The Gap Between Daily Hospital Bed Supply and Demand: Design, Implementation, and Impact of Data-Driven Pre-Noon Discharge Targets

BACKGROUND

Hospitals have sought to increase pre-noon discharges to improve capacity, although evidence is mixed on the impact of these initiatives. Past interventions have not quantified the daily gap between morning bed supply and demand. The authors quantified this gap and applied the pre-noon data to target a pre-noon discharge initiative.

METHODS

The study was conducted at a large hospital and included adult and pediatric medical/surgical wards. The researchers calculated the difference between the average cumulative bed requests and transfers in for each hour of the day in 2018, the year prior to the intervention. In 2019 an intervention on six adult general medical and two surgical wards was implemented. Eight intervention and 14 nonintervention wards were compared to determine the change in average cumulative pre-noon discharges. The change in average hospital length of stay (LOS) and 30-day readmissions was also calculated.

RESULTS

The average daily cumulative gap by noon between bed supply and demand across all general care wards was 32.1 beds (per ward average, 1.3 beds). On intervention wards, mean pre-noon discharges increased from 4.7 to 6.7 (p < 0.0000) compared with the nonintervention wards 14.0 vs. 14.6 (p = 0.19877). On intervention wards, average LOS decreased from 6.9 to 6.4 days (p < 0.001) and readmission rates were 14.3% vs 13.9% (p = 0.3490).

CONCLUSION

The gap between daily hospital bed supply and demand can be quantified and applied to create pre-noon discharge targets. In an intervention using these targets, researchers observed an increase in morning discharges, a decrease in LOS, and no significant change in readmissions.

Impact of a hospital policy to redistribute admission flow across clinical services for capacity relief during COVID-19 surges

BACKGROUND

Increased hospital admissions due to COVID-19 place a disproportionate strain on inpatient general medicine service (GMS) capacity compared to other services.

OBJECTIVE

To study the impact on capacity and safety of a hospital-wide policy to redistribute admissions from GMS to non-GMS based on admitting diagnosis during surge periods.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective case-controlled study at a large teaching hospital. The intervention included adult patients admitted to general care wards during two surge periods (January-February 2021 and 2022) whose admission diagnosis was impacted by the policy. The control cohort included admissions during a matched number of days preceding the intervention.

MAIN OUTCOMES AND MEASURES

Capacity measures included average daily admissions and hospital census occupied on GMS. Safety measures included length of stay (LOS) and adverse outcomes (death, rapid response, floor-to-intensive care unit transfer, and 30-day readmission).

RESULTS

In the control cohort, there were 365 encounters with 299 (81.9%) GMS admissions and 66 (18.1%) non-GMS versus the intervention with 384 encounters, including 94 (24.5%) GMS admissions and 290 (75.5%) non-GMS (p < .001). The average GMS census decreased from 17.9 and 21.5 during control periods to 5.5 and 8.5 during intervention periods. An interrupted time series analysis confirmed a decrease in GMS daily admissions (p < .001) and average daily hospital census (p = .014; p < .001). There were no significant differences in LOS (5.9 vs. 5.9 days, p = .059) or adverse outcomes (53, 14.5% vs. 63, 16.4%; p = .482).

CONCLUSION

Admission redistribution based on diagnosis is a safe lever to reduce capacity strain on GMS during COVID-19 surges.

Analysis of SAFB1 and SAFB2 Knockout Mice Reveals Non-Redundant Functions of the Two Estrogen Receptor Co-Repressor Paralogs

The Scaffold Attachment Factor B1 (SAFB1) and B2 (SAFB2) have been shown to be involved in chromatin organization, transcriptional regulation, and RNA processing. The paralogs SAFB1 and SAFB2 share 74% similarity at the amino acid level, with up to 98% similarity in some functional domains. These functional domains include DNA and RNA-binding domains, and a C-terminal repression domain. We have previously shown that SAFB1 and SAFB2 function as estrogen receptor (ER) corepressors – they directly bind to ER, and repress its transcriptional activity. There is also evidence that both proteins play a role in breast cancer; their shared chromosomal locus on chromosome 19p13 displays high rates of LOH, and protein loss was associated with worse survival of breast cancer patients.To understand the roles of SAFB1 and SAFB2 in development and function of hormone responsive tissues, we generated gene-specific knockout (KO) mouse models. Deletion of SAFB1 resulted in a high degree of embryonic and perinatal lethality. Surviving SAFB1 KO mice displayed severe growth retardation associated with low serum IGF-I levels, male infertility and female subfertility. In contrast, SAFB2 KO mice were born at the expected Mendelian ratio and did not show any obvious defects in growth or fertility. Initial gross pathology analysis has not yet revealed any significant defects.Since the SAFB proteins are known to play a role in estrogen response, we analyzed mammary gland development in the two mouse models. Young virgin SAFB1 KO mice showed delayed mammary gland development with a significantly reduced number of terminal end buds and decreased outgrowth compared to wild type (WT) controls. This was likely a result of delayed puberty, due to low IGF-I levels, since at the four month time point, mammary gland growth was restored in the virgin SAFB1 KO mice to that seen in WT controls. Interestingly, the KO glands exhibited increased alveolar development and side branching. To measure proliferation directly, we performed mammary gland transplantation experiments, thereby excluding secondary effects due to systemic defects. These studies showed a significant increase in proliferation in SAFB1 KO glands compared to WT control glands. In contrast to the SAFB1-null mice, we did not observe any obvious mammary gland defects in pubertal or adult SAFB2-null mice. However, mammary glands from aged virgin SAFB2 mice (1.5 years old) showed extensive side branching and precocious development of alveolar buds resembling glands of late pregnant mice. This was associated with increased proliferation of alveolar cells in the SAFB2 KO glands.In summary, genetic ablation of the ER co-repressors SAFB1 and SAFB2 results in defects in mammary gland development. In general, the two mouse models have very different phenotypes, revealing diverse and non-redundant functions of SAFB1 and SAFB2, findings that were unexpected based on their high sequence similarity. We are currently performing additional studies to finalize characterization of the in vivo phenotypes, focusing on hormone responsive tissues, and also to understand the mechanism underlying the observed phenotypes.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2162.

Heating unsaturated fatty acids in air produces hemagglutinins

When mono-unsaturated fatty acids are heated in air, they form hemagglutinins. When the double bond is delta-6,7 or delta-9,10, the titer is higher than for delta-11,12. Stearic acid does not become a hemagglutinin on heating. Hydroxy-monounsaturated fatty acids, ricinoleic (cis-12-OH-delta-9) and ricinelaidic (trans-12-OH-delta-9) are not hemagglutinins unless they are heated. Oleic acid (delta-9-octadecenoic acid, OA) has a very low agglutination titer but lyses red cells at higher concentrations. Rabbit and rat erythrocytes (RBC) give the highest titers but RBCs of other species are also agglutinated. OA was chosen for further study. Its specific titer against rat RBCs increases with time of heating in air. Thin-layer chromatography (TLC) and mass spectroscopy (MS) show that higher molecular weight compounds are formed and that activity is associated with these materials. Synthetic (oxidation of oleic acid with tert-butyl peroxide) and commercial preparations of oleic acid dimers (Emery and Unichema) and a commercial preparation of oleic trimer mixed with polymer (Emery) have high hemagglutination titers against rat erythrocytes. A cyclic, long-chain dicarboxylic acid, 5(6)-carboxy-4-hexyl-2-cyclohexene-1-octanoic acid (Westvaco) gives a very low titer unless heated and no lysis. Sialidase treatment of the red cells increases the titer. Removal of cations does not alter the titer but addition of Ca2+ or Mg2+ lowers the titer. Light microscopy was used to characterize and visualize the agglutination process with rat RBCs. Agglutination without lysis or fusion is observed for low concentrations of heated oleic acid and C-18 dimers and trimer-polymer preparations, and no large vesicles are seen. We conclude that the oligomeric fatty acids with two or more hydrophobic chains of seven or more carbons are agglutinins at physiological pH. Agglutination by dimer may be the result of the its two hydrophobic side chains inserting into adjacent RBC membranes or the result of dimer inserting completely into RBC membranes and altering their properties. The carboxyl groups may also play a role in the process by interacting with polar headgroups in the RBC membrane.