Introducing the Mid-Patient
“What? How can you even suggest that we need additional beds! We are only operating at 65% occupancy. The Board will think I'm crazy to even think about increasing our bed capacity, given such a low overall occupancy rate,” says the anonymous CEO.
Unfortunately, on any given day, many hospitals are running at an occupancy rate so high that it could have a negative impact on patient safety and quality of care–even though their overall annual occupancy is reported to be below 70%.
What explains this apparent operational dichotomy? Is it periodic and cyclical bed utilization? The organization's bed assignment and management system? The mix of private and semiprivate beds? The way operating occupancy is reported? The use of inpatient beds for “non-inpatients?” The daily change in bed availability and bed count resulting from infection control (isolation) procedures, disease management, and periodic room maintenance? How about daily bed turnover from admission/discharge overlaps, or some other phenomenon?
This operational dichotomy is probably caused by most of these factors, all of which affect hourly and daily bed availability, in turn affecting patient throughput considerations. These factors lead hospital staff to hold patients in the emergency department, surgery, PACU, and other areas while they wait for an appropriate bed assignment. Worse yet, the organization is perceived as unable to accept referred patients when the medical staff is clamoring for every available bed.
The situation described above can be attributed partly to what some characterize as the “tyranny of the averages.” Daily operational problems are masked by long-term aggregate inpatient occupancy rates (typically based on midnight census counts) that do not reflect hourly and daily bed availability.
We must remind ourselves of the several factors that influence bed availability and optimal occupancy:
A bed is not always a bed. Special and distinct units, such as birthing centers, NICUs, rehabilitation units, specialized ICUs, etc., limit the number of beds available for “general” medical surgical care.
We do not fully operate hospitals 24/7. Typically, daily surgical patient volume varies over a normal five-day schedule, while medical patient volume is less volatile over a seven-day period but has significant seasonal variability. In general, given reduced staffing levels and ancillary support service availability on 52 weekends and 10 holidays (114 days), only 69%, or 251 days, of a year is available for “full” bed utilization.
Patients are coming and going more quickly. Statistically, the shorter the average length-of-stay (ALOS; now sometimes measured in hours), the less time a bed is occupied, reducing the overall achievable aggregate potential occupancy. For example, if a patient has a 365-day ALOS, the bed is 100% occupied; if the same bed had 365 admissions, each with a 12-hour ALOS (7 a.m. to 7 p.m.) and 12-hour average turnover (overnight), the bed would be optimally occupied at the 50% level over a year. In sum, the shorter the ALOS, the higher the turnover and the lower the potential average occupancy on a finite set of beds.
Not all inpatients are really inpatients. Inpatient beds are being used by non-inpatients in support of outpatient diagnostic and treatment procedures, such as diagnostic/therapeutic catheterizations, interventional radiology procedures, short-stay surgical procedures (less than 24 hours), etc.
These factors, among others, exacerbate daily and, yes, hourly bed demands in ways that are not reflected in overall average yearly occupancy rates as usually measured by the “midnight census” count. Therefore, the perplexity of the anonymous CEO whom we quoted at the beginning of this article, can be explained, in part, by historical management information systems and their shortcomings. These systems have resulted in “lost data”—in particular, a lack of data to monitor the non-inpatients who are in inpatient beds. The data are simply not reported, and this leads to a general lack of understanding regarding how contemporary care-management protocols affect today's patient care units.
Advances in minimally invasive surgical technologies have spawned two important trends, one on the inpatient side and the other on the outpatient side. For inpatients, procedures are becoming less invasive and, as a result, postsurgical length-of-stay is expected to continue its steady decline. On the outpatient side, minimally invasive procedures have actually enabled increasingly complex interventions for these patients. This has paradoxically increased the acuity of many ambulatory patients, so that outpatient postprocedural stays ranging from more than several hours to nearly a day have become fairly common. (figure 1).
This dynamic is indicative of many long-term trends facing healthcare managers and caregivers today. Technologic advances notwithstanding, we as an industry are promoting increased consumerism, increased patient and family involvement in care, continuing system consolidation, more quality and safety initiatives, and a growing “community health status” philosophy. Additionally, the market is becoming increasingly defined by fixed payment mechanisms, declining reimbursement levels, and increasing cost shifts to patients via higher deductibles and copays. In response, providers are developing least-cost operational models and strategies to capture additional market share. To provide enhanced value and quality in this environment, facility design is being driven toward more efficient operations, reduced duplication of equipment and staff, adoption of technology-assisted modalities, and enhanced physician and hospital productivity. To our credit, our industry's strategic response has been to develop a “healing environment”–one that is safe, responsive, “smart,” technologically advanced, high-quality, and environmentally and fiscally sustainable.
One of the most complex trends we are facing is that of technology growth and its rate of adoption, and how best to respond to the demands involved. As already indicated, substitution technologies are decreasing procedure invasiveness and radically changing the related procedure venue and required care model, resulting in significantly shorter lengths-of-stay. For example, diagnostic cardiac catheterization (which was often an inpatient procedure) may be largely offset by CT coronary angioplasty, which is now largely an outpatient procedure. Stenting procedures, as well as minimally invasive, “mini-port” surgical techniques, are already driving heart bypass surgery toward shorter lengths-of-stay or outpatient angioplasty procedures. Even the traditional definitions of outpatient and inpatient surgical procedures no longer seem adequate, and will possibly be redefined as “elective” and “nonelective” procedures to reflect more predictable time frames, thereby allowing better resource management.
Radical changes in imaging technology, molecular-based medicine, and emerging nanotechnology are fostering early disease detection and treatment. Information technology, as well as potential radio-frequency applications (RFID tags), will drive “smart buildings” that will provide faster diagnosis and treatment, broader information sharing and, finally, the long-sought-after shared patient health record.
These current and future changes have created a new care- delivery model that is fostering new patient types: patients who are largely postprocedural and less acute but who require greater intensit
y of care in a shorter period of time, and patients who are chronically ill and require ongoing disease management. These patients may not fit classical definitions, but most often they are not inpatients.
Coping With the New Patient Type
Healthcare facilities are strategic resources; they must be optimally responsive in order to foster clinical programs, enhance culture, and ensure efficient operations. They also should enhance healthcare quality and safety and respond to technologic change. Most importantly, they should be grounded in the development of appropriate clinical care-delivery models and facility settings that optimize the use of finite resources. If one embraces the philosophy that resources are strategic, then it follows that emerging new patient types require a strategic organizational response.
Most of today's facilities do not match up with these emerging patient types, their care needs, or the needs of their care partners—i.e., physicians, staff, family, and loved ones. And yet we estimate that new patient-type populations represent 25% or more of a hospital's business today. And that figure looks likely to increase as technology and care-delivery/ procedure processes evolve.
In our experience, there is no common or universal definition today for ambulatory patients, outpatients, short-stay patients, inpatients, etc. In fact, in one client situation we're aware of, such patients, the non-inpatients, were described 17 different ways. Most healthcare organizations do not have adequate systems to monitor and/or track their non-inpatients on a daily and hourly basis. These patients exist and utilize significant resources but often are not counted in “official” utilization records. Their impact on the organization is perceived but not quantified. Even more confusing, patient designations and related reimbursement are sometimes changed post-discharge for reimbursement maximization, which further complicates the issue.
In this regard, we propose that a new patient classification—the “mid-patient”—be defined and tracked. Our overall proposed patient classification system defines patient types by required model of care delivery, rather than by reimbursement category, to wit:
Ambulatory, or “vertical,” patient—a patient who does not need a “bed” or horizontal surface for appropriate care. This level of care would include simple imaging procedures, lab sticks, counseling sessions, etc.
Mid-patient—a patient requiring up to a 72-hour stay on a horizontal “bed surface” in the most appropriate strategic setting, consistent with quality care processes, optimal operational efficiency, and applicable codes and regulations. The “bed surface” may not necessarily require a “licensed” bed. This level of care would encompass pre- and postprocedural care, including selected preadmission diagnostic testing procedures (with a stay of up to 72 hours) or chronic disease management (e.g., infusion services, etc.).
Inpatient—a patient who meets the criteria for inpatient admission and requires a licensed hospital bed.
If one embraces this working typology, definitive criteria for each patient type can be developed and each type's utilization patterns monitored. Several subclasses of mid-patients can be contemplated as well, given their specific average ALOS and patient-specific resource requirements. Those requirements include needed technologies, intensity of care and services, caregiver requirements and, if greater than a 24-hour ALOS, accommodations with windows.
Why worry about this?
The major premise for designing “healing environments” is a patient-centered philosophy. As such, we strive to create appropriate care settings for patients and their care partners. By definition, the mid-patient is not an acute care patient; most are not acutely ill. Instead, they comprise a growing population of pre- and postprocedural patients or patients who periodically return to the hospital for the management of their chronic disease(s). Their use of hospital resources is lower than that of acute patients, yet their needs for patient amenities, education, and family support are higher than those of typical outpatients. The design of an appropriate environment for these patients should optimize hospital resource utilization, thereby allowing for enhanced marginal revenue and appropriate patient management—in other words, the right resources at the right time. Timeliness, quality, and safety of services are the key drivers behind this new classification.
We have analyzed various potential care-delivery models and developed numerous relevant facility types, ranging from centralized models within an inpatient-type unit to decentralized outpatient-type units with “licensable” rooms. We have determined that the most appropriate model varies with each institution. One model does not fit all.
For example, a fair amount of ancillary process engineering may be required to ensure timeliness and safety for the mid-patient. Pharmacy, for instance, may well trend toward a “retail” or “rapid response” perspective. Typical scheduled laboratory inpatient batch processing tends to slow the care process down in this population; therefore, newer point-of-care technologies may prove beneficial. Imaging may require a refocus on quicker scheduling and reading as well. Logistics of services such as dietary and housekeeping also may trend toward a more rapid response model.
Care management models will also require reconsideration. This may include cross-functional integration of care-delivery teams, direct management of the postdischarge placement of patients, and investments in new clinical and administrative computer technologies to proactively optimize resource utilization, including beds.
The emerging mid-patient is the result of many contemporary macro-trends. To determine how best to respond, an organization should:
Document its current patient population situation.
Redefine and classify patients on a care-model basis and define appropriate resource requirements.
Establish adequate processes and systems to monitor patients, utilization, and required resources.
Develop the most appropriate care-delivery model and required facilities.
Assess/evaluate its facilities to determine their adequacy.
Develop an appropriate operational and facility response.
Emerging patient types require new, creative, and innovative solutions to ensure organizational success. Both operational and environmental responses must be considered to ensure optimum care that meets today's patient requirements. Accurate analysis of the patient population and its needs is critical.HD