 34). In a disaster, only orthopedic surgery could additionally provide services in the majority hospitals (76%; n = 44). Massachusetts pediatric inpatient capacity is limited in a disaster scenario. Respiratory therapies could be available in more than half of hospitals in a disaster, but the majority of hospitals lack surgical subspecialists for children under any circumstance.

79 Impact of COVID-19 wave 3 paediatric inpatient unit closures on transfers to tertiary care paediatric hospital

Abstract Background During Wave 3 of the COVID-19 pandemic, 15 community hospital paediatric inpatient units (comprising 167 beds) in Toronto were directed to close by the Greater Toronto Area (GTA) Hospital Incident Management System (IMS) Command Centre to increase adult inpatient bed capacity. All paediatric patients from closed inpatient units were redirected to a single tertiary care paediatric hospital, which increased capacity to accommodate these additional patients through activation of surge plans, while community hospitals redeployed resources to fill much needed gaps in adult care. Objectives The objective was to describe patient characteristics of all transfers during the closure to explore the impact of community paediatric inpatient unit closures on transfers to the tertiary hospital. Design/Methods A chart review of all transferred patients was conducted during the mandated closure and subsequent reopening. Transfers excluded ICU-level transfers as these were not impacted by IMS mandated closures. All transfers were categorized as requiring tertiary care (i.e. would typically be transferred) or not requiring tertiary care (i.e. only transferred due to the closure). Variables collected included sending hospital, admitting diagnosis, patient age, hospital disposition, and length of stay. Data was collected until the last paediatric unit reopened. Quality improvement project approval was granted by the institution. Results A total of 858 patients were transferred to the tertiary hospital during the 67 day closure; of those, 530 were transferred solely to increase adult bed capacity (i.e. were categorized as patients requiring non-tertiary care). The majority of patients were admitted to general paediatrics (52%), and 39% went to a surgical inpatient unit. Most patients (68%) admitted had a length of stay between 24 and 72 hours. A third of patients admitted were under 2 years old, and a third were over 12 years old. The top three diagnoses for admission were infections, gastrointestinal issues, and general surgery. Two-thirds (60%) of transfers from closed sites came from three sites. Conclusion More than half of the transfers occurred solely due to the mandated closures, and transfers returned to a stable volume once all sites re-opened. The GTA hospital system was able to respond to the mandated closure effectively through clear high-level communication, escalation processes and structures as well as responsive, real-time problem solving. Closures increased potential adult inpatient capacity by 6740 bed days and demonstrated an unprecedented system-wide approach to the provision of integrated paediatric care across the region.

Enhancing Hospital-Wide Patient Flow to Reduce Emergency Department Crowding and Boarding

IntroductionED overcrowding and boarding is a global phenomenon that negatively affects patients, hospital staff, and hospital-wide operations. Poor patient flow has been identified as a major contributing factor to ED overcrowding and boarding, which is directly linked to negative patient outcomes. This project implemented a multidisciplinary rounding team that addressed barriers to patient flow in real time. By reducing the inpatient length of stay bed capacity will improve, which in turn will help alleviate ED boarding and overcrowding. MethodsThis before-and-after process improvement project took place on a 30-bed, inpatient medicine floor of a level-I trauma, tertiary, regional transfer center. Multidisciplinary rounding was used to improve care team communication and collaboration. Concepts from a Real-Time Demand Capacity model were used in this project to help develop a plan for capacity issues regarding bed supply and demand. Outcome variables included inpatient length of stay and ED boarding hours. ResultsImplementation of multidisciplinary rounding resulted in a statistically significant reduction of 0.83 days in the length of stay for patients on this floor. By increasing inpatient bed capacity, ED boarding hours for patients targeted to the 3000-medicine floor was reduced by an average of 8.83 hours per month, a reduction > 50% from baseline. DiscussionIncreasing inpatient bed capacity helps decrease ED access block, and contributes to reducing ED overcrowding. Implementing a daily multidisciplinary rounding structure on the inpatient floor helped hospital throughput by expediting discharges, which in turn created inpatient bed capacity.

An Evaluation of Admissions to an Old Age Psychiatry Ward: A Quality Improvement Project

AimsIt has been well publicised the pressures on inpatient bed capacity within mental health services in recent years. The RCPsych have stated in their publication ‘Exploring mental health inpatient capacity’ that bed occupancy has risen above their recommended 85% occupancy target in most areas. Waiting lists for beds have also grown. The aim of this project was to identify whether there could have been any extra community resources in place that could have prevented admissions to hospital within an older adult CMHT. This in turn reducing the demand on inpatient beds.MethodsInclusion criteria: All patients from the older adult CMHT admitted to either an organic or functional mental health inpatient bed between the 1st September and 31st December 2021.All patients who met the inclusion criteria were discussed as part of a panel consisting of members of the MDT who were involved in the patients' ongoing care. The panel discussed each patient and individually scored each admission on a scale of 1–5 (where 1 was deemed to be very avoidable and 5 completely unavoidable). Where an admission did not score a 5 we considered whether anything could have been in place to have prevented the admission.ResultsOur search identified 21 patients who had been admitted to the respective old age psychiatry ward during our period of interest. The predominant diagnosis of these patients was vascular dementia (n = 5), followed by Alzheimer's disease (n = 3). Following our consensus panel discussion, we identified that the most common reason for admission to hospital was for management of behavioural and psychological symptoms of dementia (n = 10), followed by increasing patient vulnerability (n = 4) in the community. Carer stress was a theme in 2 admissions. Following panel discussion regarding potential avoidability of admission, we identified that 14 out of the total of 21 admissions scored a 5, 1 scored 4, 1 scored 3, and 5 scored 2.ConclusionBehavioural and psychological symptoms of dementia continues to remain a significant clinical challenge and was the most common reason for admission in our patient cohort. The majority of admissions to hospital in our cohort were deemed unavoidable as a result. However, we identified that carer stress was a significant theme in 2 out of our 21 admissions, suggesting potential scope to implement services which may reduce carer stress and ultimately, prevent hospital admission.

Examining the association between paramedic transport to the emergency department and hospital admission: a population-based cohort study

BackgroundIncreasing hospitalization rates present unique challenges to manage limited inpatient bed capacity and services. Transport by paramedics to the emergency department (ED) may influence hospital admission decisions independent of patient need/acuity, though this relationship has not been established. We examined whether mode of transportation to the ED was independently associated with hospital admission.MethodsWe conducted a retrospective cohort study using the National Ambulatory Care Reporting System (NACRS) from April 1, 2015 to March 31, 2020 in Ontario, Canada. We included all adult patients (≥18 years) who received a triage score in the ED and presented via paramedic transport or self-referral (walk-in). Multivariable binary logistic regression was used to determine the association of mode of transportation between hospital admission, after adjusting for important patient and visit characteristics.ResultsDuring the study period, 21,764,640 ED visits were eligible for study inclusion. Approximately one-fifth (18.5%) of all ED visits were transported by paramedics. All-cause hospital admission incidence was greater when transported by paramedics (35.0% vs. 7.5%) and with each decreasing Canadian Triage and Acuity Scale level. Paramedic transport was independently associated with hospital admission (OR = 3.76; 95%CI = 3.74–3.77), in addition to higher medical acuity, older age, male sex, greater than two comorbidities, treatment in an urban setting and discharge diagnoses specific to the circulatory or digestive systems.ConclusionsTransport by paramedics to an ED was independently associated with hospital admission as the disposition outcome, when compared against self-referred visits. Our findings highlight patient and visit characteristics associated with hospital admission, and can be used to inform proactive healthcare strategizing for in-patient bed management.

1357 Ankle Blocks: Improving Day Case Efficiency

Abstract Introduction The COVID pandemic has exerted unprecedented pressure on hospital resources. Resulting in cancellation of elective operative services, increased patient waiting lists, limited surgical training opportunities along with reduced availability of staff, theatre, and in-patient bed capacity. A novel approach for day case forefoot surgery under ankle block, to mitigate the pandemic service limitations without compromising care, was developed. Method This is a 3-month, multi-centre, prospective cohort study evaluating the novel ankle block day case forefoot surgery pathway. Patients had a minimum of three months clinical follow up with outcome scores. They were matched to a cohort undergoing similar surgery prior to the COVID pandemic. Results The utilisation of an ankle block pathway resulted in an average reduction of inpatient stay by 2 days per patient. Over the study period conservative savings of £26,659 were calculated. Anecdotally we observed a reduction in morbidity (wound complications, SSI’s) although not statistically significant. Conclusions Our novel surgical pathway has enabled continued elective operating for procedures that previously required hospital admission during a period of severe restrictions within the NHS. We observed significant reductions in cost, surgical inpatient bed utilisation and total operative time with staff, resource, and time savings. We hypothesise that prehabilitation with physiotherapy, ankle instead of thigh tourniquets and early mobilisation may have contributed to improved morbidity scores. The findings of this project have implications for training, upper limb services and are transferrable as a template to improve service efficiency while maintaining high quality care.

IN SEARCH OF THE HOLY GRAIL: WHAT IS THE RIGHT NUMBER OF INPATIENT BEDS?

This session will describe a yearlong collaboration between the American Psychiatric Association (APA) and AACAP to develop an algorithm for determining the inpatient bed capacity needed in a state or county children’s behavioral health system.

Day case unicompartmental knee replacement: An update of the Torbay experience

BackgroundHospitals throughout the United Kingdom face significant challenges in regards to inpatient bed capacity, leading to growing interest in day case arthroplasty.Day case Unicompartmental Knee Replacement (UKR) has been offered within our unit since 2010, with successive evaluations of pathway outcomes performed in 2011 and 2015. Since then, our day case UKR pathway has expanded. This study aims to evaluate the safety, efficiency and patient satisfaction with this expanded pathway. MethodsData was prospectively collected for all patients undergoing a UKR between January 2017 and August 2019. Data collected included the pathway planned, date of admission, date of discharge and re-admissions to hospital within 30 days of surgery. Patient satisfaction was evaluated via a follow-up questionnaire. Results109 patients underwent a UKR between January 2017 and August 2019.83 patients (76%) were planned through the day case pathway.63 patients were successfully discharged on the day of surgery.One day case pathway and two inpatient pathway patients were re-admitted within 30 days of surgery with medical conditions.A high level of patient satisfaction with our day case pathway was identified. ConclusionUKR with planned discharge on the day of surgery is possible for a large proportion of patients provided that robust pathway and protocol design is undertaken. Following 10 years’ experience, our day case UKR pathway has increasingly become the default for the majority of our patients. We report high patient satisfaction and low 30-day re-admission rates. However, 100% success rate for day of surgery discharge remains challenging.

The impact of inpatient bed capacity on length of stay

ObjectiveLarge reductions in inpatient length of stay and inpatient bed supply have occurred across health systems in recent years. However, the direction of causation between length of stay and bed supply is often overlooked. This study examines the impact of changes to inpatient bed supply, as a result of recession-induced healthcare expenditure changes, on emergency inpatient length of stay in Ireland between 2010 and 2015.Study designWe analyse all public hospital emergency inpatient discharges in Ireland from 2010 to 2015 using the administrative Hospital In-Patient Enquiry dataset. We use changes to inpatient bed supply across hospitals over time to examine the impact of bed supply on length of stay. Linear, negative binomial, and hospital–month-level fixed effects models are estimated.ResultsU-shaped trends are observed for both average length of stay and inpatient bed supply between 2010 and 2015. A consistently large positive relationship is found between bed supply and length of stay across all regression analyses. Between 2010 and 2012 while length of stay fell by 6.4%, our analyses estimate that approximately 42% (2.7% points) of this reduction was associated with declines in bed supply.ConclusionChanges in emergency inpatient length of stay in Ireland between 2010 and 2015 were closely related to changes in bed supply during those years. The use of length of stay as an efficiency measure should be understood in the contextual basis of other health system changes. Lower length of stay may be indicative of the lack of resources or available bed supply as opposed to reduced demand for care or the shifting of care to other settings.

National trends in emergency department closures, mergers, and utilization, 2005-2015.

To describe nationwide hospital-based emergency department (ED) closures and mergers, as well as the utilization of emergency departments and inpatient beds, over time and across varying geographic areas in the United States. Observational analysis of the American Hospital Association (AHA) Annual Survey from 2005 to 2015. Primary outcomes were hospital-based ED closure and merger. Secondary outcomes were yearly ED visits per hospital-based ED and yearly hospital admissions per hospital bed. The total number of hospital-based EDs decreased from 4,500 in 2005 to 4,460 in 2015, with 200 closures, 138 mergers, and 160 new hospital-based EDs. While yearly ED visits per hospital-based ED exhibited a 28.6% relative increase (from 25,083 to 32,248), yearly hospital admissions per hospital bed had a 3.3% relative increase (from 45.4 to 43.9) from 2005 to 2015. The number of hospital admissions and hospital beds did not change significantly in urban areas and declined in rural areas. ED visits grew more uniformly across urban and rural areas. The number of hospital-based ED closures is small when accounting for mergers, but occurs as many more patients are presenting to a stable number of EDs in larger health systems, though rural areas may differentially affected. EDs were managing accelerating patient volumes alongside stagnant inpatient bed capacity.

Non-invasive respiratory support in the management of COVID-19: Report of a series using a nasal CPAP mask

BackgroundDuring peak pandemic period of COVID-19, our hospital required rapid reorganization of resources and staff during between mid-March and early April 2020. Within this interval, the hospital responded to an overwhelming rate of admissions of patients in respiratory failure, rapidly reaching over 95% of its usual inpatient bed capacity and requiring 70 extra critical care beds and at least 40 intermediate care unit beds. This created a significant shortage of materials including ventilation equipment, requiring improvised use of available resources. AimsTo describe our use of non-invasive ventilation (NIV) with the continuous positive nasal airway pressure (CPAP) device SuperNO2VA™ (Vyaire Medical, Mettawa, IL) with hospitalized patients in acute respiratory failure due to presumed COVID-19. MethodsWe performed a retrospective analysis of 14 inpatients receiving NIV CPAP at the Hospital Ramón y Cajal in Madrid, Spain. These were inpatients presenting in respiratory failure during the peak pandemic period based on defined respiratory health, oxygenation, and comorbidity status criteria. Patient data were retrospectively acquired from patient medical records. ResultsAll 14 patients were reviewed. Our series consisted of 11 males and three females with an average age of 61.5 years. Ten of 14 patients (71.4%) NIV CPAP patients did not require intubation or reintubation. Of the four unsuccessful cases, one required intubation, two required reintubation, and one expired. ConclusionsIn a time of crisis, anesthesiologists and respiratory specialists implemented the use of NIV CPAP with SuperNO2VA to help meet the high care demand of patients in respiratory distress. Although the SuperNO2VA was not originally developed for the management of patients in respiratory failure or distress related to COVID-19, this case series demonstrates it can be used with mostly favorable results during a time of limited resources to improve the clinical situation in patients. Advantages and disadvantages are explored.

Burden of central-line-associated bloodstream infections in 106 Ministry of Health hospitals of Saudi Arabia: a 2-year surveillance study

Background: Although the Saudi Ministry of Health (MOH) is managing the majority of inpatient bed capacity in Saudi Arabia, surveillance data for central-line-associated bloodstream infections (CLABSI) have never been reported at a national level. Objectives: To estimate unit-specific CLABSI rates along with central line utilization ratios in MOH hospitals. Additionally, to benchmark such rates and ratios with recognized regional and international benchmarks. Methods: A prospective surveillance study was conducted in 106 MOH hospitals between January 2018 and December 2019. The data from 14 different types of intensive care units (ICUs) were entered into the Health Electronic Surveillance Network (HESN) program. The surveillance methodology was similar to the methods of the US National Healthcare Safety Network (NHSN) and the Gulf Cooperation Council (GCC) Center for Infection Control. Results: During the 2 years of surveillance in ICU setting covering 1,475,177 patient-days and 475,913 central line-days, a total of 1,542 CLABSI events were identified. The overall CLABSI rate was 3.24 (95% confidence interval [CI], 3.08–3.40) per 1,000 central line-days, and the overall central line utilization ratio was 0.32 (95% CI, 0.322–0.323). CLABSI-standardized infection ratios in HESN hospitals were very similar (1.01) to GCC hospitals, but 3.2 times higher than NHSN hospitals and 36% lower than International Nosocomial Infection Control Consortium (INICC) hospitals. Central-line-standardized utilization ratio in MOH hospitals was 15–30% lower than the three benchmarks. Conclusions: The overall CLABSI rate was 3.24 per 1,000 central line-days, and the overall central line utilization ratio was 0.32. MOH CLABSI rates were very similar to GCC hospitals, but higher than NHSN hospitals and lower than INICC hospitals. MOH central line utilization is slightly lower than the three benchmarks.