Patient Mix Optimization in Admission Planning under Multitype Patients and Priority Constraints.

Hospital beds are one of the most critical medical resources. Large hospitals in China have caused bed utilization rates to exceed 100% due to long-term extra beds. To alleviate the contradiction between the supply of high-quality medical resources and the demand for hospitalization, in this paper, we address the decision of choosing a case mix for a respiratory medicine department. We aim to generate an optimal admission plan of elective patients with the stochastic length of stay and different resource consumption. We assume that we can classify elective patients according to their registration information before admission. We formulated a general integer programming model considering heterogeneous patients and introducing patient priority constraints. The mathematical model is used to generate a scientific and reasonable admission planning, determining the best admission mix for multitype patients in a period. Compared with model II that does not consider priority constraints, model I proposed in this paper is better in terms of admissions and revenue. The proposed model I can adjust the priority parameters to meet the optimal output under different goals and scenarios. The daily admission planning for each type of patient obtained by model I can be used to assist the patient admission management in large general hospitals.

Trends, structural changes, and assessment of time series models for forecasting hospital discharge due to death at a Mexican tertiary care hospital.

BACKGROUND: Data on hospital discharges can be used as a valuable instrument for hospital planning and management. The quantification of deaths can be considered a measure of the effectiveness of hospital intervention, and a high percentage of hospital discharges due to death can be associated with deficiencies in the quality of hospital care. OBJECTIVE: To determine the overall percentage of hospital discharges due to death in a Mexican tertiary care hospital from its opening, to describe the characteristics of the time series generated from the monthly percentage of hospital discharges due to death and to make and evaluate predictions. METHODS: This was a retrospective study involving the medical records of 81,083 patients who were discharged from a tertiary care hospital from April 2007 to December 2019 (first 153 months of operation). The records of the first 129 months (April 2007 to December 2017) were used for the analysis and construction of the models (training dataset). In addition, the records of the last 24 months (January 2018 to December 2019) were used to evaluate the predictions made (test dataset). Structural change was identified (Chow test), ARIMA models were adjusted, predictions were estimated with and without considering the structural change, and predictions were evaluated using error indices (MAE, RMSE, MAPE, and MASE). RESULTS: The total percentage of discharges due to death was 3.41%. A structural change was observed in the time series (March 2009, p>0.001), and ARIMA(0,0,0)(1,1,2)12 with drift models were adjusted with and without consideration of the structural change. The error metrics favored the model that did not consider the structural change (MAE = 0.63, RMSE = 0.81, MAPE = 25.89%, and MASE = 0.65). CONCLUSION: Our study suggests that the ARIMA models are an adequate tool for future monitoring of the monthly percentage of hospital discharges due to death, allowing us to detect observations that depart from the described trend and identify future structural changes.

Current status of trauma surgery at a Japanese prefectural academic institute: improved organization in a regional prefecture.

PURPOSES: Balancing scheduled surgery and trauma surgery is difficult with a limited number of surgeons. To address the issues and systematize education, we analyzed the current situation and the effectiveness of having a trauma team in the ER of a regional hospital. METHODS: This retrospective study analyzed the demographics, traumatic variables, procedures, postoperative morbidities, and outcomes of 110 patients who underwent trauma surgery between 2012 and 2019. The trauma team was established in 2016 and our university hospital Emergency Room (ER) opened in 2012. RESULTS: Blunt trauma accounted for 82% of the trauma injuries and 39% of trauma victims were transported from local centers to our institute. The most frequently injured organs were in the digestive tract and about half of the interventions were for hemostatic surgery alone. Concomitant treatments for multiple organ injuries were performed in 31% of the patients. The rates of postoperative severe complications (over Clavien-Dindo IIIb) and mortality were 10% and 13%, respectively. Fourteen (12.7%) of 24 patients who underwent damage-control surgery died, with multiple organ injury being the predominant cause of death. CONCLUSION: Systematic education or training of medical students and general surgeons, as well as the co-operation of the team at the regional academic institute, are necessary to overcome the limited human resources and save trauma patients.

Bilateral internal carotid artery occlusion with compensatory perfusion in a HIV-infected patient.

BACKGROUND: Worcester Hospital is a regional healthcare facility in the Western Cape, South Africa, without a dedicated burns unit. Currently there is limited data available of burns patient management outside of academic institutions in South Africa. To describe the incidence and demographics, and to determine the outcomes of burn patients admitted to Worcester Hospital. METHODOLOGY: A retrospective descriptive study of burn patients admitted to Worcester Hospital between 1 September 2016 and 31 August 2017. RESULTS: A total of 66 burn patients were included in this study which accounted for 1.6% of the total surgical admissions for this time period. The mean age of the patients was 39 (SD ± 19) years with a male predominance (59%). The mechanism of burn was mostly flame burns (71%); 16 patients (24%) were burned with hot fluids and 3 patients (5%) sustained electrical burns. The median TBSA was 9% (IQR: 5-28). Ten patients (15%) required critical care unit admission. The burn patients' median length of stay was 6 days (IQR: 2-11 days) versus 2 days (IQR: 1-5 days) for non-burn general surgery patients. Fifty burn patients (76%) required surgical intervention comprising of either debridement or skin grafting, or a combination of this. Forty-four patients (67%) underwent skin grafting procedures and the median TBSA grafted was 5% (IQR: 3.5-9.5). The median time from admission to first surgical procedure was 25 hours (IQR: 18.33-51.08). The in-hospital mortality rate was 23% and of the 15 mortalities, 9 patients (60%) had TBSA of 30% or more and therefore classified as a major burn. CONCLUSION: Burn injuries treated at Worcester Hospital are often severe and require significant resources. This study supplies critical information regarding the burden of burn related injuries managed at a regional level.

Regionalization of emergency general surgery operations: A simulation study.

BACKGROUND: It has been theorized that a tiered, regionalized system of care for emergency general surgery (EGS) patients-akin to regional trauma systems-would translate into significant survival benefits. Yet data to support this supposition are lacking. The aim of this study was to determine the potential number of lives that could be saved by regionalizing EGS care to higher-volume, lower-mortality EGS institutions. METHODS: Adult patients who underwent one of 10 common EGS operations were identified in the California Inpatient Database (2010-2011). An algorithm was constructed that "closed" lower-volume, higher-mortality hospitals and referred those patients to higher-volume, lower-mortality institutions ("closure" based on hospital EGS volume-threshold that optimized to 95% probability of survival). Primary outcome was the number of lives saved. Fifty thousand regionalization simulations were completed (5,000 for each operation) employing a bootstrap resampling method to proportionally redistribute patients. Estimates of expected deaths at the higher-volume hospitals were recalculated for every bootstrapped sample. RESULTS: Of the 165,123 patients who underwent EGS operations over the 2-year period, 17,655 (10.7%) were regionalized to a higher-volume hospital. On average, 128 (48.8%) of lower-volume hospitals were "closed," ranging from 68 (22.0%) hospital closures for appendectomy to 205 (73.2%) for small bowel resection. The simulations demonstrated that EGS regionalization would prevent 9.7% of risk-adjusted EGS deaths, significantly saving lives for every EGS operation: from 30.8 (6.5%) deaths prevented for appendectomy to 122.8 (7.9%) for colectomy. Regionalization prevented 4.6 deaths per 100 EGS patient-transfers, ranging from 1.3 for appendectomy to 8.0 for umbilical hernia repair. CONCLUSION: This simulation study provides important new insight into the concept of EGS regionalization, suggesting that 1 in 10 risk-adjusted deaths could be prevented by a structured system of EGS care. Future work should expand upon these findings using more complex discrete-event simulation models. LEVEL OF EVIDENCE: Therapeutic/Care Management, level IV.

Hospital Preparedness Plans for Chemical Incidents and Threats: A Systematic Review.

In a wide range of events, people may be acutely exposured to chemical substances. Particular hospital preparedness plans and vital resources are essential for appropriate health-care measures. The present study aimed to conduct a systematic review to summarize and evaluate the existing evidence on hospital preparedness plans or protocols against chemical incidents and threats. In this aim, through May 15, 2018, 5 electronic databases were searched in MEDLINE (PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar) for the following key words: hospital preparedness, plan, protocol, chemical incident, and chemical threat. The final review included 11 peer-reviewed papers that met inclusion criteria. The systematic review was performed using the Preferred Reporting Items for the Systematic reviews and Meta-Analysis protocol (PRISMA) (www.prisma-statement.org). Finally, of 16,540 selected papers, 11 papers were included in the final analysis. The thematic analyses revealed 11 major categories of chemical incidents and threats planning, such as planning requirements, planning prerequisites, preparation team member (multidisciplinary team), decontamination, personal protective equipment, education and training, job descriptions and roles, communication, database, staff /volunteer organization, as well as planning barriers and challenges for chemical incidents. Most countries have launched hospital preparedness planning against chemical incidents and threat activities, but the preparedness of hospitals is often less than desirable. Many items, such as databases, hospital preparation team members, communications, etc., are still challenging.

Reducing Waiting-time of Preterm Babies at a Retinopathy of Prematurity Clinic: A Quality Improvement Project.

OBJECTIVE: To decrease the waiting time for preterm babies visiting the Retinopathy of prematurity clinic in a tertiary eye hospital. DESIGN: Interventional study. SETTING: Tertiary eye care hospital. PATIENTS: All preterm babies reporting for screening and follow up at Retinopathy of prematurity clinic. INTERVENTION/PROCEDURE: A quality improvement team comprising of a faculty (team leader), two senior residents, two junior residents, one nursing officer, and a registration staff was constituted. Fish bone analysis was done to understand various reasons for the high waiting time for preterm babies. Baseline data was collected followed by multiple Plan-Do-Study- Act (PDSA) cycles. MAIN OUTCOME MEASURE: Average waiting-time, maximum waiting-time, and last baby entry-time were measured. RESULTS: The median average waiting-time, maximum waiting-time and last baby entry-time at baseline were 90.5 min (range 74.1 to 118.8 min), 177.5 min (range 160 to 190 min) and 111 min (90 to 118 min), respectively. At the end of 3rd PDSA cycle, these reduced to 77.6 min (range 55.2 to 94.3 min), 122 min (range 110 to 135 min), and 60 min (range 45 to 80 min), respectively and were sustained; the decrease from baseline being 14.3%, 31.2%, and 46%, respectively. CONCLUSION: The time spent in the waiting area at the Retinopathy of Prematurity clinic was significantly reduced by simple changes in the process flow.

Esclerosis múltiple en Portugal continental: análisis de clusters espaciotemporales y variaciones espaciales en tendencias temporales de los ingresados entre 2002 y 2013 / Multiple sclerosis in continental Portugal: analysis of spatio-temporal clusters and spatial variations in time trends of hospitalised patients between 2002 and 2013

Introducción. La esclerosis múltiple (EM) es una enfermedad desmielinizante y autoinmune con progresión variable y alto riesgo de hospitalización. En algunos estudios, estos ingresos se utilizan como marcadores sustitutivos de la progresión de la enfermedad, pero en Portugal, debido a las asimetrías organizacionales y las opciones de seguridad clínica, esta relación no es lineal. El patrón de ingresos por EM puede proporcionar datos relevantes para el diseño de estrategias de gestión de la enfermedad y asignación de recursos. Objetivo. Caracterizar los ingresos por EM en Portugal continental entre 2002 y 2013 a través de los casos constantes en la base de datos de morbilidad hospitalaria con código de diagnóstico principal CIE-9-MC 340. Pacientes y métodos. Se utilizaron técnicas de mapeo, análisis de clusters espaciotemporales y análisis de variaciones espaciales en tendencias temporales de la tasa de ingresos por EM. Resultados. Entre 2002 y 2013, la tasa de ingreso anual por EM fue de 82,2 por 100.000 ingresos, con una tendencia decreciente anual del 3,73%. Se identificaron siete clusters espaciotemporales con tasas de ingresos por esta patología desde 2,27 a 4,23 superiores a la tasa nacional. Además, se detectaron cuatro áreas con tendencia creciente en la tasa de ingreso en este período temporal (+0,17 a +11,5%): Sintra-Cascais-Amadora, Serra da Estrela, Alentejo-Algarve y Trás-os-Montes. Conclusión. Estos resultados demuestran la asimetría esperada por las diferencias organizativas, factores ambientales, genéticos y opciones de seguridad clínica. Permite la identificación de áreas y tendencias evolutivas de las tasas de ingreso por EM, y posibilita el diseño de intervenciones en salud más enfocadas (AU)

Introduction. Multiple sclerosis (MS) is a demyelinating and autoimmune disease with variable progression and high risk of hospital admission. In some studies these hospitalizations may be used as surrogate markers of disease progression, however in Portugal, due to organizational asymmetries and clinical safety choices this relationship is not linear. The admission patterns for this pathology can provide relevant data to the design of disease’s management strategies and resource allocation. Aim. To characterize hospital admissions for MS in mainland Portugal between 2002 and 2013 through the cases included in the hospital morbidity database with the code ICD-9-CM 340 as primary diagnosis. Patients and methods. In this study mapping techniques, analysis of spatio-temporal clusters and analysis of spatial variations in temporal trends of hospital admission rates for MS were used. Results. Between 2002 and 2013 the rate of annual hospital admission for MS was 82.2/100,000 hospitalizations, with a decreasing trend of 3.73%/year. Seven spatial-temporal clusters were identified with hospital admission rates for this pathology ranging from 2.27 to 4.23 higher than the national rate. In addition, in this time period four areas with increasing trend in hospital admission rate (+ 0.17 to +11.5%) were detected: Sintra-Cascais-Amadora, Serra da Estrela, Alentejo-Algarve and Trás-os-Montes. Conclusion. These data demonstrate the expected asymmetry of organizational differences, environmental, genetic and clinical safety choices. This study allowed the identification of areas and evolutionary trends of hospital admission rates for MS, enabling the design of more focused health interventions (AU)

Predicting length of stay from an electronic patient record system: a primary total knee replacement example.

BACKGROUND: To investigate whether factors can be identified that significantly affect hospital length of stay from those available in an electronic patient record system, using primary total knee replacements as an example. To investigate whether a model can be produced to predict the length of stay based on these factors to help resource planning and patient expectations on their length of stay. METHODS: Data were extracted from the electronic patient record system for discharges from primary total knee operations from January 2007 to December 2011 (n=2,130) at one UK hospital and analysed for their effect on length of stay using Mann-Whitney and Kruskal-Wallis tests for discrete data and Spearman's correlation coefficient for continuous data. Models for predicting length of stay for primary total knee replacements were tested using the Poisson regression and the negative binomial modelling techniques. RESULTS: Factors found to have a significant effect on length of stay were age, gender, consultant, discharge destination, deprivation and ethnicity. Applying a negative binomial model to these variables was successful. The model predicted the length of stay of those patients who stayed 4-6 days (~50% of admissions) with 75% accuracy within 2 days (model data). Overall, the model predicted the total days stayed over 5 years to be only 88 days more than actual, a 6.9% uplift (test data). CONCLUSIONS: Valuable information can be found about length of stay from the analysis of variables easily extracted from an electronic patient record system. Models can be successfully created to help improve resource planning and from which a simple decision support system can be produced to help patient expectation on their length of stay.

Trends in regionalization of adrenalectomy to higher volume surgical centers.

PURPOSE: Although centralization of surgical procedures to high volume centers has been described previously, patterns of care for adrenal surgery are largely unknown. We determined the extent of regionalization of care for adrenal surgery and the extent to which this centralization has evolved with time. MATERIALS AND METHODS: Using 1996 to 2009 hospital discharge data from New York, New Jersey and Pennsylvania we identified all patients 18 years old or older treated with adrenalectomy. Hospital volume quintiles were created using 1996 hospital volumes. These cutoffs were then applied to subsequent years. Outcome variables were examined by hospital volume status with time using logistic regression models. RESULTS: A total of 8,381 patients underwent adrenalectomy from 1996 to 2009 with a significant 17% to 42% shift toward regionalization to very high volume hospitals, defined as 15 or greater procedures per year (p <0.001). For each successive year the odds of having surgery performed at a very low volume hospital decreased by 13% (OR 0.87, 95% CI 0.84-0.89). There were significant differences in patient age, race and payer group for very low volume hospitals, defined as less than 1 procedure per year, compared to very high volume hospitals (p <0.0001). Patients at very high volume hospitals were less likely to be 55 years old or older (OR 0.73, 95% CI 0.61-0.88), insured through Medicaid (OR 0.60, 95% CI 0.45-0.79) or uninsured (OR 0.34, 95% CI 0.17-0.70). When controlling for year treated, patients were less likely to die in the hospital if treated at a very high volume hospital (OR 0.38, 95% CI 0.19-0.75). CONCLUSIONS: These data reveal the increasing centralization of adrenalectomy to very high volume hospitals since 1996 with improved clinical outcomes. Inequities in access to care to higher volume centers appear to exist and require further investigation.

Regional differences in deceased donor liver transplantation and their implications for organ utilization and allocation.

We examined the UNOS database from 7/15/00-7/17/05 for Regional deceased donor liver utilization. For each region, we performed logistic regression and derived odds ratios (OR) for donor characteristics associated with livers being transplanted outside of the region or not transplanted at all. Regions with smallest and least significant OR were considered aggressive users of suboptimal organs. We estimated how many untransplanted livers from less aggressive regions might be used by more aggressive regions. Only Region 9 was significantly more aggressive than others (median OR: 6 vs. 16; p < 0.01; median OR size: 1.4 vs. 3.6; p < 0.01). Region 9 transplanted at higher median Model for End-stage Liver Disease (MELD) score (20.4 [6-73] vs. 18.3 [6-70], p < 0.01), but had the lowest one- and five-yr graft survival (p < 0.01). Of 30,474 livers, 5056 were not transplanted, of which 3690 were procured outside Region 9 but met Region 9 use criteria. Of these, 1488 and 1807 livers had donor risk indices ≤ 2, for hypothetical 12 and 8 h cold ischemia time (CIT), respectively. Regional differences in liver utilization are profound. Region 9 is significantly more aggressive. At the most, 297-361 organs per year may have been used under Region 9's use criteria but overall graft survival may have declined.

Planning the specialized care of adult congenital heart disease patients: from numbers to guidelines; an epidemiologic approach.

Guidelines published in 2001 recommended 1 regional adult congenital heart disease (ACHD) center per 3 to 10 million population. Our objective was to determine if published guidelines on the numbers of regional ACHD centers are sufficient to meet the needs of adults with congenital heart disease in the general population. Population data were examined to evaluate the recommendations for the number of regional centers. We extrapolated a population prevalence of 4.09 per 1,000 adults corresponding to 847,896 and 87,375 patients with ACHD in the United States and Canada, respectively. We reviewed the information currently available on the numbers of ACHD facilities of any kind indexed to continental populations. We examined the distribution of disease and health services in pediatric and adult populations and examined the evidence for pressure points during the transition process. Published data on 6 of the largest regional ACHD centers were used to model regional center care. We reviewed determinants and recommendations for follow-up in regional centers. We explore 3 scenarios of referral patterns to regional centers, examining their impact of the number of centers required per country population. In conclusion, we demonstrate that 1 regional ACHD center for a population of 2.0 million adults appears to be closer to what is required for improving access to specialized care for patients with ACHD in the United States and Canada.

A biobjective model for the locational planning of hospitals and health centers.

The aim of this paper is to propose a new location-allocation structure, in an effort to improve the operational shortcomings of the existing locations of primary health care centers. These shortcomings are mainly caused by the preference of patients to use local hospitals rather than health centers. The method is based on a biobjective mathematical programming model for locating hospitals and primary health care centers. Two objectives are considered: (1) minimization of distance between patients and facilities, (2) equitable distribution of the facilities among citizens. We formulate the model taking into consideration the interdependence of the locations i.e., the general hospitals and health centers. This approach enables us to introduce a new aspect to the location problem, namely public preferences and also to consider the decentralization of the health care system. In order to represent the available information we employ Geographic Information Systems (GIS). We apply this model in the area of Western Greece and then compare our results with the solution originally selected by planners. Demographic data concerning the major and minor population centers of the area were based on the latest census of 2001. The results confirm the necessity of applied scientific approaches for regulating the health care system in order to establish rational strategic planning and ensure the best use of the available resources.

Construction activity in U.S. hospitals.

Hospital construction activity is increasing, but little information exists on what types of hospital capacity are affected and what is motivating specific efforts. Our analysis of Round Five Community Tracking Study data revealed four general types of activity: new hospital construction or expansion of existing general hospital capacity; new or expanded capacity in specialty services; replacement of aged facilities; and expansion of capacity-constrained services. Some of these actions are responsive to community need, but others resemble a medical-arms-race response. Overall, current construction activity will provide more convenient access for some consumers but at high cost if excess capacity results.

2006 hospital building report. The boom goes on.

Our survey of construction trends finds that the most significant expansion and replacement of U.S. hospitals since the post-World War II building spree continues to fuel a red-hot market. And the building boom is likely to last through the rest of the decade.

Bioterrorism and mass casualty preparedness in hospitals: United States, 2003.

OBJECTIVES: This study examined the content of hospital terrorism preparedness emergency response plans; whether those plans had been updated since September 11, 2001; collaboration of hospitals with outside organizations; clinician training in the management of biological, chemical, explosive, and nuclear exposures; drills on the response plans; and equipment and bed capacity. METHODS: The National Hospital Ambulatory Medical Care Survey (NHAMCS) is an annual survey of a probability sample of approximately 500 non-Federal general and short-stay hospitals in the United States. A Bioterrorism and Mass Casualty Supplement was included in the 2003 survey and provided the data for this analysis. RESULTS: Almost all hospitals have plans for responding to natural disasters (97.3 percent). Most have plans for responding to chemical (85.5 percent), biological (84.8 percent), nuclear or radiological (77.2 percent), and explosive incidents (76.9 percent). About three-quarters of hospitals were integrated into community-wide disaster plans (76.4 percent), and 75.9 percent specifically reported a cooperative planning process with other local health care facilities. Despite these plans, only 46.1 percent reported written memoranda of understanding with these facilities to accept inpatients during a declared disaster. Hospitals varied widely in their plans for re-arranging schedules and space in the event of a disaster. Training for hospital incident command and smallpox, anthrax, chemical, and radiological exposures was ahead of training for other infectious diseases. The percentage of hospitals training their staff in any exposure varied from 92.1 percent for nurses to 49.2 percent for medical residents. Drills for natural disasters occurred more often than those for chemical, biological, explosive, nuclear, and epidemic incidents. More hospitals staged drills for biological attacks than for severe epidemics. Despite explosions being the most common form of terrorism, drills for these were staged by only one-fifth of hospitals. Hospitals collaborated on drills most often with emergency medical services, fire departments, and law enforcement agencies.

A good, old-fashioned building boom.

After a decade of little activity, the pace of hospital construction began to surge in 2000 and it shows no signs of slowing down soon. Aging facilities, staffing issues and consumer demands are fueling the boom. And hospital leaders are betting their new facilities will be flexible enough to accommodate ever-changing technology.