Associations between in-hospital bed occupancy and unplanned 72-h revisits to the emergency department: a register study

The association between bed occupancy rates and hospital quality in the English National Health Service

We study whether hospitals that exhibit systematically higher bed occupancy rates are associated with lower quality in England over 2010/11-2017/18. We develop an economic conceptual framework to guide our empirical analysis and run regressions to inform possible policy interventions. First, we run a pooled OLS regression to test if high bed occupancy is associated with, and therefore acts as a signal of, lower quality, which could trigger additional regulation. Second, we test whether this association is explained by exogenous demand-supply factors such as potential demand, and unavoidable costs. Third, we include determinants of bed occupancy (beds, length of stay, and volume) that might be associated with quality directly, rather than indirectly through bed occupancy. Last, we use a within-between random-effects specification to decompose these associations into those due to variations in characteristics between hospitals and variations within hospitals. We find that bed occupancy rates are positively associated with overall and surgical mortality, negatively associated with patient-reported health gains, but not associated with other indicators. These results are robust to controlling for demand-supply shifters, beds, and volume. The associations reduce by 12%-25% after controlling for length of stay in most cases and are explained by variations in bed occupancy between hospitals.

Managing inpatient bed setup: an action-research approach using lean technical practices and lean social practices

PURPOSE

This article aims to introduce a guide to improving hospital bed setup by combining lean technical practices (LTPs), such as kaizen and value stream mapping (VSM) and lean social practices (LSPs), such as employee empowerment.

DESIGN/METHODOLOGY/APPROACH

Action research approach was employed to analyze the process of reconfiguration of bed setup management in a Brazilian public hospital.

FINDINGS

The study introduces three contributions: (1) presents the use of VSM focused specifically on bed setup, while the current literature presents studies mainly focused on patient flow management, (2) combines the use of LSPs and LTPs in the context of bed management, expanding current studies that are focused either on mathematical models or on social and human aspects of work, (3) introduces a practical guide based on six steps that combine LSPs and LSPs to improve bed setup management.

RESEARCH LIMITATIONS/IMPLICATIONS

The research focused on the analysis of patient beds. Surgical beds, delivery, emergency care and intensive care unit (ICU) were not considered in this study. In addition, the process indicators analyzed after the implementation of the improvements did not contemplate the moment of the COVID-19 pandemic. Finally, this research focused on the implementation of the improvement in the context of only one Brazilian public hospital.

PRACTICAL IMPLICATIONS

The combined use of LSPs and LTPs can generate considerable gains in bed setup efficiency and consequently increase the capacity of a hospital to admit new patients, without the ampliation of the physical space and workforce.

SOCIAL IMPLICATIONS

The improvement of bed setup has an important social character, whereas it can generate important social benefits such as the improvement of the admission service to patients, reducing the waiting time, reducing hospitalization costs and improving the hospital capacity without additional physical resources. All these results are crucial for populations, their countries and regions.

ORIGINALITY/VALUE

While the current literature on bed management is more focused on formal models or pure human and social perspectives, this article brings these two perspectives together in a single, holistic framework. As a result, this article points out that the complex bed management problem can be efficiently solved by combining LSPs and LTPs to present theoretical and practical contributions to the important social problem of hospital bed management.

Influence of Overcrowding in the Emergency Department on Return Visit within 72 Hours

This study was conducted to determine whether overcrowding in the emergency department (ED) affects the occurrence of a return visit (RV) within 72 h. The crowding indicator of index visit was the average number of total patients, patients under observation, and boarding patients during the first 1 and 4 h from ED arrival time and the last 1 h before ED departure. Logistic regression analysis was conducted to determine whether each indicator affects the occurrence of RV and post-RV admission. Of the 87,360 discharged patients, 3743 (4.3%) returned to the ED within 72 h. Of the crowding indicators pertaining to total patients, the last 1 h significantly affected decrease in RV (p = 0.0046). Boarding patients were found to increase RV occurrence during the first 1 h (p = 0.0146) and 4 h (p = 0.0326). Crowding indicators that increased the likelihood of admission post-RV were total number of patients during the first 1 h (p = 0.0166) and 4 h (p = 0.0335) and evaluating patients during the first 1 h (p = 0.0059). Overcrowding in the ED increased the incidence of RV and likelihood of post-RV admission. However, overcrowding at the time of ED departure was related to reduced RV.

Association Between Hospital Bed Occupancy and Outcomes in Emergency Care: A Cohort Study in Stockholm Region, Sweden, 2012 to 2016

STUDY OBJECTIVE

We evaluate the importance of hospital bed occupancy for 30-day mortality, inhospital mortality, readmission for inpatient care within 30 days, and revisits to the emergency department (ED) within 7 days among all adult patients visiting the ED.

METHODS

This was an observational cohort study including all adult patients visiting 6 EDs in Stockholm Region, Sweden. ED visits from 2012 to 2016 were categorized into groups by hospital bed occupancy in 5% intervals between 85% and 105%. A proportional hazards model was used to estimate adjusted hazard ratios with 95% confidence intervals (CIs). The model was stratified by hospital and adjusted for age, sex, comorbidities, hospital stays in the year preceding the index visit, marital status, length of education, and weekday/weekend timing of visit.

RESULTS

A total of 816,832 patients with 2,084,554 visits were included. Mean hospital bed occupancy was 93.3% (SD 3.3%). In total, 28,112 patients died within 30 days, and 17,966 patients died inhospital. Hospital bed occupancy was not associated with 30-day mortality (hazard ratio for highest category of occupancy ≥105% was 1.10; 95% CI 0.96 to 1.27) or inhospital mortality. Patients discharged from the ED at occupancy levels greater than 89% had a 2% to 4% higher risk of revisits to the ED within 7 days. A 10% increase in hospital bed occupancy was associated with a 16-minute increase (95% CI 16 to 17 minutes) in ED length of stay and 1.9-percentage-point decrease (95% CI 1.7 to 2.0 percentage points) in admission rate.

CONCLUSION

We did not find an association between increasing hospital bed occupancy and mortality in our sample of 6 EDs in Stockholm Region, Sweden, despite increased length of stay in the ED and a decline in admissions for inpatient care.

[Detection of risk factors for preventable paediatric hospital readmissions]

INTRODUCTION AND OBJECTIVES

Readmission rate is an indicator of the quality of hospital care. The aim of the study is to identify potential preventable factors for paediatric readmission.

MATERIAL AND METHODS

A descriptive, analytical, longitudinal, and single centre study was carried out in the Paediatric Hospitalisation ward of a tertiary hospital during the period from June 2012 to November 2015. Readmission was defined as the one that occurs in the first 30 days of previous admission, as very early readmission if it occurs in the first 48hours, early readmission in the 2-7 days, and late readmission if occurs after 7 days. Preventable readmission is defined as one that takes place in the first 15 days and for the same reason as the first admission. Epidemiological and clinical variables were analysed. A univariate and multivariate study was carried out.

RESULTS

In the study period, 5,459 patients were admitted to the paediatric hospital, of which 226 of them were readmissions (rate of readmission: 4.1%). When the hospital occupation rate was greater than 70%, the overall percentage of readmissions was significantly higher (8.5% vs 2.5%; P<.001). In the multivariate analysis, it was found that having a chronic disease and the number of visits to emergency care units before admission, are predictive factors of preventable readmission.

CONCLUSIONS

The rate of readmissions is greater in the periods of higher care pressure. The readmission of patients with chronic condition is preventable, and therefore strategies must be designed to try to avoid them.

Exploring emergency department 4-hour target performance and cancelled elective operations: a regression analysis of routinely collected and openly reported NHS trust data

OBJECTIVE

To quantify the effect of intrahospital patient flow on emergency department (ED) performance targets and indicate if the expectations set by the National Health Service (NHS) England 5-year forward review are realistic in returning emergency services to previous performance levels.

DESIGN

Linear regression analysis of routinely reported trust activity and performance data using a series of cross-sectional studies.

SETTING

NHS trusts in England submitting routine nationally reported measures to NHS England.

PARTICIPANTS

142 acute non-specialist trusts operating in England between 2012 and 2016.

MAIN OUTCOME MEASURES

The primary outcome measures were proportion of 4-hour waiting time breaches and cancelled elective operations.

METHODS

Univariate and multivariate linear regression models were used to show relationships between the outcome measures and various measures of trust activity including empty day beds, empty night beds, day bed to night bed ratio, ED conversion ratio and delayed transfers of care.

RESULTS

Univariate regression results using the outcome of 4-hour breaches showed clear relationships with empty night beds and ED conversion ratio between 2012 and 2016. The day bed to night bed ratio showed an increasing ability to explain variation in performance between 2015 and 2016. Delayed transfers of care showed little evidence of an association. Multivariate model results indicated that the ability of patient flow variables to explain 4-hour target performance had reduced between 2012 and 2016 (19% to 12%), and had increased in explaining cancelled elective operations (7% to 17%).

CONCLUSIONS

The flow of patients through trusts is shown to influence ED performance; however, performance has become less explainable by intratrust patient flow between 2012 and 2016. Some commonly stated explanatory factors such as delayed transfers of care showed limited evidence of being related. The results indicate some of the measures proposed by NHS England to reduce pressure on EDs may not have the desired impact on returning services to previous performance levels.

Primary triage nurses do not divert patients away from the emergency department at times of high in-hospital bed occupancy - a retrospective cohort study

BACKGROUND

Emergency department (ED) overcrowding is frequently described in terms of input- throughput and output. In order to reduce ED input, a concept called primary triage has been introduced in several Swedish EDs. In short, primary triage means that a nurse separately evaluates patients who present in the Emergency Department (ED) and either refers them to primary care or discharges them home, if their complaints are perceived as being of low acuity. The aim of the present study is to elucidate whether high levels of in-hospital bed occupancy are associated with decreased permeability in primary triage. The appropriateness of discharges from primary triage is assessed by 72-h revisits to the ED.

METHODS

The study is a retrospective cohort study on administrative data from the ED at a 420-bed hospital in southern Sweden from 2011-2012. In addition to crude comparisons of proportions experiencing each outcome across strata of in-hospital bed occupancy, multivariate models are constructed in order to adjust for age, sex and other factors.

RESULTS

A total of 37,129 visits to primary triage were included in the study. 53.4 % of these were admitted to the ED. Among the cases referred to another level of care, 8.8 % made an unplanned revisit to the ED within 72 h. The permeability of primary triage was not decreased at higher levels of in-hospital bed occupancy. Rather, the permeability was slightly higher at occupancy of 100-105 % compared to <95 % (OR 1.09 95 % CI 1.02-1.16). No significant association between in-hospital bed occupancy and the probability of 72-h revisits was observed.

CONCLUSIONS

The absence of a decreased permeability of primary triage at times of high in-hospital bed occupancy is reassuring, as the opposite would have implied that patients might be denied entry not only to the hospital, but also to the ED, when in-hospital beds are scarce.

The probability of readmission within 30 days of hospital discharge is positively associated with inpatient bed occupancy at discharge--a retrospective cohort study

BACKGROUND

Previous work has suggested that given a hospital's need to admit more patients from the emergency department (ED), high inpatient bed occupancy may encourage premature hospital discharges that favor the hospital's need for beds over patients' medical interests. We argue that the effects of such action would be measurable as a greater proportion of unplanned hospital readmissions among patients discharged when the hospital was full than when not. In response, the present study tested this hypothesis by investigating the association between inpatient bed occupancy at the time of hospital discharge and the 30-day readmission rate.

METHODS

The sample included all inpatient admissions from the ED at a 420-bed emergency hospital in southern Sweden during 2011-2012 that resulted in discharge before 1 December 2012. The share of unplanned readmissions within 30 days was computed for levels of inpatient bed occupancy of <95%, 95-100%, 100-105% and >105% at the hour of discharge. A binary logistic regression model was constructed to adjust for age, time of discharge, and other factors that could affect the outcome.

RESULTS

In all, 32,811 visits were included in the study, 9.9% of which resulted in an unplanned readmission within 30 days of discharge. The proportion of readmissions was 9.0% for occupancy levels of <95% at the patient's discharge, 10.2% for 95-100% occupancy, 10.8% for 100-105% occupancy, and 10.5% for >105% occupancy (p = 0.0001). Results from the multivariate models show that the OR (95% CI) of readmission was 1.11 (1.01-1.22) for patients discharged at 95-100% occupancy, 1.17 (1.06-1.29) at 100-105% occupancy, and 1.15 (0.99-1.34) at >105% occupancy.

CONCLUSIONS

Results indicate that patients discharged from inpatient wards at times of high inpatient bed occupancy experience an increased risk of unplanned readmission within 30 days of discharge.

Patients presenting at the emergency department with acute abdominal pain are less likely to be admitted to inpatient wards at times of access block: a registry study

Background

Also known as access block, shortage of inpatient beds is a common cause of emergency department (ED) boarding and overcrowding, which are both associated with impaired quality of care. Recent studies have suggested that access block not simply causes boarding in EDs, but may also result in that patients are less likely to be admitted to the hospital from the ED. The present study’s aim was to investigate whether this effect remained for patients with acute abdominal pain, for which different management strategies have emerged. Access block was defined in terms of hospital occupancy and the appropriateness of ED discharges addressed as 72 h revisits to the ED.

Methods

As a registry study of ED administrative data, the study examined a population of patients who presented with acute abdominal pain at the ED of a 420-bed hospital in southern Sweden during 2011–2013. Associations between exposure and outcomes were addressed in contingency tables and by logistic regression models.

Results

Crude analysis revealed a negative association between access block and the probability of inpatient admission (38.6 % admitted at 0–95 % occupancy, 37.8 % at 95–100 % occupancy, and 35.0 % at ≥100 % occupancy) (p < .001). No significant associations between exposure and 72 h revisits emerged. Multivariable models indicated an odds ratio of inpatient admission of 0.992 (95 % CI: 0.986–0.997) per percentage increase in hospital occupancy.

Conclusions

Study findings indicate that patients with acute abdominal pain are less likely to be admitted to the hospital from the ED at times of access block and that other management strategies are employed instead. No association with 72 h revisits was seen, but future studies need to address more granular outcomes in order to clarify the safety aspects of the effect.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-015-0158-3) contains supplementary material, which is available to authorized users.

Unplanned 3-day re-attendance rate at Emergency Department (ED) and hospital's bed occupancy rate (BOR)

Background

Unplanned re-attendance at the Emergency Department (ED) is often monitored as a quality indicator of the care accorded to patients during their index ED visit. High bed occupancy rate (BOR) has been considered as a matter of reduced patient comfort and privacy. Most hospitals in Singapore operate under BORs above 85 %. This study aims to explore factors associated with the unplanned 3-day ED re-attendance rate and, in particular, if higher BOR is associated with higher 3-day unplanned ED re-attendance rate.

Methods

This was a multicenter retrospective study using time series data. Three acute tertiary hospitals were selected from all six adult public hospitals in Singapore based on data availability. Daily data from year 2008 to 2013 were collected from the study hospitals’ information systems. These included: ED visit date, day of week, month, year, public holiday, daily hospital BOR, daily bed waiting time (BWT) at ED (both median and 95th percentile), daily ED admission rate, and 3-day ED re-attendance rate. The primary outcome of the study was unplanned 3-day ED re-attendance rate from all reasons. Both univariate analysis and generalized linear regression were respectively applied to study the crude and adjusted association between the unplanned 3-day ED re-attendance rate and its potential associated factors. All analyses were conducted using SPSS 18 (PASW 18, IBM).

Results

The average age of patients who visited ED was 35 years old (SD = 2), 37 years old (SD = 2), and 40 years old (SD = 2) in hospitals A, B, and C respectively. The average 3-day unplanned ED re-attendance rate was 4.9 % (SE = 0.47 %) in hospital A, 3.9 % (SE = 0.35 %) in hospital B, and 4.4 % (SE = 0.30 %) in hospital C. After controlling for other covariates, the unplanned 3-day ED re-attendance rates were significantly associated with hospital, time trend, day of week, daily average BOR, and ED admission rate. Strong day-of-week effect on early ED re-attendance rate was first explored in this study. Thursday had the lowest re-attendance rate, while Sunday has the highest re-attendance rate. The patients who visited at ED on the dates with higher BOR were more likely to re-attend the ED within 3 days for hospitals A and B. There was no significant association between BOR and ED re-attendance rate in hospital C.

Conclusions

A study using time series data has been conducted to explore the factors associated with the unplanned 3-day ED re-attendance rate. Strong day-of-week effect was first reported. The association between BOR and the ED re-attendance rate varied with hospital.