Difference in determinants of ICU admission and death among COVID-19 hospitalized patients in two epidemic waves in Portugal: possible impact of healthcare burden and hospital bed occupancy on clinical management and outcomes, March-December 2020.

Aim: Identify factors associated with COVID-19 intensive care unit (ICU) admission and death among hospitalized cases in Portugal, and variations from the first to the second wave in Portugal, March-December 2020. Introduction: Determinants of ICU admission and death for COVID-19 need further understanding and may change over time. We used hospital discharge data (ICD-10 diagnosis-related groups) to identify factors associated with COVID-19 outcomes in two epidemic periods with different hospital burdens to inform policy and practice. Methods: We conducted a retrospective cohort study including all hospitalized cases of laboratory-confirmed COVID-19 in the Portuguese NHS hospitals, discharged from March to December 2020. We calculated sex, age, comorbidities, attack rates by period, and calculated adjusted relative risks (aRR) for the outcomes of admission to ICU and death, using Poisson regressions. We tested effect modification between two distinct pandemic periods (March-September/October-December) with lower and higher hospital burden, in other determinants. Results: Of 18,105 COVID-19 hospitalized cases, 10.22% were admitted to the ICU and 20.28% died in hospital before discharge. Being aged 60-69 years (when compared with those aged 0-49) was the strongest independent risk factor for ICU admission (aRR 1.91, 95%CI 1.62-2.26). Unlike ICU admission, risk of death increased continuously with age and in the presence of specific comorbidities. Overall, the probability of ICU admission was reduced in the second period but the risk of death did not change. Risk factors for ICU admission and death differed by epidemic period. Testing interactions, in the period with high hospital burden, those aged 80-89, women, and those with specific comorbidities had a significantly lower aRR for ICU admission. Risk of death increased in the second period for those with dementia and diabetes. Discussion and conclusions: The probability of ICU admission was reduced in the second period. Different patient profiles were identified for ICU and deaths among COVID-19-hospitalized patients in different pandemic periods with lower and higher hospital burden, possibly implying changes in clinical practice, priority setting, or clinical presentation that should be further investigated and discussed considering impacts of higher burden on services in health outcomes, to inform preparedness, healthcare workforce planning, and pandemic prevention measures.

Gerenciamento de Leitos: do Planejamento à Implementação em um Serviço Hospitalar / Hospital bed management: from planning to implementation in a hospital service

Objetivo: A falta de leitos hospitalares no Brasil é queixa comum entre usuários do Sistema Único de Saúde. Objetivo: Relatar a experiência da construção de um Serviço de Gerenciamento de leitos e apresentar a atuação do enfermeiro como gestor, em prol da visibilidade e fortalecimento da classe de enfermagem. Método: Relato de experiência da implementação da gestão de leitos de um hospital público estadual de médio porte, em um município do interior do estado de São Paulo. Resultado: A partir da implantação houve mudanças no perfil dos indicadores dos setores assistencias, com a utilização dos leitos aproveitados em sua capacidade máxima. Observou-se a diminuição da fila de espera para internação em consequência do acesso oportuno e ordenado à vaga. Conclusão: Pode-se inferir que o gerenciamento de leitos é efetivo e eficiente na gestão hospitalar com resultados operacionais e financeiros satisfatórios e um fator preponderante para a segurança e satisfação dos clientes.(AU)

Objective: The lack of hospital beds in Brazil is a common complaint among users of the Unified Health System. Objective: To report the experience of the construction of a Bed Management Service and to present the nurse's role as manager, for the visibility and strengthening of the nursing class. Method: Experience report of the implementation of bed management in a public hospital of medium size, in a city in the interior of the state of São Paulo. Result: From the implementation there were changes in the profile of the indicators of the care sectors, with the use of beds used to their maximum capacity. A reduction in the waiting list for hospitalization was observed as a result of the timely and orderly access to vacancies. Conclusion: It can be inferred that the management of beds is effective and efficient in hospital management with satisfactory operational and financial results and a preponderant factor for the customers' safety and satisfaction.(AU)

Objetivo: La falta de camas hospitalarias en Brasil es una queja común entre los usuarios del Sistema Único de Salud. Objetivo: Relatar la experiencia de la construcción de un Servicio de Gestión de camas y presentar la actuación de la enfermera como gestora, para la visibilidad y fortalecimiento de la clase de enfermería. Método: Relato de experiência da implementação da gestão de lechos de um hospital público estadual de médio porte, em um município do interior do estado de São Paulo. Resultado: A partir da implementação houve mudanças no perfil dos indicadores dos setores assistência, com o uso de camas utilizadas ao seu máximo de capacidade. Observou-se a diminuição da fila de espera para internação em consequência do acesso oportuno e ordenado à vaga. Conclusão: É possível inferir que a gestão de camas é eficaz e eficiente na gestão hospitalar com resultados operacionais e financeiros satisfatórios e um factor preponderante para a segurança e satisfação dos clientes.(AU)

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.

Internal Regulation Center in hospitals: Repercussions of its implementation on the health services' indicators. / Núcleo Interno de Regulação hospitalar: repercussões da implantação nos indicadores dos serviços de saúde.

OBJECTIVE: To evaluate the hospital indicators and their repercussions on the number of monthly admissions to a public university hospital, before and after implementing the Internal Regulation Center. METHOD: An evaluative research study, of the Case Study type, developed in a public university hospital. A total of 28 indicators related to structure, production, productivity and quality were measured, which are part of internal Benchmarking. The data were analyzed by means of descriptive statistics and multiple regression to identify the independent factors and those associated with the number of monthly hospitalizations with 95% confidence intervals. RESULTS: Implementation of the Center significantly increased (p<0.001) the number of discharges, the bed utilization factor and the bed renewal rate, emergency hospitalization, bed occupancy percentage, surgical procedures performed and the patient-day mean value (p=0.027). There was a reduction (p<0.001) in the number of visits to the medical, obstetric and orthopedic emergency room, in the rates of in-hospital infection and infant mortality, as well as a mean reduction of 0.81/day, approximately one day less of hospitalization per patient, or a gain of 40 available beds per month. CONCLUSION: Although the number of available beds was lower in the post-implementation period, the bed replacement interval was reduced, representing an increase of 40 more beds per month due to the reduction in the patients' length of stay in the institution.

Remdesivir and dexamethasone as tools to relieve hospital care systems stressed by COVID-19: A modelling study on bed resources and budget impact.

Remdesivir and dexamethasone are the only drugs providing reductions in the lengths of hospital stays for COVID-19 patients. We assessed the impacts of remdesivir on hospital-bed resources and budgets affected by the COVID-19 outbreak. A stochastic agent-based model was combined with epidemiological data available on the COVID-19 outbreak in France and data from two randomized control trials. Strategies involving treating with remdesivir only patients with low-flow oxygen and patients with low-flow and high-flow oxygen were examined. Treating all eligible low-flow oxygen patients during the entirety of the second wave would have decreased hospital-bed occupancy in conventional wards by 4% [2%; 7%] and intensive care unit (ICU)-bed occupancy by 9% [6%; 13%]. Extending remdesivir use to high-flow-oxygen patients would have amplified reductions in ICU-bed occupancy by up to 14% [18%; 11%]. A minimum remdesivir uptake of 20% was required to observe decreases in bed occupancy. Dexamethasone had effects of similar amplitude. Depending on the treatment strategy, using remdesivir would, in most cases, generate savings (up to 722€) or at least be cost neutral (an extra cost of 34€). Treating eligible patients could significantly limit the saturation of hospital capacities, particularly in ICUs. The generated savings would exceed the costs of medications.

Leitos de Unidade de Terapia Intensiva Pediátrico no Sistema Único de Saúde: uma análise das solicitações à Central de Regulação do município do Rio de Janeiro / Pediatric Intensive Care Unit beds in the Unified Health System: an analysis of requests to the Regulation Center in the city of Rio de Janeiro

A portaria 1559/2008 caracteriza-se como um marco legal no processo de regulação de leitos no Sistema Único de Saúde (SUS). Os pacientes pediátricos apresentam especificidade que aumentam os desafios aos gestores de saúde para disponibilizar leitos de terapia intensiva adequados a esta clientela. Dispor de informações a respeito dos fatores que impactam na solução das solicitações pode contribuir para o melhor planejamento do fluxo regulatório, permitindo o aprimoramento deste. Esta pesquisa teve como objetivo avaliar o perfil, o tempo de tramitação e os fatores associados às solicitações de leitos de Unidades de Terapia Intensiva Pediátrica via Central de Regulação do SUS no município do Rio de Janeiro no ano de 2018. Foi realizado um estudo transversal com dados do acervo de solicitações de leitos de Unidade de Terapia Intensiva Pediátrica à Central Municipal do Rio de Janeiro de janeiro a dezembro de 2018. Os dados das características dos pacientes, prestadores de serviço e processo regulatório foram extraídos dos campos abertos das solicitações registradas. Para tanto, elaborou-se um formulário em parceira com profissionais de saúde da central de regulação do município do Rio de Janeiro. As variáveis categóricas foram descritas pela frequência absoluta e seus percentuais. Os dados numéricos foram descritos pela média e desvio padrão. O teste de Qui-quadrado e o odds ratio (com intervalo de confiança de 95%) foram utilizados, respectivamente, para avaliar as variáveis relacionadas com o tempo oportuno para captação de leito e a sua força de associação. O modelo de árvore de regressão auxiliou na identificação e hierarquização dos fatores relacionados aos diferentes motivos de encerramento de uma solicitação. Observou-se que solicitações classificadas como sendo de emergência ou realizadas a prestadores que ofertam leitos exclusivamente para o SUS aumentam a chance de uma solicitação ser resolvida em menos de 24 horas. O modelo de árvore de regressão indicou que a variação do tempo de tramitação e solução das solicitações estava associada primeiramente a questões jurídico administrativas e de infraestrutura dos prestadores de serviço e posteriormente às questões clínico-epidemiológica dos pacientes, entretanto, em apenas 3,9% das solicitações a não captação dos leitos foi precedida por óbito. Este estudo permitiu uma análise exploratória do processo regulatório como um todo, com ênfase no período proposto, contribuindo para uma compreensão não só da relevância deste para o andamento do sistema de saúde, assim como do fluxo de informações.

Ministerial decree 1559/2008 is characterized as a legal framework in the process of regulating beds in the Unified Health System (SUS). Pediatric patients have specificities that increase the challenges for health managers to provide adequate intensive care beds for this public. Having information about the factors that impact the resolution of requests can contribute to better planning the regulatory flow, allowing for its improvement. This research aims to analyze requests for beds in pediatric intensive care units at the SUS regulation center in the city of Rio de Janeiro. A cross-sectional study was carried out with data from the collection of requests for beds from the Pediatric Intensive Care Unit to the Municipal Center of Rio de Janeiro from January to December 2018. Data on patient characteristics, service providers and regulatory process were extracted from the open fields from registered requests. To this end, a form was developed in partnership with health professionals from the regulation center of the city of Rio de Janeiro. Categorical variables were described by absolute frequency and their percentages. Numerical data were described by the mean and the standard deviation. The chi-square test and the odds ratio (with a 95% confidence interval) were used, respectively, to assess the variables related to the timing of bed capture and their strength of association. The regression tree model helped to identify and prioritize the factors related to the different reasons for closing a request. It was observed that requests classified as emergency or made to providers that offer beds exclusively for the SUS increase the chance of a request being resolved in less than 24 hours. The regression tree model indicated that the variation in the processing time and resolution of requests is associated primarily with legal administrative and infrastructure issues of service providers and later with clinical epidemiological issues of patients. However, in only 3.9% of not capturing beds requests are preceded by death. This study allowed an exploratory analysis of the regulatory process, contributing to an understanding not only of its relevance to the progress of the health system, but also of the flow of information.

Association of COVID-19 Hospitalization Volume and Case Growth at US Hospitals with Patient Outcomes.

BACKGROUND: Whether the volume of coronavirus disease 2019 (COVID-19) hospitalizations is associated with outcomes has important implications for the organization of hospital care both during this pandemic and future novel and rapidly evolving high-volume conditions. METHODS: We identified COVID-19 hospitalizations at US hospitals in the American Heart Association COVID-19 Cardiovascular Disease Registry with ≥10 cases between January and August 2020. We evaluated the association of COVID-19 hospitalization volume and weekly case growth indexed to hospital bed capacity, with hospital risk-standardized in-hospital case-fatality rate (rsCFR). RESULTS: There were 85 hospitals with 15,329 COVID-19 hospitalizations, with a median hospital case volume was 118 (interquartile range, 57, 252) and median growth rate of 2 cases per 100 beds per week but varied widely (interquartile range: 0.9 to 4.5). There was no significant association between overall hospital COVID-19 case volume and rsCFR (rho, 0.18, P = .09). However, hospitals with more rapid COVID-19 case-growth had higher rsCFR (rho, 0.22, P = 0.047), increasing across case growth quartiles (P trend = .03). Although there were no differences in medical treatments or intensive care unit therapies (mechanical ventilation, vasopressors), the highest case growth quartile had 4-fold higher odds of above median rsCFR, compared with the lowest quartile (odds ratio, 4.00; 1.15 to 13.8, P = .03). CONCLUSIONS: An accelerated case growth trajectory is a marker of hospitals at risk of poor COVID-19 outcomes, identifying sites that may be targets for influx of additional resources or triage strategies. Early identification of such hospital signatures is essential as our health system prepares for future health challenges.

Assessment of surgeon and hospital volume for robot-assisted and laparoscopic benign hysterectomy in Sweden.

INTRODUCTION: The study aims to analyze differences between robot-assisted total laparoscopic hysterectomy (RATLH) and total laparoscopic hysterectomy (TLH) in benign indications, emphasizing surgeon and hospital volume. MATERIAL AND METHODS: All women in Sweden undergoing a total hysterectomy for benign indications with or without a bilateral salpingo-oophorectomy from January 1, 2015 to December 31, 2017 (n = 12 386) were identified from three national Swedish registers. Operative time, blood loss, conversion rate, complications, readmission, reoperation, length of hospital stays, and time to daily life activity were evaluated by univariable and multivariable regression models in RATLH and TLH. Surgeon and hospital volume were obtained from the Swedish National Quality Register of Gynecological Surgery and divided into subclasses. RESULTS: TLH was associated with a higher rate of intraoperative complications (adjusted odds ratios [aOR] 2.8, 95% CI 1.3-5.8) and postoperative bleeding complications (aOR 1.8, 95% CI 1.2-2.9) compared with RATLH. Intraoperative data showed a higher conversion rate (aOR 13.5, 95% CI 7.2-25.4), a higher blood loss (200-500 mL aOR 3.5, 95% CI 2.7-4.7; > 500 mL aOR 7.6, 95% CI 4.0-14.6) and a longer operative time (1-2 h aOR 16.7 95% CI 10.2-27.5; >2 h aOR 47.6, 95% CI 27.9-81.1) in TLH compared with RATLH. The TLH group had a lower caseload per year than the RATLH group. Higher surgical volume was associated with lower median blood loss, shorter operative time, a lower conversion rate, and a lower perioperative complication rate. Differences in conversion rate or operative time in RATLH were not affected by surgeon volume when compared with TLH. One year after surgery, patient satisfaction was higher in RATLH than in TLH (aOR 0.6, 95% CI 0.4-0.9). CONCLUSIONS: RATLH led to better perioperative outcome and higher patient satisfaction 1 year after surgery. These outcome differences were slightly more pronounced in very low-volume surgeons but persisted across all surgeon volume groups.

Medical Triage During the COVID-19 Pandemic: A Medical and Ethical Burden.

During the COVID-19 pandemic, the number of patients who require intensive care treatment may outnumber the number of intensive care beds, even in industrialized nations. Consequently, triage may become necessary. In Italy, France, and Spain, age has been used as a leading parameter to decide who is admitted to the intensive care unit, and who receives palliative care. Although age is an objective and easy-to-use parameter, it is ethically not ideal to withdraw ventilator therapy from elderly people who suffer from COVID-19. We have developed a simple and easy-to-use scoring system to allow for triage that is based upon scientific outcome data and, at the same time, fulfills ethical standards.

Healthcare indicators associated with COVID-19 death rates in the European Union.

OBJECTIVES: Identification of environmental and hospital indicators that may influence coronavirus disease 2019 (COVID-19) mortality in different countries is essential for better management of this infectious disease. STUDY DESIGN: Correlation analysis between healthcare system indicators and COVID-19 mortality rate in Europe. METHODS: For each country in the European Union (EU), the date of the first diagnosed case and the crude death rate for COVID-19 were retrieved from the John Hopkins University website. These data were then combined with environmental, hospital and clinical indicators extracted from the European Health Information Gateway of the World Health Organization. RESULTS: The COVID-19 death rate in EU countries (mean 1.9 ± 0.8%) was inversely associated with the number of available general hospitals, physicians and nurses. Significant positive associations were also found with the rate of acute care bed occupancy, as well as with the proportion of population who were aged older than 65 years, overweight or who had cancer. Total healthcare expenditure, public sector health expenditure and the number of hospital and acute care beds did not influence COVID-19 death rate. CONCLUSIONS: Some common healthcare system inadequacies, such as limited numbers of general hospitals, physicians and nurses, in addition to high acute care bed occupancy, may be significant drivers of nationwide COVID-19 mortality rates in EU countries.

Higher hospital referral concentration associated with lower-risk patients in skilled nursing facilities.

OBJECTIVE: To examine whether stronger referral relationships between hospitals and skilled nursing facilities (SNF) are associated with lower-risk patients being admitted to SNF. DATA SOURCES/COLLECTION: We used MedPAR data to estimate referral relationship strength and nursing home survey data (OSCAR and CASPER) to determine the risk of patient admissions at nearly 14 000 SNFs from 2008 to 2014. STUDY DESIGN: We examined the association of hospital referral concentration with the percentage of higher-risk patients admitted to non-hospital-based (freestanding) SNFs using an instrumental variables approach. We used the distance between patients and SNFs and hospitals and SNFs as the instrument. DATA COLLECTION/EXTRACTION METHODS: We used previously collected MedPAR and OSCAR/CASPER survey data. PRINCIPAL FINDINGS: We find greater observed referral concentration among freestanding SNFs is associated with lower percentages of patients with pressure sores (coefficient, -2.64; 95% CI, [-2.82 to -2.46]), catheters (-0.55; [-0.74 to -0.36]), and physical restraints (-0.16; [-0.29 to -0.03]) at admission to a skilled nursing facility. CONCLUSIONS: We find evidence that freestanding SNFs with stronger hospital referral relationships may be admitting less risky patients, possibly contributing to disparities across SNFs.

Análisis de la demanda asistencial en la urgencia y unidad de hospitalización psiquiátrica en el contexto de pandemia por COVID-19 / Analysis of the demand for care in a psychiatric emergency room and an acute inpatient unit in the context of the COVID-19 pandemic

INTRODUCCIÓN: El objetivo consiste en analizar el impacto del COVID-19 en la demanda asistencial de las urgencias y en los ingresos psiquiátricos durante el primer mes de la pandemia. MÉTODOS: Realizamos un estudio transversal observacional retrospectivo en pacientes que acuden a urgencias psiquiátricas entre el 11 de marzo y el 11 de abril de 2019 y 2020 respectivamente. Se incluyeron variables sociodemográficas y clínicas en el estudio. Se realizaron las pruebas de Chi Cuadrado o Test exacto de Fisher para el contraste de hipótesis de variables categóricas y la prueba U Mann-Whitney para el contraste de variables cuantitativas. El nivel de significación estadística se estableció en p<0.05. Los análisis se realizaron con IBM SPSS Statistics. RESULTADOS: Se observa un descenso significativo de la media de pacientes atendidos al día en urgencias entre ambos periodos, siendo esta de 5,91 (±2,53) en 2019 y de 2,41 (±1,81) en 2020 (p<0.001). Se ha visto una disminución significativa de la ocupación media de camas en la UHB, ocupándose un 91,84% (±7,72) de camas en 2019 y un 58,85% (±13,81) en 2020 (p<0,001). En cuanto a la proporción de ingresos de los pacientes que acuden a urgencias, se ha visto un aumento significativo en el año 2020 respecto al año anterior. CONCLUSIONES: La demanda en la urgencia de pacientes psiquiátricos y la ocupación media de camas se ha reducido durante el primer mes tras la declaración de la pandemia. El miedo al contagio puede actuar como modulador de la demanda psiquiátrica.

INTRODUCTION: The aim is to analyze the impact of COVID-19 on the demand for emergency care and psychiatric admissions during the first month of the pandemic. METHODS: We conducted a retrospective, observational and cross-sectional study. We reviewed the clinical records of all patients attending the psychiatric emergency room (ER) between March 11th and April 11th, of both 2019 and 2020. Sociodemographic and clinical variables were included in the study. Chi-square test or Fisher's exact test were performed to compare categorical variables, while U Mann-Whitney U test was used for quantitative variables. The level of statistical significance was set at p<0.05. Analysis were conducted using IBM SPSS Statistics. RESULTS: The was a significant decrease in the number of patients attended in the ER. An average of 5.91 (±2.53) patients were treated per day in 2019 compared to 2.41 (±1.81) in 2020 (p<0.001). There was also a significant decrease in the occupancy rate at the inpatient psychiatric unit, with a 91.84% (±7.72) of beds occupied in 2019 and only 58.85% (±13.81) in 2020 (p<0.001). Regarding the percentage of patients admitted after assessment in the ER, there was a significant increase in 2020 compared to the previous year. CONCLUSIONS: The demand for care in the psychiatric emergency room and the average bed occupancy have decreased during the first month after the declaration of the pandemic. Fear of contagion may act as a modulator of psychiatric demand.

Impact of a prolonged COVID-19 lockdown on patterns of admission, mortality and performance indicators in a cardiovascular intensive care unit.

BACKGROUND: The effects of an early and prolonged lockdown during the coronavirus disease 2019 (COVID-19) pandemic on cardiovascular intensive care units (CICUs) are not well established. OBJECTIVES: This study analyses patterns of admission, mortality and performance indicators in a CICU before and during the Argentine lockdown in the COVID-19 pandemic. METHODS: This is a retrospective observational cross-sectional study of all consecutive patients aged 18 years or more admitted to the cardiac intensive care unit at a high-volume reference hospital in Buenos Aires, Argentina, comparing hospitalization rates, primary causes of admission, inpatient utilization indicators, pharmacy supplies' expenditures and in-hospital mortality between 5 March and 31 July 2020, with two corresponding control periods in 2019 and 2018. RESULTS: We included 722 female patients [mean age of 61.6 (SD 15.5) years; 237 (32.8%)]. Overall hospitalizations dropped 53.2% (95%CI: 45.3, 61.0%), from 295.5 patients/year over the periods 2018/2019 to 137 patients in 2020. Cardiovascular disease-related admissions dropped 59.9%, while admission for non-cardiac causes doubled its prevalence from 9.6% over the periods 2018/2019 to 22.6% in the study period (P < 0.001).In the period 2020, the bed occupancy rate fell from 82.2% to 77.4%, and the bed turnover rate dropped 50% from 7.88 to 3.91 monthly discharges/bed. The average length of stay doubled from 3.26 to 6.75 days, and the turnover interval increased from 3.8 to 8.39 days in 2020.Pharmacy supplies' expenditures per discharge increased 134% along with a rise in antibiotics usage from 6.5 to 11.4 vials/ampoules per discharge (P < 0.02).Overall mortality increased from 7% (n = 41) to 13.9% (n = 19) (P = 0.008) at the expense of non-cardiac-related admissions (3.6-19.4%, P = 0.01). CONCLUSIONS: This study found a significant reduction in overall and cardiovascular disease-related causes of admission to the cardiac intensive care unit, worse performance indicators and increased in-hospital mortality along the first 5 months of the early and long-lasting COVID-19 lockdown in Argentina. These results highlight the need to foster public awareness concerning the risks of avoiding hospital attendance. Moreover, health systems should follow strict screening protocols to prevent potential biases in the admission of patients with critical conditions unrelated to the COVID-19 pandemic.

Developing a nursing dependency scoring tool for children's palliative care: the impact on hospice care.

BACKGROUND: Occupancy is commonly used to measure bed management in hospices. However, the increasing complexity of children and young people and growing dependence on technology mean that this is no longer effective. AIM: To develop a dependency tool that enables the hospice to safely and effectively manage the use of beds for planned short breaks (respite care), preserving capacity for children requiring symptom management and end-of-life care. METHODS: A comprehensive literature review and existing tools were used to inform the development of the Martin House Dependency Tool Framework. Training was provided to staff and the tool was piloted before applying it across the hospice caseload. FINDINGS: The tool has been used on 431 children (93.1% of caseload). The tool enabled consistency of assessment and more effective management of resources, due to a contemporaneous understanding of the clinical needs of those on the caseload. CONCLUSION: The tool has enabled consistent and transparent assessment of children, improving safety, effectiveness and responsiveness, and the management of the workforce and resources.

Decision Model for Allocation of Intensive Care Unit Beds for Suspected COVID-19 Patients under Scarce Resources.

This paper puts forward a decision model for allocation of intensive care unit (ICU) beds under scarce resources in healthcare systems during the COVID-19 pandemic. The model is built upon a portfolio selection approach under the concepts of the Utility Theory. A binary integer optimization model is developed in order to find the best allocation for ICU beds, considering candidate patients with suspected/confirmed COVID-19. Experts' subjective knowledge and prior probabilities are considered to estimate the input data for the proposed model, considering the particular aspects of the decision problem. Since the chances of survival of patients in several scenarios may not be precisely defined due to the inherent subjectivity of such kinds of information, the proposed model works based on imprecise information provided by users. A Monte-Carlo simulation is performed to build a recommendation, and a robustness index is computed for each alternative according to its performance as evidenced by the results of the simulation.

Demographic and public health characteristics explain large part of variability in COVID-19 mortality across countries.

BACKGROUND: The numbers of coronavirus disease 2019 (COVID-19) deaths per million people differ widely across countries. Often, the causal effects of interventions taken by authorities are unjustifiably concluded based on the comparison of pure mortalities in countries where interventions consisting different strategies have been taken. Moreover, the possible effects of other factors are only rarely considered. METHODS: We used data from open databases (European Centre for Disease Prevention and Control, World Bank Open Data, The BCG World Atlas) and publications to develop a model that could largely explain the differences in cumulative mortality between countries using non-interventional (mostly socio-demographic) factors. RESULTS: Statistically significant associations with the logarithmic COVID-19 mortality were found with the following: proportion of people aged 80 years and above, population density, proportion of urban population, gross domestic product, number of hospital beds per population, average temperature in March and incidence of tuberculosis. The final model could explain 67% of the variability. This finding could also be interpreted as follows: less than a third of the variability in logarithmic mortality differences could be modified by diverse non-pharmaceutical interventions ranging from case isolation to comprehensive measures, constituting case isolation, social distancing of the entire population and closure of schools and borders. CONCLUSIONS: In particular countries, the number of people who will die from COVID-19 is largely given by factors that cannot be drastically changed as an immediate reaction to the pandemic and authorities should focus on modifiable variables, e.g. the number of hospital beds.

The Impact of Halting Elective Admissions in Anticipation of a Demand Surge Due to the Coronavirus Pandemic (COVID-19).

BACKGROUND: In anticipation of a demand surge for hospital beds attributed to the coronavirus pandemic (COVID-19) many US states have mandated that hospitals postpone elective admissions. OBJECTIVES: To estimate excess demand for hospital beds due to COVID-19, the net financial impact of eliminating elective admissions in order to meet demand, and to explore the scenario when demand remains below capacity. RESEARCH DESIGN: An economic simulation to estimate the net financial impact of halting elective admissions, combining epidemiological reports, the US Census, American Hospital Association Annual Survey, and the National Inpatient Sample. Deterministic sensitivity analyses explored the results while varying assumptions for demand and capacity. SUBJECTS: Inputs regarding disease prevalence and inpatient utilization were representative of the US population. Our base case relied on a hospital admission rate reported by the Center for Disease Control and Prevention of 137.6 per 100,000, with the highest rates in people aged 65 years and older (378.8 per 100,000) and 50-64 years (207.4 per 100,000). On average, elective admissions accounted for 20% of total hospital admissions, and the average rate of unoccupied beds across hospitals was 30%. MEASURES: Net financial impact of halting elective admissions. RESULTS: On average, hospitals COVID-19 demand for hospital bed-days fell well short of hospital capacity, resulting in a substantial financial loss. The net financial impact of a 90-day COVID surge on a hospital was only favorable under a narrow circumstance when capacity was filled by a high proportion of COVID-19 cases among hospitals with low rates of elective admissions. CONCLUSIONS: Hospitals that restricted elective care took on a substantial financial risk, potentially threatening viability. A sustainable public policy should therefore consider support to hospitals that responsibly served their communities through the crisis.

How Many Intensive Care Beds are Justifiable for Hospital Pandemic Preparedness? A Cost-effectiveness Analysis for COVID-19 in Germany.

INTRODUCTION: Germany is experiencing the second COVID-19 pandemic wave. The intensive care unit (ICU) bed capacity is an important consideration in the response to the pandemic. The purpose of this study was to determine the costs and benefits of maintaining or expanding a staffed ICU bed reserve capacity in Germany. METHODS: This study compared the provision of additional capacity to no intervention from a societal perspective. A decision model was developed using, e.g. information on age-specific fatality rates, ICU costs and outcomes, and the herd protection threshold. The net monetary benefit (NMB) was calculated based upon the willingness to pay for new medicines for the treatment of cancer, a condition with a similar disease burden in the near term. RESULTS: The marginal cost-effectiveness ratio (MCER) of the last bed added to the existing ICU capacity is €21,958 per life-year gained assuming full bed utilization. The NMB decreases with an additional expansion but remains positive for utilization rates as low as 2%. In a sensitivity analysis, the variables with the highest impact on the MCER were the mortality rates in the ICU and after discharge. CONCLUSIONS: This article demonstrates the applicability of cost-effectiveness analysis to policies of hospital pandemic preparedness and response capacity strengthening. In Germany, the provision of a staffed ICU bed reserve capacity appears to be cost-effective even for a low probability of bed utilization.

Characteristics, clinical care, and disposition barriers for mental health patients boarding in the emergency department.

BACKGROUND AND OBJECTIVES: Lack of mental health resources, such as inpatient psychiatric beds, has increased frequency and duration of boarding for mental health patients presenting to U.S. emergency departments (EDs). The purpose of this study is to describe characteristics of mental health patients with an ED length of stay of one week or longer and to identify barriers to their disposition. METHODS: This study was conducted in an academic ED in which emergency psychiatric evaluations and care are provided by a Psychiatric Emergency Services (PES) team contained within the Department of Emergency Medicine. Prolonged boarding was defined as an ED length of stay of 7 days or more. Pediatric, adult, and geriatric mental health patients with prolonged ED boarding from January 1 to August 31, 2019 were included. This study includes prospective data collection of the boarding group and retrospective identification and data collection of a comparison group of non-barding patients over the same 8-month period to compare patient characteristics and outcomes for each group. RESULTS: Between January 1 and August 31, 2019, the PES team completed 2,745 new assessments of mental health patients, of whom 39 met criteria for prolonged ED boarding. The following characteristics were associated with boarding: child (8%), male (64%), having Medicaid (49%) or both Medicaid and Medicare (18%), and having either a neurodevelopmental (15%) or neurocognitive disorder (15%) with a median stay of 18 days. Barriers to discharge included being declined from all state inpatient psychiatric hospitals (69%), declined from community living environments (21%), or declined from both (10%). The most common ED non-boarding patients were: Caucasian (64%), have a diagnosis of unspecified mental disorder (including suicidal ideation) or other specified mental disorder (59%) and have private insurance (42%) with a median stay of 1 day. CONCLUSION: In this study of mental health patients with prolonged ED stays, the primary barrier to disposition was the lack of patient acceptance to inpatient psychiatric hospitals, community settings, or other housing. Early identification of potential prolonged boarding, quality treatment and care for those patients, and effective case management, may resolve the ongoing challenges of boarding within the ED.