Sickle cell hospital unit: a disease-specific model

American urban hospitals often serve large populations of sickle cell disease (SCD) patients. Those hospitals that choose to implement an adult SCD-specific inpatient unit have the opportunity to acquire multiple operational benefits. Such units may ultimately reduce patient morbidity and mortality; improve timely access to quality medical care in a cost-effective manner; reduce overcrowding in the emergency department; and increase patient, family, physician, and payer satisfaction. SCD is a serious, painful, genetic blood disorder that affects a growing population of adults in the United States. A single mistake in the gene that codes for hemoglobin causes crescent-shaped red blood cells that are sticky, are stiff, and have a short life span. These cells cause blockages, tremendous pain brought on by lack of oxygen in the muscles, organ damage, stroke, and problems with infections. The cells' short life span often results in anemia. The unpredictable pain event-sickle cell disease with crisis-is the most common reason for presentation to the emergency department and for hospital admission. For many SCD patients, the emergency department process and the general, overly conservative approach to pain relief lead to a delay in treatment and prolong needless suffering. Regional Medical Center at Memphis (Tennessee) established an SCD unit and developed an inpatient care delivery model that decreases the burden of caring for SCD patients on its busy emergency department, improves SCD patients' satisfaction and access to timely quality care, and reduces the needless pain and suffering of SCD patients. This SCD model may be replicated in large urban hospitals with a daily SCD patient census of five or more.     

Frequency, determinants and impact of overcrowding in emergency departments in Canada: a national survey

Several reports have documented the prevalence and severity of emergency department (ED) overcrowding at specific hospitals or cities in Canada; however, no study has examined the issue at a national level. A 54-item, self-administered, postal and web-based questionnaire was distributed to 243 ED directors in Canada to collect data on the frequency, impact and factors associated with ED overcrowding. The survey was completed by 158 (65% response rate) ED directors, 62% of whom reported overcrowding as a major or severe problem during the past year. Directors attributed overcrowding to a variety of issues including a lack of admitting beds (85%), lack of acute care beds (74%) and the increased length of stay of admitted patients in the ED (63%). They perceived ED overcrowding to have a major impact on increasing stress among nurses (82%), ED wait times (79%) and the boarding of admitted patients in the ED while waiting for beds (67%). Overcrowding is not limited to large urban centres; nor is it limited to academic and teaching hospitals. The perspective of ED directors reinforces the need for further examination of effective policies and interventions to reduce ED overcrowding.     

When overcrowding paralyzes an emergency department

Emergency department overcrowding is a critical problem nation-wide. A survey by the Lewin Group in 2002 found that 90 percent of Level 1 trauma centers and hospitals with more than 300 beds reported being over capacity. Although ED overcrowding has many causes, external factors are most commonly blamed--too many patients, lack of inpatient capacity, inappropriate use of the ED, the Emergency Medical Treatment and Active Labor Act (EMTALA), lack of primary care availability, and lack of access to health care for the uninsured. In this article, we describe a series of changes that were implemented in the ED of a regional medical center. Those changes improved operational efficiency, expedited patient care, and reduced ED overcrowding. The changes focused on patient input, throughput, and output. In terms of input, we revamped the triage and admission processes. To improve throughput, we modified the physical layout of the urgent care area to maximize efficiency in staff movement and communications, changed staffing patterns to match anticipated patient volume, and revised our policies regarding exchanges with the radiology staff. To facilitate patient flow out of the ED, we identified the causes of delays in discharges and admissions, instituted the practice of flagging the charts of patients ready for discharge, and implemented admission orders to decrease patient waiting times. Improving patient throughput increases ED efficiency, and thus capacity, in terms of the number of patients that can be treated over a given time period, and it promotes the cost-effective use of institutional resources. Decreased waiting times should ultimately lead to increased patient satisfaction and better patient care.     

Emergency department observation units: A clinical and financial benefit for hospitals

INTRODUCTION: 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. BACKGROUND: 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. METHODS: 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. FINDINGS AND PRACTICE IMPLICATIONS: 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.     

Underutilization of acute care settings in a tertiary care hospital.

OBJECTIVE: To estimate underutilization of acute care settings in a tertiary care hospital. DESIGN: A retrospective and concurrent cohort study using chart reviews and the Intensity of service, Severity of illness, Discharge screen for Acute Care (ISD-AC(R)) tool to measure appropriateness of acute care for patients who were receiving care in a less acute setting, as an indicator of underutilization. SETTING: A 450-bed tertiary care teaching hospital. STUDY PARTICIPANTS: Patients discharged from the emergency department, patients discharged from acute care inpatient units and patients in acute, non-critical care settings. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The percentage of patients discharged from the emergency department who did not meet the criteria for acute care discharge screens; the percentage of patients discharged from an acute care inpatient unit who did not meet the criteria for discharge screens; and the percentage of patients who were in acute, non-critical care beds and who met the criteria for critical care. RESULTS: It was found that six out of 168 patients [3.57%; 95% confidence interval (CI), 1.32-7.61%] did not meet the discharge screens at the time of discharge from the emergency department. Four out of 156 patients (2.56%; 95% CI, 0.70-6.43%) did not meet the discharge screens at the time of discharge from an acute care inpatient service and two out of 156 acute care patients (1.33%; 95% CI, 0.02-4.73%) who were in non-critical care beds met the criteria for critical care. CONCLUSION: These findings of underutilization may help to quantitate an unmet need in health care.     

Patient flow in hospitals: understanding and controlling it better

Because waits, delays, and cancellations are so common in healthcare, patients and providers assume that waiting is an inevitable, but regrettable, part of the care process. For years, hospitals responded to delays by adding resources--more beds and buildings or more staff--as the only way to deal with an increasingly needy population. Furthermore, as long as payment for services covered the costs, more construction and more staff allowed for continued inefficiencies in the system. Today, few organizations can afford this solution. Moreover, recent work on assessing the reasons for delays suggests that adding resources is not the answer. In many cases, delays are not a resource problem; they are a flow problem. The Institute for Healthcare Improvement has worked with more than 60 hospitals in the United States and the United Kingdom to evaluate what influences the smooth and timely flow of patients through hospital departments and to develop and implement methods for improving flow. Specific areas of focus include smoothing the flow of elective surgery, reducing waits for inpatient admission through emergency departments, achieving timely and efficient transfer of patients from the intensive care unit to medical/surgical units, and improving flow from the inpatient setting to long-term-care facilities.     

Measuring quality of care in psychiatric emergencies: construction and evaluation of a Bayesian index.

OBJECTIVE. This study was conducted to determine whether an index for measuring quality of care for psychiatric emergencies is reliable and valid. DATA SOURCES/STUDY SETTING. The study used primary data collected over a 12-month period from two urban hospitals in the Northeast. One had 700 inpatient beds, an inpatient psychiatric unit, and community mental health personnel located in the emergency department. The other had 300 beds but none of the other hospital's features. STUDY DESIGN. The index was developed by a panel of experts in emergency psychiatry using a subjective Bayesian statistical methodology and was evaluated in terms of its ability to: (1) predict a second panel's judgments of quality; (2) predict a specific quality-related patient outcome, i.e., compliance with follow-up recommendations; (3) provide a reliable measurement procedure; and (4) detect variations in patterns of emergency department practices. DATA COLLECTION/EXTRACTION METHODS. Data were collected on 2,231 randomly selected emergency psychiatric patients (psychiatric diagnosis, alcohol abuse, nonverbal patients experiencing a psychiatric emergency, and patients with somatic complaints such as life crisis) treated in the emergency departments of the two hospitals. PRINCIPAL FINDINGS. The index predicted physician judgments of quality, was reliable, exhibited sufficient variation in scores, and was strongly associated with patient compliance. CONCLUSIONS. The study demonstrated that a subjective Bayesian model can be used to develop a reliable and valid index for measuring quality of care, with potential for practical application in management of health services.     

Hospital-at-Home Expands Hospital Capacity During COVID-19 Pandemic

A Coronavirus Disease 2019 (COVID-19)–specific Hospital-at-Home was implemented in a 400-bed tertiary hospital in Barcelona, Spain. Senior or immune-compromised physicians oversaw patient care. The alternative to inpatient care more than doubled beds available for hospitalization and decreased the risk of transmission among patients and health care professionals. Mild cases from either the emergency department or after hospital discharge were deemed suitable for admission to the Hospital-at-Home. More than half of all patients had pneumonia. Standardized protocols and management criteria were provided. Only 6% of cases required referral for inpatient hospitalization. These results are promising and may provide valuable insight for centers undertaking Hospital-at-Home initiatives or in the case of new COVID-19 outbreaks.     

The impact of improved access to after-hours primary care on emergency department and primary care utilization: A systematic review

Access to after-hours primary care is problematic in many developed countries, leading patients to instead visit the emergency department for non-urgent conditions. However, emergency department utilization for conditions treatable in primary care settings may contribute to emergency department overcrowding and increased health system costs. This systematic review examines the impact of various initiatives by developed countries to improve access to after-hours primary care on emergency department and primary care utilization. We performed a systematic review on the impact of improved access to after-hours primary and searched CINAHL, EMBASE, MEDLINE, and Scopus. We identified 20 studies that examined the impact of improved access to after-hours primary care on ED utilization and 6 studies that examined the impact on primary care utilization. Improved access to after-hours primary care was associated with increased primary care utilization, but had a mixed effect on emergency department utilization, with limited evidence of a reduction in non-urgent and semi-urgent emergency department visits. Although our review suggests that improved access to after-hours primary care may limit emergency department utilization by shifting patient care from the emergency department back to primary care, rigorous research in a given institutional context is required before introducing any initiative to improve access to after-hours primary care.     

Reasons for crowded EDs vary among hospitals,communities, GAO says

While no single issue explains the main reason for overcrowding in hospital emergency departments (EDs), the inability to transfer emergency patients to inpatient beds quickly once a decision to admit them has been made appears to be an important contributing factor at many hospitals, according to a new report on ED overcrowding from the U.S. General Accounting Office.     

Linking health services at the Community level

This study describes a series of interventions linking hospitals, medical staff physicians, long-term care providers and mental health services in the metropolitan area of Syracuse, New York. The objectives of these interventions were to improve patient outcomes and system-wide efficiency. The study demonstrated that these linkages, including system-wide data feedback, contributed to limitation of emergency department overcrowding, reduction of physician lengths of stay, elimination of duplication of medical staff credentialing, as well as access to and efficiency of long-term care and mental health services.     

Strategies for cutting hospital beds: the impact on patient service.

OBJECTIVE: To develop insights on the impact of size, average length of stay, variability, and organization of clinical services on the relationship between occupancy rates and delays for beds. DATA SOURCES: The primary data source was Beth Israel Deaconess Medical Center in Boston. Secondary data were obtained from the United Hospital Fund of New York reflecting data from about 150 hospitals. STUDY DESIGN: Data from Beth Israel Deaconess on discharges and length of stay were analyzed and fit into appropriate queueing models to generate tables and graphs illustrating the relationship between the variables mentioned above and the relationship between occupancy levels and delays. In addition, specific issues of current concern to hospital administrators were analyzed, including the impact of consolidation of clinical services and utilizing hospital beds uniformly across seven days a week rather than five. PRINCIPAL FINDINGS: Using target occupancy levels as the primary determinant of bed capacity is inadequate and may lead to excessive delays for beds. Also, attempts to reduce hospital beds by consolidation of different clinical services into single nursing units may be counterproductive. CONCLUSIONS: More sophisticated methodologies are needed to support decisions that involve bed capacity and organization in order to understand the impact on patient service.     

Medical care capacity for influenza outbreaks,Los Angeles

In December 1997, media reported hospital overcrowding and "the worst [flu epidemic] in the past two decades" in Los Angeles County (LAC). We found that rates of pneumonia and influenza deaths, hospitalizations, and claims were substantially higher for the 1997-98 influenza season than the previous six seasons. Hours of emergency medical services (EMS) diversion (when emergency departments could not receive incoming patients) peaked during the influenza seasons studied; the number of EMS diversion hours per season also increased during the seasons 1993-94 to 1997-98, suggesting a decrease in medical care capacity during influenza seasons. Over the seven influenza seasons studied, the number of licensed beds decreased 12%, while the LAC population increased 5%. Our findings suggest that the capacity of health-care systems to handle patient visits during influenza seasons is diminishing.     

Reorganizing ambulatory care: an administrator's view

Citing a continuing increase in the utilization of hospital outpatient services, the authors discuss the reorganization of the ambulatory care delivery system at a 300-bed community hospital serving the Cambridge, Massachusetts area. Due to the attrition of community-based physicians, the Mount Auburn Hospital had an overburdened emergency services and an underutilized outpatient department. To improve this situation, full-time physicians and a non-physician administrator were hired for the outpatient area. In the four years following the reorganization, patient volume has increased and utilization has shifted from emergency to primary care which has required the hospital to adjust staffing in several ancillary departments. The hospital has now reached the point where growth must be carefully planned and controlled in order to preserve cost-effective, high quality care. The authors conclude that planning for hospital-based ambulatory care units should include: (1) defining the needs of the target communities; (2) marketing programs; and (3) anticipating legislation which will influence the demand for outpatient services.     

Carrot and sticks? The Community Care Act (2003) and the effect of financial incentives on delays in discharge from hospitals in England

BACKGROUND: The belief that many delays in discharge from hospital were caused by social service departments (SSDs) led to the Community Care Act 2003 giving NHS hospitals in England the power to charge SSDs. METHODS: We surveyed 150 SSDs in England about the implementation of the Act and used routine data to analyse trends in the number of delayed discharge patients; the number and cause of delayed discharge bed days by sector; and the proportion of inpatient bed days that consisted of delayed discharges. FINDINGS: Most hospitals opted not to charge SSDs for delays. Almost two thirds of SSDs (62%) made no payment of any kind to an acute hospital in 2004/05 and 2005/06, preferring to work collaboratively. The fall in number of 'delayed discharge patients' is a long term trend which precedes the implementation of the 2003 Act. Delayed discharge bed days accounted for 1.58% of all inpatient bed days in 2004/05. Contrary to popular opinion, the NHS accounted for two thirds (67%) of bed day delays, lack of suitable alternative NHS provision and services is a key factor. Patients are being discharged in greater numbers and earlier in their post-acute recovery phase. There are however questions about the quality and safety of early discharge. For example, emergency hospital readmissions rates have risen from 5.4% in 2002/03 to 6.7% in 2005/06, and patient dissatisfaction is significant. CONCLUSION: Although delays in discharge from acute hospital beds have fallen, the quality of discharge and the capacity of Primary Care Trusts (PCTs) and SSDs to ensure appropriate and adequate post-discharge care is not as it should be. Contrary to popular perception, social services delays are of less significance than delays attributable to the NHS. There is no evidence to support government policy of charging SSDs for delay. Other factors, including NHS provision, are important, and a comprehensive overview of health and social care is vital.     

Organisational implications of concentration orthopaedic services

The re-organisation of the acute health services in 1999 is causing many acute trusts to consider the practical implications of concentrating services. This may be in terms of the complete merger of departments at different units or a less radical policy of the alternation of the responsibility for emergency receiving between units. The benefits may include the opportunity to improve the quality of care by providing more specialist services, more attractive working conditions with a larger pool of specialists providing the on-call rota and enhanced opportunity for training. Economic theory indicates that concentration should lead to economies of scale by greater sharing of fixed overhead costs, whilst statistical theory specifies that concentration should produce a relative decline in the variability of demand. This paper examines the effects of concentration on emergency admissions in an orthopaedic department by means of a series of simulation experiments. It examines the potential economies of scale for theatre utilisation and bed usage associated with increasing the volume of non-elective patients. As the volume of patients increases so the relative variability of demand decreases and the relative demand for emergency operating theatre time declines. Concentration could offer savings on theatre time allocated to trauma patients, but the impact on wards is less significant with concentration having a limited effect on the demand for beds.     

Food Insecurity and Health Care Utilization Among Older Adults in the United States

This study examined the relationships between food insecurity and utilization of four health services among older Americans: office visits, inpatient hospital nights, emergency department visits, and home health care. Nationally representative data from the 2011 and 2012 National Health Interview Survey were used (N = 13,589). Nearly 83.0% of the sample had two or more office visits, 17.0% reported at least one hospital night, 23.0% had at least one emergency room visit, and 8.1% used home health care during the past 12 months. Adjusting for confounders, food-insecure older adults had higher odds of using more office visits, inpatient hospital nights, and emergency department visits than food-secure older adults, but similar odds of home health care utilization. The findings of this study suggest that programs and policies aimed at reducing food insecurity among older adults may have a potential to reduce utilization of health care services.     

The impact of the observation ward on acute admissions at Guy's Hospital

This paper describes an evaluation of the short-stay ward at Guy's Hospital Accident and Emergency Department. It includes an audit of the operational policy, the care provided to patients, and the impact of the short-stay ward on hospital admissions. The results indicate that by concentrating patients in a short-stay ward, the quality of care is improved, delays are reduced, and the pressure on inpatient beds is relieved.     

The future of community-centred health services in Australia - an alternative view

Community-centred healthcare works in conjunction with hospital-centred healthcare. Both have strengths and limitations. Community-centred healthcare has been demonstrated to be a more cost-efficient and cost-effective alternative to hospital-centred care at best in a limited fashion. If hospital-centred services dominate healthcare services in Australia, as argued previously in this journal, then this has not extended to maintenance of inpatient bed provision. The author, as a hospital-based emergency specialist, has observed case load and models of care in hospitals and emergency departments for 30 years and is sceptical of promises to substantially further decrease emergency department demand and acute bed requirements. The real benefits of community, primary and preventive care should not be over sold.