Theoretical bounds and approximation of the probability mass function of future hospital bed demand.

Failing to match the supply of resources to the demand for resources in a hospital can cause non-clinical transfers, diversions, safety risks, and expensive under-utilized resource capacity. Forecasting bed demand helps achieve appropriate safety standards and cost management by proactively adjusting staffing levels and patient flow protocols. This paper defines the theoretical bounds on optimal bed demand prediction accuracy and develops a flexible statistical model to approximate the probability mass function of future bed demand. A case study validates the model using blinded data from a mid-sized Massachusetts community hospital. This approach expands upon similar work by forecasting multiple days in advance instead of a single day, providing a probability mass function of demand instead of a point estimate, using the exact surgery schedule instead of assuming a cyclic schedule, and using patient-level duration-varying length-of-stay distributions instead of assuming patient homogeneity and exponential length of stay distributions. The primary results of this work are an accurate and lengthy forecast, which provides managers better information and more time to optimize short-term staffing adaptations to stochastic bed demand, and a derivation of the minimum mean absolute error of an ideal forecast.

Predictors of surgical approach for the management of renal cell carcinoma: a population-based study from New South Wales.

BACKGROUND: The simultaneous adoption of laparoscopy and partial nephrectomy (PN) has been reported to result in unintended consequences. We aim to examine the contemporary (2001-2009) trends in use of PN and laparoscopy within a population-wide database. METHODS: All renal cell carcinomas diagnosed between 2001 and 2009 in New South Wales, Australia, were identified from the Central Cancer Registry. Records of treatment were electronically linked. All patients with localized renal cell carcinoma who underwent surgical treatment were selected for this study (3771 patients). Follow-up was to the end of 2010. Multivariable logistic regression analysis was used to determine predictors of PN and laparoscopy. RESULTS: In the entire cohort, 150 (4%), 495 (13%), 1516 (40%) and 1610 (43%) received laparoscopic PN, open PN, laparoscopic radical nephrectomy (RN) and open RN, respectively. Between the years 2001 and 2009, there was a gradual increase in the use of PN except between 2005 and 2007. Between 2001 and 2009, a rapid uptake of laparoscopy was observed. Multivariable analysis demonstrated that age (OR: 0.99 (0.98-0.99)), year of surgery (OR: 1.15 (1.11-1.19)), comorbidity (OR: 1.40 (1.12-1.76)) and hospital case load >8/year (OR: 2.39 (1.49-3.81)) predicted use of PN. Year of surgery (OR: 1.19 (1.15-1.21)), comorbidity (OR: 0.70 (0.58-0.85)), non-teaching hospital (OR: 0.70 (0.53-0.93)), private hospital (OR: 1.86 (1.45-2.38)) and hospital case load > 8/year (OR: 3.36 (2.22-5.09)) predicted use of laparoscopy. CONCLUSION: The unintended decrease in PN associated with increased use of laparoscopic RN had reversed by 2009. Hospital case load predicts the use of PN and laparoscopy.

Trends in elderly psychiatric admissions to the Brazilian public health care system

Objective: To evaluate trends in psychiatric bed occupancy by elderly inpatients in the Brazilian public health care system between 2000 and 2010 and to determine the leading psychiatric diagnosis for hospital admissions. Methods: Data from all 895,476 elderly psychiatric admissions recorded in the Brazilian Public Health Care Database (DATASUS) between January 2000 and February 2010 were analyzed. Polynomial regression models with estimated curve models were used to determine the trends. The number of inpatient days was calculated for the overall psychiatric admissions and according to specific diagnoses. Results: A moderate decreasing trend (p < 0.001) in the number of inpatient days was observed in all geriatric psychiatric admissions (R2 = 0.768) and in admissions for organic mental disorders (R2 = 0.823), disorders due to psychoactive substance use (R2 = 0.767), schizophrenia (R2 = 0.680), and other diagnoses (R2 = 0.770), but not for mood disorders (R2 = 0.472). Most admissions (60 to 65%) were due to schizophrenia. Conclusion: There was a decreasing trend in inpatient days for elderly psychiatric patients between 2000 and 2010. The highest bed occupancy was due to schizophrenia, schizotypal, and delusional disorders.

Nova abordagem de gerenciamento de leitos associada à agenda cirúrgica / A new approach between bed management and surgery schedule

Introdução: Atualmente, um dos desafios para os hospitais é ser hábil em acomodar os pacientes provenientes do Serviço de Urgência e Emergência sem comprometer a programação cirúrgica eletiva. Objetivo: Maximizar o uso dos leitos hospitalares bem como a produção cirúrgica. Metodologia: Implantação do Gerenciamento Interno de Leitos e Agenda Cirúrgica (GILAC). Resultados: Em março de 2009, com 165 leitos, foram realizadas 390 internações, com taxa de ocupação de 77 e 57 por cento dos leitos clínicos e cirúrgicos respectivamente; em março de 2010, com 225 leitos, internaram-se 828 pacientes, com taxa de ocupação de 87 e 79 por cento dos leitos clínicos e cirúrgicos respectivamente; a média de permanência foi de 8,7 dias e de 5,0 dias para pacientes clínicos e cirúrgicos, respectivamente. No contexto do gerenciamento cirúrgico, em março de 2009, com 3 salas, realizaram-se 209 cirurgias, obtendo taxa de ocupação do centro cirúrgico de 70 por cento; em março de 2010, com 8 salas, foram realizadas 483 cirurgias, com 82 por cento de taxa de ocupação e 2,03 por cento de taxa de cirurgia suspensão. Conclusão: Foi possível desenvolver e aperfeiçoar um sistema de gestão hospitalar que não só atende as necessidades do paciente, mas também aumenta, de forma significativa, a eficiência do Instituto do Câncer do Estado de São Paulo (ICESP), com base na ferramenta de tecnologia de informação, combinando o uso racional de leitos e salas cirúrgicas.

Trends in hospital bed utilisation in New Zealand 1989 to 2006: more or less beds in the future?

AIMS: Reduction in hospital bed utilisation has been a key factor in controlling costs in recent decades in many health systems, including New Zealand's. This paper has the following aims: to analyse trends in hospital bed utilisation from 1988 to 2006; to examine variation between district health boards (DHBs); to consider factors which may explain the trends observed; to compare the results with international trends; and to discuss future need for beds and factors affecting this need, including the integrated DHB system. METHODS: Ministry of Health Hospital Throughput reports for 1988/89 to 2005/06 were accessed and present standardised, filtered, and truncated data on discharges, average length of stay (ALOS), bed days, and DHB comparisons. Data on beds were also obtained from the Private Surgical Hospitals Association. Rates of utilisation were calculated using Statistics New Zealand and the Ministry of Health population data. Australian, UK, and US comparisons were obtained. RESULTS: The New Zealand data showed a continuing rise in discharge rates, especially case weighted. This was almost entirely due to the increase in day patients. There was a marked downward trend in bed day rates due to a more than 50% decline in the ALOS and a corresponding decline in bed availability. There was a marked variation between DHBs in standardised discharge ratios in 2005/06, with low rates indicating potential benchmarks to which higher utilisation DHBs might aspire. New Zealand was well ahead of both Australia and the UK National Health System (NHS) in reducing bed utilisation but comparisons with Kaiser Permanente indicated that DHBs could potentially, even dramatically, reduce bed utilisation through reducing admissions. CONCLUSIONS: The findings point to important progress in New Zealand in containing costs associated with hospital bed utilisation. Future strategies need to focus strongly on reducing hospital admissions through PHO action to provide community alternatives and chronic disease management.

Are elective surgical operations cancelled due to increasing medical admissions?

BACKGROUND: Cancellation of operations increases theatre costs and decreases efficiency. We examined the causes of theatre cancellations in general surgery. METHODS: The Beaumont hospital database (ORSUS system) and theatre records were examined retrospectively between April 1997 and March 2002. The number and causes of theatre cancellations, the number of emergency admissions and their length of hospital stay were studied. RESULTS: The number of elective operations cancelled between April 1997-March 1998 and April 2001-March 2002 were 368 and 427 respectively. 'No bed' was the reason for theatre cancellation in 114 (31.0%) cases between April 1997-March 1998 and this increased to 267 (62.5%) cases between April 2001-March 2002. Between April 1997-March 1998 and April 2001-March 2002, general surgical emergency admissions decreased by 6.74% (3,116 to 2,906), and emergency surgical admissions across the specialties decreased by 2.02% (4,002 to 3,921). In the same time interval, general medical emergency admissions rose from 4,195 to 5,386 (a 28.39% increase), and emergency medical admissions across the specialties rose from 5,401 to 6,689 (a 23.84% increase). General surgical bed days for emergency admissions fell between April 1997-March 1998 and April 2001-March 2002 from 28,839 to 26,698 (7.4% decrease). There was a similar decrease from 38,188 to 36,004 (5.7% decrease) for all surgical specialties. Total bed days necessitated by general medical emergency admissions increased from 53,226 to 61,623 (15.8%). Across the medical specialties, an increase from 71,590 to 82,180 bed days (14.79%) was seen. CONCLUSIONS: Elective surgery cancellation is a significant problem with far-reaching consequences. While multifactorial in aetiology, increased bed usage by medical specialties is one important factor. This study has implications for doctors, training, administrators and patients.

A comparison of hospital and critical-care activity.

When compared with changes in hospital activity, corresponding fluctuations in critical-care activity are not clear. Therefore, trends in hospital activity were compared with those of the critical-care services and simple patient demographic details. The results suggest that while the size of hospitals remained static, hospital admissions and outpatient attendances increased by 5% each year. During the same period, the number of critical-care beds increased by 21.4%. Despite this increase in capacity, the activity of the critical-care services continued to increase by a similar 5% per annum, indicating a huge surge in critical-care workload. The results indicate that the increase in the rate of activity in hospitals and critical-care services is similar but the workload of the critical-care services is increasing much faster. This suggests that the demand for critical care may be generated from within hospitals.

NISPLAN--projecting hospital beds and hospital stays.

The paper describes a computer model for projections of hospital stays and hospital beds, developed by NIS Health Services Research in Norway. The model takes into account demographic changes, changes in medical technology, needs for hospital services, morbidity and hospital structure and population preferences as to choice of hospital. It has been used in several projects in Norway, both by central and local authorities.

O sistema de pagamento prospectivo por procedimento no Hospital Universitário de Juiz de Fora

Observa as mudanças ocorridas nos indicadores de produçao e na evoluçao das fontes de receitas do Hospital Universitário (HU), unidade da Universidade Federal de Juiz de Fora (UFJF), entre 1986 e 1997, a partir da implantaçao do sistema de pagamento prospectivo por procedimento para os prestadores universitários em 1987. Foram utilizadas as bases de dados do Sistema de Informaçoes Hospitalares (SIH-SUS) e do Sistema de Informaçoes Ambulatoriais (SIA-SUS), além de documentos do próprio HU. Tomando como base para a construçao das hipóteses a experiência norte-americana de implantaçao do Prospective Payment System (PPS), no início dos anos oitenta, foi possível encontrar resultados significativos no HU estudado. Os dados indicaram uma tendência discreta (14 por cento) de crescimento das internaçoes durante o período. A variável tempo médio de permanência registrou uma reduçao de 29 por cento, em termos globais, enquanto que a taxa de ocupaçao de leitos hospitalares apresentou tendência ao crescimento em todas as Clínicas oferecidas, com exceçao da Clínica Médica, apesar de o HU nao ter utilizado totalmente a capacidade instalada de leitos. Em relaçao à composiçao do produto hospitalar, os dados indicaram que a instituiçao estudada nao alterou sobremaneira a sua produçao, porém observou-se alternâncias na ordem de importância dos principais procedimentos, durante o período proposto para a análise, concluindo-se que essa unidade de saúde presta assistência a pacientes com patologias de diferentes graus de complexidade. No que se refere às transferências financeiras federais advindas do Ministério da Saúde (MS), a evoluçao foi expressiva, principalmente, a partir do início desta década, nao somente sob o ponto de vista da recuperaçao do faturamento com produçao, mas também pela organizaçao financeira que o modelo permitiu ao HU analisado. Destaca também a crescente participaçao das receitas com atividades ambulatoriais quando comparada ao reembolso obtido com internações.

O sistema de pagamento prospectivo por procedimento no Hospital Universitário de Juiz de Fora / The system of prospective payment for procedure in the University Hospital of Juiz de Fora

Observa as mudanças ocorridas nos indicadores de produçao e na evoluçao das fontes de receitas do Hospital Universitário (HU), unidade da Universidade Federal de Juiz de Fora (UFJF), entre 1986 e 1997, a partir da implantaçao do sistema de pagamento prospectivo por procedimento para os prestadores universitários em 1987. Foram utilizadas as bases de dados do Sistema de Informaçoes Hospitalares (SIH-SUS) e do Sistema de Informaçoes Ambulatoriais (SIA-SUS), além de documentos do próprio HU. Tomando como base para a construçao das hipóteses a experiência norte-americana de implantaçao do Prospective Payment System (PPS), no início dos anos oitenta, foi possível encontrar resultados significativos no HU estudado. Os dados indicaram uma tendência discreta (14 por cento) de crescimento das internaçoes durante o período. A variável tempo médio de permanência registrou uma reduçao de 29 por cento, em termos globais, enquanto que a taxa de ocupaçao de leitos hospitalares apresentou tendência ao crescimento em todas as Clínicas oferecidas, com exceçao da Clínica Médica, apesar de o HU nao ter utilizado totalmente a capacidade instalada de leitos. Em relaçao à composiçao do produto hospitalar, os dados indicaram que a instituiçao estudada nao alterou sobremaneira a sua produçao, porém observou-se alternâncias na ordem de importância dos principais procedimentos, durante o período proposto para a análise, concluindo-se que essa unidade de saúde presta assistência a pacientes com patologias de diferentes graus de complexidade. No que se refere às transferências financeiras federais advindas do Ministério da Saúde (MS), a evoluçao foi expressiva, principalmente, a partir do início desta década, nao somente sob o ponto de vista da recuperaçao do faturamento com produçao, mas também pela organizaçao financeira que o modelo permitiu ao HU analisado. Destaca também a crescente participaçao das itas com atividades ambulatoriais quando comparada ao reembolso obtido com internaçöes.

The impact and consequences of hip fracture in Ontario.

OBJECTIVES: To assess the magnitude and the burden of hip fracture on the health care system, including time trends in hip fracture rates, in-hospital death rates, length of hospital stay (LHS) and discharge destination. DESIGN: A retrospective study of discharge abstracts. SETTING: The Province of Ontario. PATIENTS: All patients (n = 93,660) over the age of 50 years and with a diagnosis of hip fracture discharged from hospital between 1981 and 1992 (excluding transfers). MAIN OUTCOME MEASURES: Age-sex standardized hip fracture rates per 1000 population, in-hospital death rates and age-adjusted mean LHS. RESULTS: The overall hip fracture rate was 3.3 per 1000 persons (1.7 per 1000 men and 4.6 per 1000 women). There was no change in rates between 1981 and 1992 (p = 0.089), but there have been increases in the numbers of hip fractures. There was no change in the in-hospital death rate over time (p = 0.78). The age-adjusted mean LHS in 1981 was 28.6 days compared with 22.2 days in 1992. The numbers of hip fractures will increase from 8490 in 1990 to 16 963 in 2010. CONCLUSIONS: Despite stable age-adjusted rates of hip fractures, the doubling of the number of hip fractures by the year 2010 due to an aging population will become an increasing burden on the health care system.

[Ambulatory surgery in the Netherlands]. / Ambulante Chirurgie in den Niederlanden.

Day care treatment is encouraged in the Netherlands on the one hand by the government and on the other hand by the request of the patients. There is a continuous shift from clinical to day care cases and through diversification, f.i. 24-hour admittance and short stay, one will be able to further reduce the number of expensive long stay hospital beds.

Evolving role of intensive and high-dependency care.

As stratified patient care evolves, and with an increasing population of elderly patients undergoing major surgery there is a growing demand for critical and high-dependency care beds. Results of an audit comparing the activity of a combined Intensive Care and High-Dependency Unit (ITU/HDU) in 1981 with 1991 has shown an increase in the number of patients admitted, particularly for high-dependency care. The overall mortality in 1981 was 12% compared with 9.5% in 1991. The greatest improvement was seen in ventilated patients, where the mortality was reduced from 54% in 1981 to 30% in 1991. An attempt is made to predict the demand for critical care and high-dependency beds for the future in a population of approximately 250,000 based on current trends. It is perceived that it will be necessary to establish a six-bed ITU and eight high-dependency surgical beds in two separate but adjacent units, where there will be a free interchange of skills at the different levels of care.

The incidence of proximal femoral fractures in an English county.

We have studied the incidence of fractures of the proximal femur in one English county from 1968 to 1991. Numbers have increased steadily, but the age-specific incidence has remained relatively unchanged since 1981. The increase is due to the rise in the population most at risk; this is likely to continue causing a 20% increase in demand for treatment by the year 2000. Suitable allocation of resources must be planned.

Models for forecasting hospital bed requirements in the acute sector.

STUDY OBJECTIVE: The aim was to evaluate the current approach to forecasting hospital bed requirements. DESIGN: The study was a time series and regression analysis. The time series for mean duration of stay for general surgery in the age group 15-44 years (1969-1982) was used in the evaluation of different methods of forecasting future values of mean duration of stay and its subsequent use in the formation of hospital bed requirements. RESULTS: It has been suggested that the simple trend fitting approach suffers from model specification error and imposes unjustified restrictions on the data. Time series approach (Box-Jenkins method) was shown to be a more appropriate way of modelling the data. CONCLUSION: The simple trend fitting approach is inferior to the time series approach in modelling hospital bed requirements.