Proactive Scheduling Helps Hospitals Control Occupancy

Steven Fox

May 24, 2011

May 24, 2011 — Crowding can be a problem at hospitals, especially during the week, when patient admissions are generally higher than during weekends. However, results from a study of admissions data at 39 children's hospitals, published online May 24 in the Journal of Hospital Medicine, now show that when hospitals proactively control the admission of patients throughout the week, they can reduce weekday crowding, provide patients more consistent care, and make better use of facilities.

Principal author Evan Fieldston, MD, MBA, MSHP, assistant professor of pediatrics at the University of Pennsylvania and attending physician at The Children's Hospital of Philadelphia, and colleagues notes that admitting too many patients at one time can put patients at risk. The researchers suggest that "smoothing" admissions — scheduling planned admissions throughout the week and on weekends — can help hospitals reduce crowding and protect patients from problems associated with crowded conditions.

"The concept is to proactively control the entry of patients, when possible, to achieve more even levels of occupancy, instead of the peak and troughs commonly encountered," they write. Though the merits of that approach would seem to be self-evident, the authors say it is not widely used by hospitals.

"While it is obvious that smoothing will reduce peaks to average levels (and also raise troughs)," write the authors. "We sought to quantify just how large this difference was — and thereby quantify the potential of smoothing to reduce inpatient crowding."

The group evaluated retrospective inpatient census data from 39 freestanding tertiary-care children's hospitals during 2007. They checked weekday vs weekend occupancy and quantified the effect that smoothing of admissions had on variations in occupancy throughout the week. They also checked to see what proportion of planned admissions would need to be rescheduled to achieve within-week smoothing.

"A retrospective smoothing algorithm set each hospital's daily occupancy during a week to that hospital's mean occupancy for the week, effectively spreading the week's volume of patients evenly across the days of the week," they said.

To find out the number of patient admissions that would need to be rescheduled to even out occupancy rates for the week, the researchers determined the total number of patient-days in the week that required different scheduling and divided that number by the average length of stay for the week. Then they divided the number of admissions that needed changing by total weekly admissions. That gave the researchers the percentage of admissions at each hospital that needed to be changed across all 52 weeks of the year.

On the basis of that analysis, the researchers reported that the hospitals' mean occupancy rates ranged from 70.9% to 108.1% on weekdays and 65.7% to 94.9% on weekends. Occupancy on weekdays exceeded that on weekends by a median of 8.2%.

Postsmoothing, mean reduction in weekly maximum occupancy across all hospitals was 6.6%, the researchers said.

Using the smoothing approach in scheduling admissions, the hospitals as a whole were able to prevent 39,607 patients from being exposed to occupancy levels greater than 95%. The researchers also found that to even out admissions throughout the week, relatively few admissions — a median of only 2.6% — had to be rescheduled for a different day of the week. That equated to a median of about 7.4 patients per week.

"This type of proactive 'smoothing' decreases peak occupancy on weekdays, reducing the safety risks associated with high occupancy, improving acute access for emergent patients, shortening wait-times and loss of scheduled patients to another facility, and increasing procedure volume," the authors said.

They add that smoothing also increases quality and safety on weekends, as emergent patients admitted on weekends tend to experience more delays in necessary treatment and have worse outcomes.

Scheduling admissions to include weekends also may make it easier for working parents to visit their children, the authors noted.

Another plus is that smoothing admissions may benefit hospital staff members who prefer flexible scheduling.

"Increasing weekend hospital capacity is safe, feasible, and economical, even when considering the increased wages for weekend work," the researchers said. In addition, evening out admissions over the whole week allows fixed costs, such as surgical equipment and imaging equipment, to be allocated over a full 7 days, rather than 5.

The authors stress the need for more studies. "Further qualitative evaluation is also warranted around child, family, and staff preference concerning scheduled admissions, school, and work," they said.

Study authors received salary support from the Robert Wood Johnson Foundation Clinical Scholars Program, the Agency for Healthcare Research and Quality, and the National Institute of Allergy and Infectious Diseases. The authors have disclosed no relevant financial relationships.

J Hosp Med. Published online May 24, 2011.

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