MINNEAPOLIS – Smoothing hospital occupancy over the entire week could reduce weekday inpatient crowding, according to two retrospective cohort studies.
Traditionally, hospital occupancy is higher on weekdays than on weekends, typically because elective admissions are scheduled for Monday with an eye toward discharging patients by the weekend. This results in peaks and troughs in occupancy that cause midweek crowding and unused capacity on other days, particularly weekends.
Dr. Evan Fieldston
Indeed, a study of 22,310 pediatric admissions, of which 22% were scheduled, found that Mondays generated 25% of all scheduled patient-hours defined as the number of patients multiplied by length of stay (LOS). Tuesday and Wednesday generated 20% each, whereas Saturdays and Sundays combined generated less than 3% of patient-hours.
Not surprisingly, Wednesday and Thursday had the highest peak daily occupancy, and were the days most likely to have occupancy above 90% and 95%, Dr. Evan Fieldston and his colleagues reported in a poster presentation at the Pediatric Hospital Medicine 2010 meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The median LOS for scheduled patients admitted on Monday and staying less than 1 week was significantly longer at 2.49 days compared with 2.08 days for their counterparts admitted on any other weekday.
Hospitals usually respond to midweek crowding by attempting to reduce LOS, but that may not sufficiently increase functional capacity, explained Dr. Fieldston, a pediatric hospitalist at Children’s Hospital of Philadelphia. By proactively managing the inflow of scheduled admissions, hospitals can avoid unused capacity and optimize patient flow.
“Many people [believe] that nobody wants to work on weekends and no patients want to come in on weekends, but there are a number of patients who would be very happy to come on the weekends and some staff who would like to work weekends for family reasons,” he said in an interview. “It’s a matter of aligning incentives.
“The other important thing to think about with staffing is that the estimated cost of adding a bed to a children’s hospital is $2 million per bed. So if you’re going to build 20 beds to deal with your overcrowding, $40 million dollars can bring in a lot of staff.”
The researchers conducted a second study to quantify the theoretical effect of smoothing on inpatient occupancy at 39 tertiary care children’s hospitals in the Pediatric Health Information System. A retrospective smoothing algorithm was used to set each hospital’s daily occupancy to the hospital’s mean occupancy for each week. Post-smoothing reductions in weekly maximum occupancy were averaged for the entire year for each hospital.
Before smoothing, there were 550,543 discharges, with a median LOS of 3 days. The hospitals’ mean midnight occupancy ranged from 71% to 108% on weekdays and from 66% to 95% on weekends, Dr. Fieldston reported. Over all of the hospitals, the median difference between weekday and weekend occupancy was 8.2% points. For a 300-bed hospital, this would translate to a 24-patient lower census on weekends than on weekdays.
Before smoothing, the number of hospitals with mean weekday occupancy above threshold was 33 at greater than 85% occupancy, 25 at more than 90% occupancy, 14 at more than 95% occupancy, and 6 at greater than 100% occupancy. After smoothing, the number of hospitals above threshold was reduced to 32, 22, 10 and 1, respectively, which was significant at each threshold, except the 85%-threshold, he said.
By smoothing, 39,607 patients from the 39 hospitals could be removed from exposure to occupancy exceeding 95%.
Only a small percentage of all admissions (median, 2.6%; range, 0.02%-9.2% across hospitals) would have to be scheduled differently each week to achieve within-week smoothing of occupancy, Dr. Fieldston said. This represents about one-tenth of scheduled admissions per week.
The authors acknowledged that the study assumed a fixed number of beds for the whole year, that the ability to smooth occupancy rests on an adequate number of scheduled admissions to shift during a week, and that midnight census rather than peak daily census was used to determine occupancy.
Still, they concluded that “smoothing has the potential to help optimize patient flow and increase quality and safety in health care delivery.”
If this were to occur, however, then the negative associations surrounding weekend hospital stays would have to change.
“The issue of the weekends not being the best time to be in the hospital shouldn’t be a reason to not bring in patients,” Dr. Fieldston said. “We truly ought to be a 7-day institution.
“We shouldn’t make a hospital less safe for the patients who need to be there on the weekends. And potentially, you have the positive catch-22 that if you purposely schedule patients to be there on the weekend, you will bring in revenue and make it in everyone’s best interest to make the weekend safer and provide better care to all patients,” said Dr. Fieldston, who reported no conflicts of interest.