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Overwhelmed on Wednesdays?

May 2011
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Published in the May 2011 issue of Today’s Hospitalist

EVER WONDER WHY WEDNESDAYS, Thursdays and Fridays are so hectic and you’re overloaded with patients?

It could be because scheduled admissions at your hospital are bunched together at the beginning of the week. That common practice is driving variability in day-to-day occupancy rates, leading to potentially dangerous mid-week crowding and empty beds on weekends. Researchers are now linking that variability to access and safety issues.

"Hospitals with high crowding have logistical issues getting new patients into beds for tests or procedures," says Evan Fieldston, MD, MBA, an assistant professor of pediatrics at the University of Pennsylvania School of Medicine and a pediatric hospitalist at The Children’s Hospital of Philadelphia (CHOP). He is the lead author of a study in the February 2011 Journal of Hospital Medicine (JHM) that looked at the relationship between scheduled admissions and high occupancy. "We know from other studies that very high occupancy levels in hospitals or in micro-systems within hospitals are associated with lower quality," he says.

Hospitalists reeling from big swings in occupancy rates may want "to work with their colleagues on understanding the flow of patients and rationalizing that flow," he adds, "or altering staffing patterns to match the workload." By smoothing out variations, hospitals can reduce crowding without delaying admissions or investing in expensive new beds.

That won’t necessarily turn your hospital into a fully staffed 24/7 operation. But it may stop your workload from teetering between being overwhelming and grinding to a halt.

"Hospitals have high fixed costs," Dr. Fieldston points out. "Not using resources seven days a week may not be the most value-oriented approach to health care."

The impact of scheduled admissions
Dr. Fieldston and his associates examined the effect of scheduled admissions on CHOP’s daily peak occupancy. The study, which included more than 22,300 admissions in one year, found that scheduled admissions accounted for a much smaller proportion of the inpatient population than emergent cases. However, they contributed significantly to occupancy variation over the course of the week.

Length of stay for both emergent and scheduled admissions at CHOP, as in most children’s hospitals, tended to be short. But scheduled admissions “many of which were for otolaryngology procedures, video encephalography and chemotherapy “produced far more variability in admission patterns and occupancy rates than emergent ones. While scheduled cases made up only 22% of total admissions, 42% of those were admitted on Mondays and Tuesdays. Variability was even worse from October through April, when the hospital runs a higher census due to seasonal viruses.

According to the study, the scheduled case load combined with a steady flow of emergency patients during the week led to crowding from Wednesday afternoon through Friday. CHOP’s peak daily occupancy was more than 90% on Wednesdays, Thursdays and Fridays for almost 60% of the year. For nearly one-third of the Wednesdays that year, peak daily occupancy topped 95%.

Simulating admission changes
Dr. Fieldston’s study is part of a multiyear effort to evaluate and better manage CHOP’s patient flow. The JHM study grew out of work done last year to analyze the highest-volume services for scheduled medical patients. As a result of that analysis, some clinical divisions began offering more admitting slots on Friday for patients staying only 24 or 48 hours.

"Those divisions reported that the demand for Friday admissions was quite high," Dr. Fieldston says. "Families appreciated not having to miss school or work."

This year, CHOP is assessing its patterns of surgical scheduled admissions to find ways to increase functional capacity over the entire week. Dr. Fieldston and his team want to use tools, such as discrete-event simulation, to evaluate the impact of potential changes on daily census and volume variability.

Because much of that work remains theoretical, Dr. Fieldston admits that he hasn’t yet had to convince surgeons to shift some elective surgeries toward the end of the week. How does he think those conversations will go?

"It depends on the size of the surgical group and how onerous it is to work weekends," he notes. Surgeons who already come to the hospital to follow patients on weekends or those interested in more OR time may, he adds, "actually appreciate the opportunity, especially if the hospital can match their effort with a fuller complement of weekend services." That may particularly be the case if hospitals or surgeons believe they’re losing cases because of crowding or that patients are waiting too long to be admitted.

Already, Dr. Fieldston says, several hospitals around the country have reported changing surgical schedules and resources. Both Cincinnati Children’s Hospital and Boston Medical Center, for instance, have separated OR facilities for elective and emergent surgeries so elective procedures won’t have to be bumped to free up space for emergent ones. Other facilities have increased capacity late in the week or on weekends, which has evened out the surgical census “and saved those hospitals money.

Smoothing out variation
Dr. Fieldston’s research provides a simple methodology that hospitalists can use to understand patient flow in their hospital: Determine the number of admissions per day, divide them into scheduled and emergent cases, look at the census and occupancy for each day of the week, and calculate the variation associated with scheduled admissions.

"Ideally, you would do this with the daily peak census, not the midnight census," Dr. Fieldston explains.

When they find high occupancy mid-week, hospitals can begin to explore patient-flow options and boost weekend staffing to accommodate more patients. One option is shared staffing, where social workers and other staff would each cover only one weekend a month, or hospitals could move to half-day weekend coverage. Another option is more weekend roles for nurse practitioners and physician assistants.

The changes needed do not have to involve a large number of patients. "The point is to try to smooth out the variation so you move a small number of scheduled admissions to other days of the week to bring down your peak and raise your trough," Dr. Fieldston says.

Another added benefit of more scheduled patients being treated on weekends: "You improve the care of patients who arrive emergently," he says. "The increased costs of staffing on weekends are likely small compared to the benefits that accrue."

At the same time, Dr. Fieldston says, hospitals have to take "a deliberate approach" to running a truly seven-day-a-week hospital.

"Make sure you are not running numbers through a computer or a simulation and then imposing a schedule on staff members or patients and families," Dr. Fieldston says. "Otherwise, the outcome may not be optimal."

Karen Sandrick is a freelance health care writer based in Chicago.

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