Inpatient Capacity Research Articles

Healthcare provision for insect venom allergy patients during the COVID-19 pandemic.

The population prevalence of insect venom allergy ranges between 3–5%, and it can lead to potentially life-threatening allergic reactions. Patients who have experienced a systemic allergic reaction following an insect sting should be referred to an allergy specialist for diagnosis and treatment. Due to the widespread reduction in outpatient and inpatient care capacities in recent months as a result of the COVID-19 pandemic, the various allergy specialized centers in Germany, Austria, and Switzerland have taken different measures to ensure that patients with insect venom allergy will continue to receive optimal allergy care. A recent data analysis from the various centers revealed that there has been a major reduction in newly initiated insect venom immunotherapy (a 48.5% decline from March–June 2019 compared to March–June 2020: data from various centers in Germany, Austria, and Switzerland). The present article proposes defined organizational measures (e.g., telephone and video appointments, rearranging waiting areas and implementing hygiene measures and social distancing rules at stable patient numbers) and medical measures (collaboration with practice-based physicians with regard to primary diagnostics, rapid COVID-19 testing, continuing already-initiated insect venom immunotherapy in the outpatient setting by making use of the maximal permitted injection intervals, prompt initiation of insect venom immunotherapy during the summer season, and, where necessary, using outpatient regimens particularly out of season) for the care of insect venom allergy patients during the COVID-19 pandemic.

Involuntary Commitments: Billing Patients for Forced Psychiatric Care

Involuntary Commitments: Billing Patients for Forced Psychiatric Care

Insights From Rapid Deployment of a "Virtual Hospital" as Standard Care During the COVID-19 Pandemic.

Pandemics disrupt traditional health care operations by overwhelming system resource capacity but also create opportunities for care innovation. To describe the development and rapid deployment of a virtual hospital program, Atrium Health hospital at home (AH-HaH), within a large health care system. Prospective case series. Atrium Health, a large integrated health care organization in the southeastern United States. 1477 patients diagnosed with coronavirus disease 2019 (COVID-19) from 23 March to 7 May 2020 who received care via AH-HaH. A virtual hospital model providing proactive home monitoring and hospital-level care through a virtual observation unit (VOU) and a virtual acute care unit (VACU) in the home setting for eligible patients with COVID-19. Patient demographic characteristics, comorbid conditions, treatments administered (intravenous fluids, antibiotics, supplemental oxygen, and respiratory medications), transfer to inpatient care, and hospital outcomes (length of stay, intensive care unit [ICU] admission, mechanical ventilation, and death) were collected from electronic health record data. 1477 patients received care in either the AH-HaH VOU or VACU or both settings, with a median length of stay of 11 days. Of these, 1293 (88%) patients received care in the VOU only, with 40 (3%) requiring inpatient hospitalization. Of these 40 patients, 16 (40%) spent time in the ICU, 7 (18%) required ventilator support, and 2 (5%) died during their hospital admission. In total, 184 (12%) patients were ever admitted to the VACU, during which 21 patients (11%) required intravenous fluids, 16 (9%) received antibiotics, 40 (22%) required respiratory inhaler or nebulizer treatments, 41 (22%) used supplemental oxygen, and 24 (13%) were admitted as an inpatient to a conventional hospital. Of these 24 patients, 10 (42%) required ICU admission, 1 (3%) required a ventilator, and none died during their hospital admission. Generalizability is limited to patients with a working telephone and the ability to comply with the monitoring protocols. Virtual hospital programs have the potential to provide health systems with additional inpatient capacity during the COVID-19 pandemic and beyond. Atrium Health.

Emergency department crowding and hospital transformation during COVID-19, a retrospective, descriptive study of a university hospital in Stockholm, Sweden

ObjectivesCOVID-19 presents challenges to the emergency care system that could lead to emergency department (ED) crowding. The Huddinge site at the Karolinska university hospital (KH) responded through a rapid transformation of inpatient care capacity together with changing working methods in the ED. The aim is to describe the KH response to the COVID-19 crisis, and how ED crowding, and important input, throughput and output factors for ED crowding developed at KH during a 30-day baseline period followed by the first 60 days of the COVID-19 outbreak in Stockholm Region.MethodsDifferent phases in the development of the crisis were described and identified retrospectively based on major events that changed the conditions for the ED. Results were presented for each phase separately. The outcome ED length of stay (ED LOS) was calculated with mean and 95% confidence intervals. Input, throughput, output and demographic factors were described using distributions, proportions and means. Pearson correlation between ED LOS and emergency ward occupancy by phase was estimated with 95% confidence interval.ResultsAs new working methods were introduced between phase 2 and 3, ED LOS declined from mean (95% CI) 386 (373–399) minutes to 307 (297–317). Imaging proportion was reduced from 29 to 18% and admission rate increased from 34 to 43%. Correlation (95% CI) between emergency ward occupancy and ED LOS by phase was 0.94 (0.55–0.99).ConclusionsIt is possible to avoid ED crowding, even during extreme and quickly changing conditions by leveraging previously known input, throughput and output factors. One key factor was the change in working methods in the ED with higher competence, less diagnostics and increased focus on rapid clinical admission decisions. Another important factor was the reduction in bed occupancy in emergency wards that enabled a timely admission to inpatient care. A key limitation was the retrospective study design.

Impact of DRGs-based inpatient service management on the performance of regional inpatient services in Shanghai, China: an interrupted time series study, 2013\u20132019

BackgroundThe asymmetry of information brings difficulty for government to manage public hospitals. Therefore, Jiading District of Shanghai has been establishing DRGs-based inpatient service management system (ISMS) to effectively compare the output of different hospitals through DRGs, reward desired hospital performance and enhance inpatient service capacity. However, the impact of the implementation of DRGs-based inpatient service management (ISM) policy in Jiading district is still unknow. We therefore conducted this study to evaluate the impact of DRGs-based ISM policy on the performance of inpatient service since its implementation in Jiading District, Shanghai, China in 2017.MethodsUsing an interrupted time series design, we analyzed quarterly data of seven DRGs-based performance measures from the ISMS which covered all five public hospitals in Jiading District from 2013 to 2019. We utilized the segmented linear regression model to assess the change of level and trend of performance indicators before and after ISM policy. Dickey–Fuller test was used to examine the stationary of the data. Durbin-Watson test was performed to check the series autocorrelation of indicators.ResultsSignificant changes in the following indicators were observed since the implementation of ISM policy. The case-mix index (CMI) level decreased by 0.103 (P < 0.05), the trend increased by 0.008 (P < 0.05). The total weight level decreased by 3719.05 (P < 0.05), and the trend increased by 250.13 (P < 0.05). The time efficiency index (TEI) level increased by 0.12 (P < 0.05), and the trend decreased by 0.01 (P < 0.05). The cost efficiency index (CEI) level increased by 0.31 (P < 0.05), and the trend decreased by 0.02 (P < 0.05). No significant difference was found in the change of DRGs number, inpatient mortality of low-risk group cases (IMLRG) and inpatient mortality of medium-to-low risk group cases (IMMLRG).ConclusionsFindings highlight the role of ISM policy in improving the capacity and efficiency of regional inpatient service. Three prerequisites, including a good information system, high-quality EMR data, and a management team, are needed for other countries to implement their own ISM policy to help government manage public hospitals and improve the performance of regional inpatient service.

Admission scheduling of inpatients by considering two inter-related resources: beds and operating rooms

ABSTRACT This paper studies the admission scheduling problem with considering the capacity usage of two inter-related resources (beds and operating rooms) between three consecutive stages of care during surgical patients' admissions to Chinese public hospitals, namely (1) pre-surgical inpatient bed, (2) surgery, (3) post-surgical inpatient bed. Demand comes from two types of patients: (1) emergency patients, who arise randomly and have to be admitted immediately, and (2) elective patients, whose admissions can be scheduled. The authors develop a Markov Decision Process (MDP) model that decides how many elective patients should be admitted each day, with the objective of optimally using both operating room and inpatient bed capacity. The authors demonstrate that the number of elective admissions scheduled each day is monotonically increasing in the state of the system and in the bed capacity, indicating that a higher level of waiting elective patients and available (or total) bed capacity pulls more elective admissions through the system. The total discounted expected cost of the system exhibits decreasing marginal returns as the capacity in each stage increases independently of other stages. Through numerical experiments, there is substantial value in making admission scheduling decisions by jointly considering inpatient beds and operating rooms.

Demand for Surgical Procedures Following COVID-19: The Need for Operational Strategies That Optimize Resource Utilization and Value.

Demand for Surgical Procedures Following COVID-19: The Need for Operational Strategies That Optimize Resource Utilization and Value.

A machine learning algorithm to increase COVID-19 inpatient diagnostic capacity.

Worldwide, testing capacity for SARS-CoV-2 is limited and bottlenecks in the scale up of polymerase chain reaction (PCR-based testing exist. Our aim was to develop and evaluate a machine learning algorithm to diagnose COVID-19 in the inpatient setting. The algorithm was based on basic demographic and laboratory features to serve as a screening tool at hospitals where testing is scarce or unavailable. We used retrospectively collected data from the UCLA Health System in Los Angeles, California. We included all emergency room or inpatient cases receiving SARS-CoV-2 PCR testing who also had a set of ancillary laboratory features (n = 1,455) between 1 March 2020 and 24 May 2020. We tested seven machine learning models and used a combination of those models for the final diagnostic classification. In the test set (n = 392), our combined model had an area under the receiver operator curve of 0.91 (95% confidence interval 0.87-0.96). The model achieved a sensitivity of 0.93 (95% CI 0.85-0.98), specificity of 0.64 (95% CI 0.58-0.69). We found that our machine learning algorithm had excellent diagnostic metrics compared to SARS-CoV-2 PCR. This ensemble machine learning algorithm to diagnose COVID-19 has the potential to be used as a screening tool in hospital settings where PCR testing is scarce or unavailable.

Clinical Predictors Influencing the Length of Stay in Emergency Department Patients Presenting with Acute Heart Failure.

Background and objectives: Acute heart failure is a common problem encountered in the emergency department (ED). More than 80% of the patients with the condition subsequently require lengthy and repeated hospitalization. In a setting with limited in-patient capacity, the patient flow is often obstructed. Appropriate disposition decisions must be made by emergency physicians to deliver effective care and alleviate ED overcrowding. This study aimed to explore clinical predictors influencing the length of stay (LOS) in patients with acute heart failure who present to the ED. Materials and Methods: We conducted prognostic factor research with a retrospective cohort design. Medical records of patients with acute heart failure who presented to the ED of Ramathibodi Hospital from January to December 2015 were assessed for eligibility. Thirteen potential clinical predictors were selected as candidates for statistical modeling based on previous reports. Multivariable Poisson regression was used to estimate the difference in LOS between patients with and without potential predictors. Results: A total of 207 patients were included in the analysis. Most patients were male with a mean age of 74.2 ± 12.5 years. The median LOS was 54.6 h (Interquartile range 17.5, 149.3 h). From the multivariable analysis, four clinical characteristics were identified as independent predictors with an increase in LOS. These were patients with New York Heart Association (NYHA) functional class III/IV (+72.9 h, 95%Confidence interval (CI) 23.9, 121.8, p = 0.004), respiratory rate >24 per minute (+80.7 h, 95%CI 28.0, 133.3, p = 0.003), hemoglobin level <10 mg/dL (+60.4 h, 95%CI 8.6, 112.3, p = 0.022), and serum albumin <3.5 g/dL (+52.8 h, 95%CI 3.6, 102.0, p = 0.035). Conclusions: Poor NYHA functional class, tachypnea, anemia, and hypoalbuminemia are significant clinical predictors of patients with acute heart failure who required longer LOS.

A simulation modelling toolkit for organising outpatient dialysis services during the COVID-19 pandemic.

This study presents two simulation modelling tools to support the organisation of networks of dialysis services during the COVID-19 pandemic. These tools were developed to support renal services in the South of England (the Wessex region caring for 650 dialysis patients), but are applicable elsewhere. A discrete-event simulation was used to model a worst case spread of COVID-19, to stress-test plans for dialysis provision throughout the COVID-19 outbreak. We investigated the ability of the system to manage the mix of COVID-19 positive and negative patients, the likely effects on patients, outpatient workloads across all units, and inpatient workload at the centralised COVID-positive inpatient unit. A second Monte-Carlo vehicle routing model estimated the feasibility of patient transport plans. If current outpatient capacity is maintained there is sufficient capacity in the South of England to keep COVID-19 negative/recovered and positive patients in separate sessions, but rapid reallocation of patients may be needed. Outpatient COVID-19 cases will spillover to a secondary site while other sites will experience a reduction in workload. The primary site chosen to manage infected patients will experience a significant increase in outpatients and inpatients. At the peak of infection, it is predicted there will be up to 140 COVID-19 positive patients with 40 to 90 of these as inpatients, likely breaching current inpatient capacity. Patient transport services will also come under considerable pressure. If patient transport operates on a policy of one positive patient at a time, and two-way transport is needed, a likely scenario estimates 80 ambulance drive time hours per day (not including fixed drop-off and ambulance cleaning times). Relaxing policies on individual patient transport to 2-4 patients per trip can save 40-60% of drive time. In mixed urban/rural geographies steps may need to be taken to temporarily accommodate renal COVID-19 positive patients closer to treatment facilities.

Safety of Same and Next Day Discharge Following Revision Hip and Knee Arthroplasty Using Modern Perioperative Protocols

BackgroundAdvances in perioperative care have enabled early discharge and outpatient primary total joint arthroplasty (TJA). However, the safety of early discharge after revision TJA (rTJA) remains unknown and the COVID-19 pandemic will force decreased hospitalization. This study compared 90-day outcomes in patients undergoing aseptic rTJA discharged the same or next day (early) to those discharged 2 or 3 days postoperatively (later). MethodsIn total, 530 aseptic rTJAs performed at a single tertiary care referral center (December 5, 2011 to December 30, 2019) were identified. Early and later discharge patients were matched as closely as possible on procedure type, sex, American Society of Anesthesiologists physical status classification, age, and body mass index. All patients were optimized using modern perioperative protocols. The rate of 90-day emergency department (ED) visits and hospital admissions was compared between groups. ResultsIn total, 183 early discharge rTJAs (54 hips, 129 knees) in 178 patients were matched to 183 later discharge rTJAs (71 hips, 112 knees) in 165 patients. Sixty-two percent of the sample was female, with an overall average age and body mass index of 63 ± 9.9 (range: 18-92) years and 32 ± 6.9 (range: 18-58) kg/m2. There was no statistical difference in 90-day ED visit rates between early (6/178, 3.4%) and later (11/165, 6.7%) discharge patients (P = .214). Ninety-day hospital admission rates for early (7/178, 3.9%) and later (4/165, 2.4%) discharges did not differ (P = .545). ConclusionUsing modern perioperative protocols with appropriate patient selection, early discharge following aseptic rTJA does not increase 90-day readmissions or ED visits. As hospital inpatient capacity remains limited due to COVID-19, select rTJA patients may safely discharge home the same or next day to preserve hospital beds and resources for more critical illness.

The Need And Benefit of Implementing Telemedicine in Clinical Practice

The Need And Benefit of Implementing Telemedicine in Clinical Practice

High-Efficiency Same-Day Approach to Breast Reconstruction During the COVID-19 Crisis.

PurposeAs our hospitals conserve and re-allocate resources during the COVID-19 crisis, there is urgent need to determine how best to continue caring for breast cancer patients. During the time window before the COVID-19 critical peak and particularly thereafter, as hospitals are able to resume cancer operations, we anticipate that there will be great need to maximize efficiency to treat breast cancer. The goal of this study is to present a same-day protocol that minimizes resource utilization to enable hospitals to increase inpatient capacity, while providing care for breast cancer patients undergoing mastectomy and immediate breast reconstruction during the COVID-19 crisis.MethodsIRB exempt patient quality improvement initiative was conducted to detail the operationalization of a novel same-day breast reconstruction protocol. Consecutive patients having undergone immediate breast reconstruction were prospectively enrolled between February and March of 2020 at Massachusetts General Hospital during the COVID-19 crisis. Peri-operative results and postoperative complications were summarized.ResultsTime interval from surgical closure to patient discharge was 5.02 ± 1.29 h. All patients were discharged home, with no re-admissions or emergency department visits. No postoperative complications were observed.ConclusionThis report provides an instruction manual to operationalize a same-day breast reconstruction protocol, to meet demands of providing appropriate cancer treatment during times of unprecedented resource limitations. Pre-pectoral implant-based breast reconstruction can be the definitive procedure or be used as a bridge to autologous reconstruction. Importantly, we hope this work will be helpful to our patients and community as we emerge from the COVID-19 pandemic.Electronic supplementary materialThe online version of this article (10.1007/s10549-020-05739-7) contains supplementary material, which is available to authorized users.

Post-Acute Care Preparedness in a COVID-19 World.

Coronavirus disease 2019 (COVID‐19) has led to a surge of patients requiring post‐acute care. In order to support federal, state and corporate planning, we offer a four‐stage regionally oriented approach to achieving optimal systemwide resource allocation across a region's post‐acute service settings and providers over time. In the first stage, the post‐acute care system must, to the extent possible, help relieve acute hospitals of non‐COVID‐19 patients to create as much inpatient capacity as possible over the surge period. In the second stage after the initial surge as subsided, post‐acute providers must protect vulnerable populations from COVID‐19, prepare treat‐in‐place protocols for non‐COVID‐19 admissions, and create and formalize COVID‐19 specific settings. In the third stage after a vaccine has been developed or an effective prophylactic option is available, post‐acute care providers must assist with distribution and administration of vaccinations and prophylaxis, develop strategies to deliver non‐COVID‐19 related medical care, and begin to transition to the post‐COVID‐19 landscape. In the final stage, we must create health advisory bodies to review post‐acute sector's response, identify opportunities to improve performance going forward, and develop a pandemic response plan for post‐acute care providers. J Am Geriatr Soc 68:1150–1154, 2020.

Reflections on the coronavirus disease 2019 (COVID-19) epidemic: The first 30 days in one of New York’s largest academic departments of surgery

Reflections on the coronavirus disease 2019 (COVID-19) epidemic: The first 30 days in one of New York’s largest academic departments of surgery

ECHO’s ECHO: Overcoming modern healthcare operational challenges with provider-to-provider video communication

The Extension for Community Health Outcomes (ECHO) project uses teleconferencing to improve access to care for patients who are unable to access academic medical centers. The model can also be used to address key operational issues facing academic medical centers today. Furthermore, the current healthcare landscape is well primed to accept this innovation. We propose application of this model to solve current challenges in healthcare, including: inpatient capacity, network development and access. Applied in these ways, this program has the potential to alleviate stress on hospital systems, ultimately improving patient care and the patient and provider experience.

Safety of outpatient adrenalectomy across 3 minimally invasive approaches at 2 academic medical centers

BackgroundOutpatient adrenalectomy has the potential to decrease costs, improve inpatient capacity, and decrease patient exposure to hospital-acquired conditions. Still, the practice has yet to be widely adopted and current studies demonstrating the safety of outpatient adrenalectomy are limited by sample size, extensive exclusion criteria, and no comparison to inpatient cases. We aimed to study the characteristics and safety of outpatient adrenalectomy using the largest such sample to date across 2 academic medical centers and 3 minimally invasive approaches. MethodsAll minimally invasive adrenalectomies were identified, starting from the time outpatient adrenalectomy was initiated at each institution. Cases involving removal of other organs, bilateral adrenalectomies, and cases in which a patient was admitted to the hospital before the day of surgery were excluded. Patient, tumor, and case characteristics were compared between outpatient and inpatient cases, and multivariable regression analysis was used to assess odds of 30-day readmission and/or complication. ResultsOf 203 patients undergoing minimally invasive adrenalectomy, 49% (n = 99) were performed on an outpatient basis. Outpatient disposition was more likely in the setting of lower estimated blood loss, case completion before 3 pm, and for surgery performed in the setting of nodule/mass and primary hyperaldosteronism versus Cushing’s syndrome, pheochromocytoma, and metastasis (P < .05). There were no significant differences in patient age, body mass index, American Society of Anesthesiologists class, procedure performed, or total time under anesthesia between inpatient and outpatient cases. On adjusted analysis, outpatient adrenalectomy was not associated with increased 30-day readmission rate (odds ratio 0.23 [confidence interval 0.04–1.26] P = .09) or 30-day complication rate (odds ratio 0.21 [confidence interval 0.06–0.81] P = .02). ConclusionOutpatient adrenalectomy can be performed safely without increased risk of 30-day complications or readmission in appropriately selected candidates.

COVID-19-Response - Strategies of the Task-Force Coronavirus and experiences upon implementation in the management of 115 cases at the University Medical Center Freiburg

Zusammenfassung Hintergrund Das neue, pandemische Coronavirus SARS-CoV-2 und die damit einhergehende Erkrankung COVID-19 (Coronavirus Disease 2019) stellt die medizinischen Versorgungssysteme vor große Herausforderungen. Die vorliegende Arbeit fasst die Strategie, Organisation und Maßnahmen der COVID-Taskforce des Universitätsklinikums Freiburg zusammen und berichtet über Erfahrungen und Behandlungsergebnisse von der Versorgung der ersten 115 COVID-19-Patienten. Methoden Retrospektive, narrative Prozessbeschreibung und -analyse des Zeitraums Ende Januar bis Anfang April 2020, durchgeführt unter Mitwirken der beteiligten Departments, Kliniken und Institute des Universitätsklinikums Freiburg. Ergänzend erfolgte eine retrospektive Beobachtungsstudie mit deskriptiver statistischer Auswertung der epidemiologischen und klinischen Daten aller bis 31. März 2020 hospitalisierten COVID-19-Patienten. Ergebnisse Durch eine interdisziplinär zusammengesetzte Taskforce Coronavirus wurden Maßnahmen in den Bereichen ambulante Testung und Beratung, Separierung der Patientenströme sowie Eskalation der Versorgungskapazitäten auf Normal- und Intensivstationen im Sinne eines dynamischen Stufenmodells angeregt und umgesetzt. Die Versorgung der ersten 115 Patienten gelang somit ohne Entstehung von Engpässen. Diskussion Durch Zusammenwirken sämtlicher Disziplinen und Abteilungen des Universitätsklinikums Freiburg konnte eine adäquate Versorgung von COVID-19-Patienten sichergestellt und die Handlungsfähigkeit des Klinikums in der aktuellen Ausbruchsituation erhalten werden.

Maxillofacial Trauma Management During COVID-19: Multidisciplinary Recommendations.

Maxillofacial Trauma Management During COVID-19: Multidisciplinary Recommendations.

Transforming Care: supporting people with learning disabilities, autism and mental health issues to move out of long-stay hospitals

The Transforming Care programme was devised by NHS England in 2015 with the aim of supporting people with a learning disability and/or autism who exhibit behaviour that challenges, including those with a mental health condition, to move out of long-stay hospitals and live in the community. The driving factor behind the programme was abuse and neglect experienced by people in long-stay settings, including those living at Winterbourne View, a private hospital near Bristol that was closed in 2011 after revelations that patients had been ill-treated. By March 2019, when the programme ended, the target to reduce inpatient bed capacity by 50% had not been met.This article discusses the author’s experience as a dual-qualified social worker and mental health nurse employed by a Transforming Care Partnership. In this role, the author coordinated the discharge process for five people with learning disabilities and/or autism, often with co-morbid mental health issues, who had lived in hospital for 7-21 years. The complex multiagency work that enabled these successful discharges is explored and the article considers how this work can be built on in future to ensure more people with learning disabilities are able to live in their own homes.