Inpatient Capacity Research Articles

Inpatient Capacity at Children's Hospitals during Pandemic (H1N1) 2009 Outbreak, United States

Quantifying how close hospitals came to exhausting capacity during the outbreak of pandemic influenza A (H1N1) 2009 can help the health care system plan for more virulent pandemics. This ecologic analysis used emergency department (ED) and inpatient data from 34 US children's hospitals. For the 11-week pandemic (H1N1) 2009 period during fall 2009, inpatient occupancy reached 95%, which was lower than the 101% occupancy during the 2008–09 seasonal influenza period. Fewer than 1 additional admission per 10 inpatient beds would have caused hospitals to reach 100% occupancy. Using parameters based on historical precedent, we built 5 models projecting inpatient occupancy, varying the ED visit numbers and admission rate for influenza-related ED visits. The 5 scenarios projected median occupancy as high as 132% of capacity. The pandemic did not exhaust inpatient bed capacity, but a more virulent pandemic has the potential to push children’s hospitals past their maximum inpatient capacity.

Cancellation of Scheduled Procedures as a Mechanism to Generate Hospital Bed Surge Capacity—A Pilot Study

The ability to generate hospital beds in response to a mass-casualty incident is an essential component of public health preparedness. Although many acute care hospitals' emergency response plans include some provision for delaying or cancelling elective procedures in the event of an inpatient surge, no standardized method for implementing and quantifying the impact of this strategy exists in the literature. The aim of this study was to develop a methodology to prospectively emergency plan for implementing a strategy of delaying procedures and quantifying the potential impact of this strategy on creating hospital bed capacity. This is a pilot study. A categorization methodology was devised and applied retrospectively to all scheduled procedures during four one-week periods chosen by convenience. The categorization scheme grouped procedures into four categories: (A) procedures with no impact on inpatient capacity; (B) procedures that could be delayed indefinitely; (C) procedures that could be delayed by one week; and (D) procedures that could not be delayed. The categorization scheme was applied by two research assistants and an emergency medicine resident. All three raters categorized the first 100 cases to allow for calculation of inter-rater reliability. Maximal hospital bed capacity was defined as the 95th percentile weekday occupancy, as this is more representative of functional bed capacity than is the number of licensed beds. The main outcome was the number of hospital beds that could be created by postponing procedures in categories B and C. Maximal hospital bed capacity was 816 beds. Mean occupancy during weekdays was 759 versus 694 on weekends. By postponing Group B and C procedures, a mean of 60 beds (51 general medical/surgical and nine intensive care unit (ICU)) could be created on weekdays, and four beds (three general medical/surgical and one ICU) on weekends. This represents 7.3% and 0.49% of maximal hospital bed capacity and ICU capacity, respectively. In the event that sustained surge is needed, delaying all category B and C procedures for one week would lead to the generation of 1,235 hospital-bed days. Inter-rater reliability was high (kappa = 0.74) indicating good agreement between all three raters. For the institution studied, the strategy of delaying scheduled procedures could generate inpatient capacity with maximal impact during weekdays and little impact on weekends. Future research is needed to validate the categorization scheme and increase the ability to predict inpatient surge capacity across various hospital types and sizes.

Emergency department observation units

There are nearly 120 million visits to emergency departments each year, one for every three people in the United States. Fifty percent of all hospital admissions come from this group, a marked change from the mid-1990s when the emergency department was a source of only a third of admissions. As the population increases and ages, the growth rate for emergency department visits and the resulting admissions will exceed historical trends creating a surge in demand for inpatient beds. Current health care reform efforts are highlighting deficiencies in access, cost, and quality of care in the United States. The need for more inpatient capacity brings attention to short-stay admissions and whether they are necessary. Emergency department observation units provide a suitable alternate venue for many such patients at lower cost without adversely affecting access or quality. This article serves as a literature synthesis in support of observation units, with special emphasis on the clinical and financial aspects of their use. The observation medicine literature was reviewed using PubMed, and selected sources were used to summarize the current state of practice. In addition, the authors introduce a novel conceptual framework around measures of observation unit efficiency. Observation units provide high-quality and efficient care to patients with common complaints seen in the emergency department. More frequent use of observation can increase patient safety and satisfaction while decreasing unnecessary inpatient admissions and improving fiscal performance for both emergency departments and the hospitals in which they operate. For institutions with the volume to justify the fixed costs of operating an observation unit, the dominant strategy for all stakeholders is to create one.

An open source software project for obstetrical procedure scheduling and occupancy analysis

Increases in the rate of births via cesarean section and induced labor have led to challenging scheduling and capacity planning problems for hospital inpatient obstetrical units. We present occupancy and patient scheduling models to help address these challenges. These patient flow models can be used to explore the relationship between procedure scheduling practices and the resulting occupancy on inpatient obstetrical units such as labor and delivery and postpartum. The models capture numerous important characteristics of inpatient obstetrical patient flow such as time of day and day of week dependent arrivals and length of stay, multiple patient types and clinical interventions, and multiple patient care units with inter-unit patient transfers. We have used these models in several projects at different hospitals involving design of procedure scheduling templates and analysis of inpatient obstetrical capacity. In the development of these models, we made heavy use of open source software tools and have released the entire project as a free and open source model and software toolkit.

Use of psychiatric inpatient capacities and diagnostic practice in Tashkent/Uzbekistan as compared to Berlin/Germany

The present study shows a comparison of diagnoses used for the treatment of urban psychiatric inpatients in Tashkent/Uzbekistan and Berlin/Germany. Differential diagnostic practices related to different traditions in psychopathology between the two settings are analysed to explain part of the difference in relative frequencies of the diagnoses. We conducted a cross-sectional survey of diagnoses used for the treatment of 845 inpatients including 17 out of 18 wards of the Tashkent psychiatric hospital and of all 2,260 psychiatric and psychotherapeutic inpatients in Berlin in October 2008. Relative frequencies of diagnostic categories were calculated for each setting and compared between the two settings using the Chi-square test. A descriptive analysis of differential diagnostic practice is used to explain differences in relative frequencies. Patients diagnosed with schizophrenia (59.3 vs. 21.0%), with organic mental disorders (20.5 vs. 8.3%), with mental retardation (6.9 vs. 0.2%) and with neurasthenia (1.4 vs. 0.0%) had larger relative frequencies of the psychiatric inpatient population in Tashkent than in Berlin. Patients diagnosed with unipolar depression (24.1 vs. 0.9%), substance use disorder (17.4 vs. 6.4%), adjustment disorder (6.0 vs. 0.4%), schizoaffective disorder (4.9 vs. 0.0%), mania and bipolar disorder (5.3 vs. 0.4%), personality disorder (3.2 vs. 2.0%) and anxiety disorder (3.1 vs. 0.1%) had larger relative frequencies in Berlin than in Tashkent. The diagnostic concept of schizophrenia in Tashkent includes patients with affective psychoses, schizoaffective psychoses and delusional disorders. In Tashkent, mental disorders are more readily associated with organic brain disease such as head trauma or vascular disease than in Berlin. In Tashkent, most of the psychiatric inpatient capacities are used for the treatment of schizophrenia and organic mental disorders, whereas in Berlin patients with affective disorders, schizophrenia and substance use disorders are most commonly treated as inpatients. The differences can in part be explained by differential diagnostic traditions between the Russian/post-Soviet nosology and the use of the ICD.

Laboratory malaria diagnostic capacity in health facilities in five administrative zones of Oromia Regional State, Ethiopia

Quality laboratory services are a requisite to guide rational case management of malaria. Using a pre-tested, standardized assessment tool, we assessed laboratory diagnostic capacity in 69 primary, secondary and tertiary health facilities as well as specialized laboratories in five administrative zones in Oromia Regional State, Ethiopia, during February and March 2009. There was marked variability in laboratory diagnostic capacity among the facilities assessed. Of 69 facilities surveyed, 53 provided both comprehensive malaria laboratory diagnosis and outpatient treatment services, five provided malaria microscopy services (referring elsewhere for treatment), and 11 primary care health posts provided rapid diagnostic testing and outpatient malaria treatment. The facilities' median catchment population was 39, 562 and 3581 people for secondary/tertiary and primary health facilities, respectively. Depending on facility type, facilities provided services 24 hrs a day, had inpatient capacity, and access to water and electricity. Facilities were staffed by general practitioners, health officers, nurses or health extension workers. Of the 58 facilities providing laboratory services, 24% of the 159 laboratory staff had received malaria microscopy training in the year prior to this survey, and 72% of the facilities had at least one functional electric binocular microscope. Facilities had variable levels of equipment, materials and biosafety procedures necessary for laboratory diagnosis of malaria. The mean monthly number of malaria blood films processed at secondary/tertiary facilities was 225, with a mean monthly 56 confirmed parasitologically. In primary facilities, the mean monthly number of clinical malaria cases seen was 75, of which 57 were tested by rapid diagnostic test (RDTs). None of the surveyed laboratory facilities had formal quality assurance/quality control protocols for either microscopy or RDTs. This is the first published report on malaria diagnostic capacity in Ethiopia. While our assessment indicated that malaria laboratory diagnosis was available in most facilities surveyed, we observed significant gaps in laboratory services which could significantly impact quality and accessibility of malaria diagnosis, including laboratory infrastructure, equipment, laboratory supplies and human resources.

Trends in the Duration of Emergency Department Visits, 2001-2006

Trends in the Duration of Emergency Department Visits, 2001-2006

Implementation of crowding solutions from the American College of Emergency Physicians Task Force Report on Boarding

Study ObjectiveWe sought to measure the self-reported implementation of the crowding solutions outlined in the 2008 American College of Emergency Physicians (ACEP) Boarding Task Force report “Emergency Department Crowding: High-Impact Solutions.” We also tested the hypothesis that the self-reported crowding of emergency departments (EDs) was positively associated with the implementation of these solutions.MethodsIn early 2009, we mailed a survey to all medical or nursing directors from EDs in four US states asking for information regarding their EDs in 2008. Geographic information about the EDs was included in the analysis, along with survey responses about their ED capacity status and implementation of specific ACEP crowding solutions.ResultsA total of 284 of 351 EDs responded (81%). The majority of EDs were in urban areas (56%), non-teaching hospitals (93%), and not critical access hospitals (76%). The percentage of EDs “over capacity” ranged from 10–49% in each state. The mean number of crowding solutions used in EDs that were at or over capacity ranged from 3.6–4.6 in each state. EDs with visit volumes greater than or equal to three patients/hour were more likely to be over capacity than at capacity or at a good balance (46% vs. 31% and 15%, respectively). In terms of the use of high-impact crowding solutions, hospitals over capacity were more likely to utilize inpatient full capacity protocols (40% vs. 25% and 25%) but not inpatient discharge coordination (29% vs. 27% and 34%) or surgical schedule smoothing (31% vs. 28% and 32%). Hospitals over capacity were also more likely to have fast track units (44% vs. 32% and 16%) and physicians at triage (48% vs. 29% and 17%).ConclusionLess than half of EDs in each state reported operation above capacity. Implementation of some crowding solutions was more common in the above-capacity EDs, although these solutions were not consistently used across geographic locations and hospitals. Given that the majority of EDs were not over capacity, the implementation of these solutions does not seem to be universally necessary.

Inanspruchnahme stationärer Behandlungen nach Abbau stationärer Kapazitäten: Das Angebot beeinflußt die Nachfrage

Next to socio-economic factors, subjective need, political and health economiaspects play an important role in the planning of psychiatric structures. The aim of this study was to assess the consequences of a reduction of inpatient capacities fort the usage of psychiatric inpatient care. The admissions of inpatients from a region in which the inpatient service has been replaced by the inpatient service from another region in the canton of Zurich, Switzerland, has been analysed. Within the first two years after the omission of the service the admissions of patients with social health insurance policies from the relative sector decreased significantly as compared to the rest of the canton. In contrast to this, admissions of patients with private health insurances from the relative region and from the rest of the canton increased in a similar way. It can be stated that in the first time after a reduction of inpatient capacities patients with social health insurance policies do not use inpatient alternatives even when these are easily accessible. This finding is meaningful for the arrangement of alternative offers for this very large group of patients in psychiatric health care planning.

Impact of Local Resources on Hospitalization Patterns of Medicare Beneficiaries and Propensity to Travel Outside Local Markets

To examine how local health care resources impact travel patterns of patients age 65 and older across the rural urban continuum. Information on inpatient hospital discharges was drawn from complete 2004 hospital discharge files from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) for New York, California, and Florida, and the 2003 hospital discharge file for Pennsylvania. The study population was Medicare patients with admissions for ambulatory care sensitive conditions. Analysis was at the patient-level, and area contextual variables were developed at the Primary Care Service Area (PCSA) level. Local resources considered included inpatient supply, provider supply, supply of international medical graduates, and critical access hospitals (CAHs) in the patient's PCSA. Findings generally confirmed enhanced retention of the elderly in local markets with greater availability of community resources, although we observed considerable heterogeneity across states. Community resource variables such as median household income or inpatient hospital capacity were stronger and more consistent predictors along the urban rural continuum than any of the provider or CAH variables. Only in California and New York did we see significant effects for provider supply or CAH, but they were robust across the 2 states and models of travel propensity, always reducing the travel propensity. Findings support policies aimed at augmenting supplies of critical access hospitals in rural communities, and increasing primary care physicians and hospital resources in both rural and urban communities.

Creation of Inpatient Capacity During a Major Hospital Relocation

To identify tools to aid the creation of disaster surge capacity using a model of planned inpatient census reduction prior to relocation of a university hospital. Prospective analysis of hospital operations for 1-week periods beginning 2 weeks (baseline) and 1 week (transition) prior to move day; analysis of regional hospital and emergency department capacity. Large metropolitan university teaching hospital. Hospital census figures and patient outcomes. Census was reduced by 36% from 537 at baseline to 345 on move day, a rate of 18 patients/d (P < .005). Census reduction was greater for surgical services than nonsurgical services (46% vs 30%; P = .02). Daily volume of elective operations also decreased significantly, while the number of emergency operations was unchanged. Hospital admissions were decreased by 42%, and the adjusted discharges per occupied bed were increased by 8% (both P < .05). Inpatient mortality was not affected. Regional capacity to absorb new patients was limited. During a period in which southern California population grew by 8.5%, acute care beds fell by 3.3%, while Los Angeles County emergency departments experienced a 13% diversion rate due to overcrowding. Local or regional disasters of any size can overwhelm the system's ability to respond. Our strategy produced a surge capacity of 36% without interruption of emergency department and trauma services but required 3 to 4 days for implementation, making it applicable to disasters and mass casualty events with longer lead times. These principles may aid in disaster preparedness and planning.

167: Implementation of Crowding Solutions From the American College of Emergency Physicians Task Force Report on Boarding

In 2008, the Task Force Report on Boarding proposed high-impact crowding solutions such as hospital discharge coordination, inpatient full capacity protocols, and the coordination of elective surgeries. To date, there are no data on the implementation of these crowding solutions. The purpose of this study is to crowding and solutions in EDs of different annual visit volumes in a single state.

The Preparedness of Hospital Health Information Services for System Failures Due to Internal Disasters

The unimpeded functioning of hospital Health Information Services (HIS) is essential for patient care, clinical governance, organisational performance measurement, funding and research. In an investigation of hospital Health Information Services' preparedness for internal disasters, all hospitals in the state of Victoria with the following characteristics were surveyed: they have a Health Information Service/ Department; there is a Manager of the Health Information Service/Department; and their inpatient capacity is greater than 80 beds. Fifty percent of the respondents have experienced an internal disaster within the past decade, the majority affecting the Health Information Service. The most commonly occurring internal disasters were computer system failure and floods. Two-thirds of the hospitals have internal disaster plans; the most frequently occurring scenarios provided for are computer system failure, power failure and fire. More large hospitals have established back-up systems than medium- and small-size hospitals. Fifty-three percent of hospitals have a recovery plan for internal disasters. Hospitals typically self-rate as having a 'medium' level of internal disaster preparedness. Overall, large hospitals are better prepared for internal disasters than medium and small hospitals, and preparation for disruption of computer systems and medical record services is relatively high on their agendas.

Creation of Surge Capacity by Early Discharge of Hospitalized Patients at Low Risk for Untoward Events

US hospitals are expected to function without external aid for up to 96 hours during a disaster; however, concern exists that there is insufficient capacity in hospitals to absorb large numbers of acute casualties. The aim of the study was to determine the potential for creation of inpatient bed surge capacity from the early discharge (reverse triage) of hospital inpatients at low risk of untoward events for up to 96 hours. In a health system with 3 capacity-constrained hospitals that are representative of US facilities (academic, teaching affiliate, community), a variety (N = 50) of inpatient units were prospectively canvassed in rotation using a blocked randomized design for 19 weeks ending in February 2006. Intensive care units (ICUs), nurseries, and pediatric units were excluded. Assuming a disaster occurred on the day of enrollment, patients who did not require any (previously defined) critical intervention for 4 days were deemed suitable for early discharge. Of 3491 patients, 44% did not require any critical intervention and were suitable for early discharge. Accounting for additional routine patient discharges, full use of staffed and unstaffed licensed beds, gross surge capacity was estimated at 77%, 95%, and 103% for the 3 hospitals. Factoring likely continuance of nonvictim emergency admissions, net surge capacity available for disaster victims was estimated at 66%, 71%, and 81%, respectively. Reverse triage made up the majority (50%, 55%, 59%) of surge beds. Most realized capacity was available within 24 to 48 hours. Hospital surge capacity for standard inpatient beds may be greater than previously believed. Reverse triage, if appropriately harnessed, can be a major contributor to surge capacity.

The influence of institutional characteristics on length of stay for psychiatric patients: A national database study in South Korea

The institutionalization of psychiatric patients has put a tremendous burden on many societies, but few studies have examined the effects of institutional characteristics on patient length of stay (LOS). This paper investigated the association between institutional characteristics and LOS for 160,517 psychiatric patients in South Korea by applying a two-level modeling technique to administrative claims databases covering the entire patient population. Patient LOS, expressed in terms of days, was analyzed by taking account of institutional type, ownership, location, inpatient capacity, staffing, and patient demographics. The characteristics of inpatients were used as control variables and consisted of gender, age, sub-diagnosis, and the type of national health security program. The main findings of this study are: (1) patient LOS was 69% longer at psychiatric hospitals than at tertiary-care hospitals; (2) neither location nor inpatient capacity was associated with LOS; (3) larger staffs reduced LOS; and (4), LOS increased with a higher proportion of male inpatients, inpatients ≥65 years old, or inpatients diagnosed with organic or schizophrenic disorders, possibly through contextual effects. The results of this study suggest that researchers and policy makers could improve their assessment of psychiatric patient LOS and its association with health outcome by taking into account institutional characteristics and using multi-level analyses.

Is It Safe to Admit Boarder Patients to Inpatient Hallways

Caring for emergency department patients in hallways has become the norm as hospital crowding has become pervasive. One approach to reducing ED crowding during times of high ED and inpatient census is to augment inpatient capacity by admitting selected ED boarder patients to hallways on inpatient floors, instead of boarding them in the ED. This approach essentially “shares the pain” of hospital crowding. In a …

Overcrowding: Harming the Patients of Tomorrow?

It is 3 AM on August 1st, 2018, in a busy hospital when a 47-year-old male presents with chest pain. The emergency physician on duty, who is a new residency graduate, performs a history and physical, orders an ECG, chest x-ray, and blood work. After reviewing the data, the patient is given aspirin, nitroglycerin, and heparin and admitted to observation for a rule-out with serial enzymes. At 7 AM, the patient’s chest pain worsens and he suffers a cardiac arrest. An autopsy reveals cardiac tamponade and a large thoracic aortic dissection.

A queuing-based decision support methodology to estimate hospital inpatient bed demand

Hospital inpatient bed capacity might be better described as evolved than planned. At least two challenges lead to this behaviour: different views of patient demand implied by different data sets in a hospital and limited use of scientific methods for capacity estimation. In this paper, we statistically examine four distinct hospital inpatient data sets for internal consistency and potential usefulness for estimating true patient bed demand. We conclude that posterior financial data, billing data, rather than the census data commonly relied upon, yields true hospital bed demand. Subsequently, a capacity planning tool, based upon queuing theory and financial data only, is developed. The delivery mechanism is an Excel spreadsheet. One adjusts input parameters including patient volume and mix and instantaneously monitors the effect on bed needs across multiple levels of care. A case study from a major hospital in Phoenix, Arizona, USA is used throughout to demonstrate the methodologies.

Enhancing Work Flow to Reduce Crowding

Approximately one third of hospitals in the United States report increases in ambulance diversion in a given year, whereas up to half report crowded conditions in the emergency department (ED). In a recent national survey, 40% of hospital leaders viewed ED crowding as a symptom of workforce shortages. Many health systems are implementing a variety of strategies to improve flow and reduce crowding. Virtually all work-flow initiatives use operations management techniques that include some or all of four domains: performance measurement, demand forecasting, flow redesign, and capacity management. These are often implemented using rapid improvement techniques. Most initiatives tend to focus on functional increases in inpatient capacity. Successful strategies to improve patient flow are distinguished by an organizationwide commitment to measurement, transparency in data reporting, and sustained management attention. Focusing on transitions between ED and inpatient units and maximizing overall hospital capacity appears necessary for improvement. Hence, reductions in ED crowding require strategies that go far beyond the ED. Health systems can take tangible, immediate steps to improve flow and reduce crowding. Efforts would be enhanced by more controlled trials of existing strategies in the context of uniform performance measures.

Variation in functional independence in hospitalized elderly related to social and health variables

The aging process, non-transmissible chronic diseases and hospitalizations can cause functional decline in the elderly. Objective: to identify the variation in functional capacity in elderly during hospitalization and correlate it with social and health variables. Method: The study was developed at a University Hospital in Campinas, SP, with 28 elderly inpatients of both sexes, admitted for clinical treatment, with a mean age of 68 years. The Functional Independence Measure (FIM) was used at the admission, during the hospitalization, at the discharge and one month after the discharge. The variation in FIM scores was calculated at different moments of evaluation, expressed by deltas and correlated with the variables: gender, previous hospitalization, presence of caregiver and use of medications. Results: There was a significant difference in the deltas of FIM between the discharge-home return periods (p=0.0010) and the admission-discharge periods (p&lt;0.0001), in total FIM and its domains, showing decreased functional independence during hospitalization and recovery after the return home. The gender, previous hospitalization and presence of caregiver did not significantly influence the functional capacity of the elderly inpatients; however the increased number of prescribed medications between the admission and the discharge periods presented a moderate (r=0.5059) and a very significant correlation (p=0.0071) with functional decline in this period. Conclusion: There was a functional decrease in elderly inpatients during the hospitalization, being more significant among inpatients that had an increased number of prescribed medications during hospitalization.