Hospital indicators after implementation of bed regulation strategies: an integrative review

Maldonado, Rayane Nascimbeni; Savio, Renata Olszewski; Feijó, Vivian Biazon El Reda; Aroni, Patrícia; Rossaneis, Mariana Angela; Haddad, Maria do Carmo Fernandez Lourenço

doi:10.1590/0034-7167-2020-0022

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Sumário

REVIEW • Rev. Bras. Enferm. 74 (2) • 2021 • https://doi.org/10.1590/0034-7167-2020-0022 copy

Hospital indicators after implementation of bed regulation strategies: an integrative review

Indicadores hospitalarios después de implementar estrategias relacionadas con la regulación de camas: una revisión integradora

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objectives:

to analyze the scientific evidence available in literature on hospital indicators after implementation of bed regulation strategies.

Methods:

this is an integrative review conducted with studies available in five databases and in the reference database of the Center for Study and Research in Nursing Services Management in October 2019. Articles on hospital bed management, available in full in English, Spanish or Portuguese, without temporal delimitation were included.

Results:

1,118 eligible articles were found, of which 37 were duplicated. Among 1,081 pre-selected studies, 112 studies were eligible and 11 articles were included. Six studies addressed the emergency services. Three addressed hospital indicators in general, another focused on a psychiatric ward and one analyzed the indicators of two hospitals administered differently.

Conclusions:

the studies focused on emergency services, demonstrating the importance of organizing these services for health institutions.

Descriptors:
Indicators; Management Indicators; Strategies; Bed Occupancy; Beds

Database

Strategy

LILACS

(Indicadores de Qualidade em Assistência à Saúde) OR (Indicadores Básicos de saúde) OR (Indicadores de gestão) OR (Gestão da Informação em Saúde) OR (Indicadores de serviços) OR (Indicador de Qualidade) OR (Indicadores de Qualidade) OR (Indicadores da Eficiência do Sistema de Saúde) OR (Estimativa de Risco de Saúde) OR (Estimativa de Riscos para a Saúde) OR (Indicadores de Saúde) OR (Indicador de Saúde) OR (Medição de Risco em Saúde) OR (Indicadores do Nível de Saúde) OR (Gerenciamento de Informação em Saúde) AND (Organização e Administração) OR (Ocupação de leitos) OR (Leitos) OR (Número de leitos em hospital) OR (Administração Hospitalar) OR (Gerência) OR (Gerenciamento) OR (Gestão) OR (Leito Hospitalar) OR (Leitos Hospitalares) OR (Organização e Administração Hospitalar) OR (Organização e Administração de Hospitais) OR (Gestão Hospitalar) OR (Núcleo de regulação de leitos) OR (gerenciamento de leitos) OR (Núcleo interno de regulação de leitos) OR (acesso aos serviços de saúde) OR (regulação e fiscalização em saúde) AND (Bed management)

MEDLINE
WOS
Scopus
CINAHL

(Quality Indicators, Health Care OR Global Trigger Tool, Healthcare OR Healthcare Global Trigger Tool OR Quality Indicators, Healthcare OR Health Information management) AND (Bed occupancy OR Hospital Administration OR Administration, Hospital OR Hospital Organization and Administration OR Organization and Administration, Hospital OR Benchmarking OR Benchmarking, Health Care OR Benchmarking, Healthcare OR Departament of bed occupancy OR Access to health services OR Regulation and supervision of health) AND (Bed management)

Authors Year Database Level of Scientific Evidence (LoE)	Objective (s)	Rated indicators	Main results
ADLINGTON et al.⁽¹¹11 Adlington K, Brown J, Ralph L. Better care: reducing length of stay and bed occupancy on an older adult psychiatric ward. BMJ Open Quality. 2018; 7:e000149. https://doi.org/10.1136/bmjoq-2017-000149 https://doi.org/10.1136/bmjoq-2017-00014... ⁾ 2018 MEDLINE LoE: 6	Demonstrating the results of the implementation of a project to reduce length of stay and occupancy rates of the Leadenhall ward.	Average length of stay, occupancy rate, number of beds occupied per day, number of admissions per week and readmission rate in 28 days.	In the first year, the average length of stay decreased from 47 to 30 days. The occupancy rate went from 77% to 55%. The number of admissions did not change, but the number of occupied beds decreased due to the reduction of the average length of stay and stable admission and readmission rates.
SAJADI et al.⁽¹²12 Sajadi HS, Sajadi ZS, Sajadi FA, Hadi M, Zahmatkesh M. The comparison of hospitals' performance indicators before and after the Iran's hospital care transformations plan. J Educ Health Promot. 2017;4;6:89. https://doi.org/10.4103/jehp.jehp_134_16 https://doi.org/10.4103/jehp.jehp_134_16... ⁾ 2017 MEDLINE LoE: 6	Comparing the performance indicators of all types of hospitals before and after implementing the Hospital Care Transformation Plan (HCTP).	Occupancy rate, average length of stay, turnover rate, days of occupied beds, internal care, outpatient care, emergency care, hospital mortality rate, number of surgery and normal delivery rate.	The average occupancy rate went from 62.79 to 68.5. The average length of stay was 2.82 to 2.65 days. The average turnover rate went from 6.7 to 8. The average number of occupied beds increased from 116,405 to 130,804. Regarding the average number of inpatients, outpatients and emergency patients, it went from 39,791 to 46,463, 606,068 to 639,086, and from 125,185 to 127,910, respectively. The mean hospital mortality rate decreased from 13.2 to 11.1. The average number of surgeries increased from 17,388 to 21,097 and the mean normal delivery rate went from 34 to 38. Occupancy rate, turnover rate, bed occupancy, care of hospitalized patients and the number of surgeries increased in all types of hospitals. Outpatient care increased in all institutions, except in private ones. The results revealed that length of stay and mortality rate decreased in all types of hospitals, while the mortality rate had a higher decrease in public hospitals and a smaller decrease in semi-public hospitals.
RICHARDSON et al.⁽¹³13 Richardson DB, Brockman K, Abigail A, Hollis GJ. Effects of a hospital-wide intervention on emergency department crowding and quality: a prospective study. Emerg Med Australas. 2017;29(4):415-420. https://doi.org/10.1111/1742-6723.12771 https://doi.org/10.1111/1742-6723.12771... ⁾ 2017 MEDLINE LoE: 6	Determining the impact of a multimodal hospital intervention, supported by management, on measures of accommodation and quality of emergency service.	Number of emergency room visits, average number of patients in the emergency department, number of bed admissions, number of admissions slated for short-stay, number of patients who do not wait for care, percentage of patients seen within 4 hours, average hours for accommodation and resubmission rate within 72 hours.	During the intervention period, the emergency service increased by 9.1% compared to the previous year. It increased care for older adults. The number of admissions to the ward and short-term hospitalization increased 13.0% and 42.3%, respectively. The average occupancy fell to 22.6%. There was a significant increase in relation to care within 4 hours. The readmission rate showed no significant difference.
KHALIFA⁽¹⁴14 Khalifa M. Improving emergency room performance by reducing patients' length of stay. Stud Health Technol Inform. 2015;213:41-44. https://doi.org/10.3233/978-1-61499-538-8-41 https://doi.org/10.3233/978-1-61499-538-... ⁾ 2015 MEDLINE LoE: 6	Assessing the effects of the training program of nurses of the emergency service and accessibility of information on the length of stay of patients.	Time between arrival at the service and screening, time between sorting and transfer to bed, time between transfer to bed and medical care, time between care and conduct (discharge or hospitalization), length of stay in the emergency service.	Comparing the indicators of the first quarter of 2015 and the first quarter of 2014, there were reductions of 25.5% in the time interval between patients' arrival and screening, of 17.7% between screening for transfer to bed, an improvement of 16.1% in the interval between transfer to bed and medical care and 13.2% improvement in the interval between the doctor and the conduct (discharge or hospitalization).
CRILLY et al.⁽¹⁵15 Crilly JL, Boyle J, Jessup M, Wallis M, Lind J, Green D, et al. The implementation and evaluation of the patient admission prediction tool: assessing its impact on decision-making strategies and patient flow outcomes in 2 Australian hospitals. Qual Manag Health Care. 2015;24(4):169-76. https://doi.org/10.1097/QMH.0000000000000070 https://doi.org/10.1097/QMH.000000000000... ⁾ 2015 MEDLINE LoE: 6	Implementing the Patient Admission Prediction Tool (PAPT) and assessing its effects on decision-making strategies and daily and weekly patient flow results.	Number of patients in the emergency service awaiting ward bed, level of operational safety in the emergency service, forecasts for the number of total hospitalizations in the emergency service and elective surgery.	The average number of daily visits increased between pre- and post-intervention in hospital A and decreased in hospital B. The number of hospital admissions did not increase significantly in hospital A, but increased in hospital B. The average number of hospital admissions to both hospitals did not differ significantly before and after the intervention. In hospital A, total occupation increased, with no change in functional occupation; in hospital B, total occupation decreased while functional occupation increased. All hospital occupancy rates exceeded 90% in 125 of 179 days.
SULLIVAN et al.⁽¹⁶16 Sullivan CM, Staib A, Flores J, Aggarwal L, Scanlon A, Martin JH, et al. Aiming to be NEAT: safely improving and sustaining access to emergency care in a tertiary referral hospital. Aust Health Rev. 2014;38(5):564-74. https://doi.org/10.1071/AH14083 https://doi.org/10.1071/AH14083... ⁾ 2014 MEDLINE LoE: 6	Describing the process of development and implementation of the reform of access to emergency services, assessing the effects on patient flow and indicators at Princess Alexandra Hospital over 12 months.	Percentage of patients who left the emergency department; length of stay in the emergency service; unadjusted hospital mortality and standardized hospital mortality rate; readmission fee in service in 48 hours; call rate of the rapid response team on admission; number of complaints from the emergency department and employee perception of the reform National Emergency Access Target (NEAT).	Care within 4 hours increased for all emergency room patients (from 32% to 62%). The mean length of stay in the emergency department was reduced from 7.2 to 4.4 hours and for patients who were hospitalized went from 9.7 to 6.7 hours. Each phase of patient care in the emergency service decreased by approximately 30%. Mortality decreased from 2.3% to 1.7% (p=0.045) and the standardized hospital mortality rate for all acute hospitalizations decreased from 93 to 72 (p <0.001). The reduction in the standardized hospital mortality rate was inversely correlated with increased compliance with neat access (p <0.001). The number of patients who did not wait for care decreased (from 6.9% to 1.9%; p <0.001) as well as the number of complaints (from 12 to 6 per month). There was an increase in resubmissions to the emergency department within 48 h among patients discharged (from 3.1% to 3.8%; p=0.023) without additional increase in maintenance period. The annual number of attendance increased by about 5%. The perception of resistance to changes in practice and interaction with other professionals and uncertainty regarding the relevance of NEAT stood out. Communication, collaboration between units, reduction of overcrowding and greater patient satisfaction were positive aspects highlighted.
GHOLIPOUR et al.⁽¹⁷17 Gholipour K, Delgoshai B, Masudi-Asl I, Hajinabi K, Iezadi S. Comparing performance of Tabriz obstetrics and gynecology hospitals managed as autonomous and budgetary units using Pabon Lasso Method. Australas Med J. 2013;6(12):701-07. https://doi.org/10.4066/AMJ.2013.1903 https://doi.org/10.4066/AMJ.2013.1903... ⁾ 2013 MEDLINE LoE: 6	Assessing the performance of Tabriz obstetrics and gynecology hospitals using the Pabon Lasso model to make comparations between Al-Zahra and Taleghani hospitals and determine whether Al-Zahr Hospital performed better.	Occupancy rate, turnover rate and average length of stay.	The length of stay at Al-Zahra Hospital is 3.15 (2.15) days, 1.88 (0.97) days for prenatal wards and 6.13 (0.97) days for neonatal wards) while at Hospital Taleghani it is 3.37 (3.09) days 1.74 (0.14) days for perinatal wards and 5.96 (3.55) days for neonatal wards). The maximum occupancy rate at Hospital Al-Zahra was 86.92% for Taleghani was 70.09%. The lowest occupancy rate was at Hospital Taleghani (68.44%) (p <0.001). Regarding the performance of hospitals in a Pabon Lasso Model, Hospital Taleghani remains mainly in zone 1 and some cases in zone 2, while the indicators of Hospital Al-Zahra fall in zones 2 and 4 of the graph. Al-Zahra Hospital faces overload and Taleghani Hospital does not fully use its capacity. Hospital Al-Zahra performed better.
SULKU⁽¹⁸18 Sulku SN. The health sector reforms and the efficiency of public hospitals in Turkey: provincial markets. Eur J Public Health. 2012;22(5):634-38. https://doi.org/10.1093/eurpub/ckr163 https://doi.org/10.1093/eurpub/ckr163... ⁾ 2011 MEDLINE LoE: 6	Investigating the impact of the Health Transformation Programme (HTP) on the efficiency and productivity of public hospitals in Turkey.	Number of outpatient care, number of hospitalizations, number of surgeries, number of beds (general and specialty), total number of surgeries, bed occupancy rate, mortality rate, length of hospital stay.	There was an increase in the number of outpatient care, number of hospitalizations, number of adjusted hospitalization cases per case and surgeries increased between 2001 and 2016, as well as the number of surgeries, 78%, 30.3%, 20% and 122%, respectively. The total number of beds, specialties and general practitioners increased by 18%, 26% and 27.7%, respectively. The occupancy rate remained unchanged (55%). Ministry of Health (MoH) hospitals, on average, showed growth in total factor productivity. HTP has generally been successful, boosting productivity due to advances in technology and technical efficiency, but in socially and economically disadvantaged institutions, productivity gains have not been achieved.
DE FARIA, et al.⁽³3 Faria E, Ryuko K, Costa A, Santos MA, Fumio MK. Nova abordagem de gerenciamento de leitos associada à agenda cirúrgica. Rev Adm Saúde. 2010;12(47):63-70. Available from: https://cqh.org.br/portal/pag/anexos/baixar.php?p_ndoc=207&p_nanexo=286 https://cqh.org.br/portal/pag/anexos/bai... ⁾ 2010 Other source (NEPGESE) LoE: 6	Maximizing the use of hospital beds as well as increase surgical production with the implementation of Internal Bed Management and Surgical Agenda (GILAC).	Total hospital admissions per specialty, replacement interval, turnover rate, occupancy rate per specialty, average length of stay per specialty, number of surgeries, number of operating rooms, operating room occupancy rate, number of surgeries per working day, number of surgeries per room per working day.	One year after the implementation of GILAC, the number of hospitalizations increased from 390 to 825. The number of beds increased from 165 to 225. The turnover index increased from 3.06 to 3.40, and the substitution interval went from 2.94 to 1.5. Occupancy rates for clinical and surgical beds increased from 77 and 57% to 87 and 79%. The average length of stay for clinical patients decreased from 9.88 to 8.7 days, while for surgical patients, it increased from 4.05 to 5.0 days. The number of procedures increased from 209 with three operating rooms to 483 operations with eight operating rooms. The occupancy rate of the surgical center went from 71 to 82%.
KINSMAN et al.⁽¹⁹19 Kinsman L, Champion R, Lee G, Martin M, Masman K, May E, et al. Assessing the impact of streaming in a regional emergency department. Emerg Med Australas. 2008;20(3):221-7. https://doi.org/10.1111/j.1742-6723.2008.01077.x https://doi.org/10.1111/j.1742-6723.2008... ⁾ 2008 MEDLINE LoE: 6	Assessing the impact of a streaming model, previously validated in metropolitan emergency services, on selected performance indicators in a regional emergency service.	Percentage of emergency patients admitted to an inpatient bed within 8 h of emergency patients not admitted with a length of stay of less than 4 hours of emergency patients who left without being seen by a doctor or nurse.	After 12 months the streaming was implemented, there was a 9% increase in emergency care. Approximately 47% of the visits were allocated to the gold stream (complex treatment), while 53% were allocated in the blue stream (less complex treatment). After the intervention (streaming), the service in less than 8 hours increased on average 0.30% per month, representing a net reversal in the trend of 0.62% per month (p=0.008). After the intervention, the upward trend in 4 hours was reversed, increasing on average 0.20% per month, representing a net reversal in the trend of 0.54% per month (p=0.004). There was no significant trend in the indicator "not waiting for care" of the doctor or the nursing team after the intervention.
COBELAS et al.⁽²⁰20 Cobelas C, Cooper C, Ell M, Hawthorne G, Kennedy M, Leach D. Quality management and the Emergency Services Enhancement Program. J Qual Clin Pract. 2001;21(3):80-5. https://doi.org/10.1046/j.1440-1762.2001.00408.x https://doi.org/10.1046/j.1440-1762.2001... ⁾ 2001 MEDLINE LoE: 6	Focusing on teams' perceptions about changes in performance indicators between 1995 and 1998, the possible factors that helped or slowed performance changes, and to what extent the Emergency Services Enhancement Program (ESEP) contributed to changes in patient care.	Changes after the introduction of the ESEP: ambulance diversion rates, emergency waiting time, access to the bed, perceived general change and factors that aid or delay change.	One hundred one employees participated in focus groups. Participants noticed an improvement of 20% in waiting times and 0.5% in access to the bed. In statistical analysis of real changes in access to the bed, there was a tendency for improvement; however, it did not show statistical significance. Most respondents (43%) reported that there was improvement over the 3 years with ESEP. The factors cited as capable of bringing improvements were changes in the profile team, managing patient flow through the emergency service, changes in administrative policies, changes in work practices and changes in the number of employees. There was considerable disparity between the perceptions of managers and employees of the emergency service as well as the hospital type in relation to the change and the perceived contribution of ESEP.

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[1] Corresponding author: Rayane Nascimbeni Maldonado E-mail: rayane_nascimbeni@hotmail.com