Capacity Management Strategies

A number of strategies surrounding bed capacity management have already been addressed.

• (1) Use of Care Management to provide real time reviews of patients for level of care at strategic points within the organization including the ED, Operating Room, and Cath lab.
• (2) Centralized Bed Assignment with defined priorities related to bed utilization. Those priorities in order were patients requiring the ICU—then Operating Room and Cath lab—then directs and transfers and finally the Emergency Department.

Here are some additional strategies:

Hospital Prep

In today’s healthcare environment, in which many hospitals run extremely high census (over 95% occupancy), it is not uncommon for hospitals to start Monday morning 70 or 80 beds in the hole. Planned surgeries, Cath lab cases, directs,

Figure 6.1 Sample of Operational Planning tool for next week volumes (use historical intelligence of Current Week plus next week demand to forecast next week needs).

and transfers, anticipated admissions through the ED and perhaps a quantity of ED boarders might all be waiting for a bed that morning. Many organizations, instead of planning for the inevitable Monday rush (or any other foreseeable bed capacity management issue), start to react only when beds become tight (Figure 6.1).

As noted above, Sunday night, with its lower average volume of incoming patients, presents an opportunity to plan and prepare. During any slower time, it should be possible to prepare the hospital for the inevitable increase in activity.

With time to prepare, managers can reserve certain beds, holding them for the post-surgical and post-Cath cases which will begin to flow through on Monday morning. This prevents patients having to be hurried out of these beds and reduces the possibility of a backed up Operating Room or Cath lab. This is also an opportunity to allocate staff appropriately to care for these patients (see Figure 6.2).

It is possible to estimate anticipated volume and plan around it. This type of planning will incorporate:

• (1) Scheduled elective surgeries
• (2) Cardiac catheterizations and procedures

Figure 6.2 Sample of Daily Planning Tool for next week. Uses known fixed schedule plus anticipated unconstrained ED volumes.

• (3) Average daily transfers and directs based on prior 6-month statistics
• (4) Average daily ED admissions based on prior 6-month statistics

The resulting estimate can help determine staffing needs, provision ancillary services, or prepare to house patients as necessary. This proactive approach, in addition to being more effective, can also be used to help prepare the hospital for the following week’s schedule, including the scheduling of surgeries and other procedures. This strategy is most effective if it is centralized, particularly when allocating staff.

In hospitals which are assigning beds to higher priority patients, the ED can get backed up, housing admitted patients who cannot be assigned a bed. An effective means of combating this problem is with staff allocation. Nurses can be reallocated to the ED to provide care to admitted patients, freeing up the ED staff to care for incoming patients. If possible, each population should be kept in a separate area, with admitted patients clustered together. This keeps the extra staff out of the way. I remember suggesting this strategy to a chief nursing officer at a busy hospital. The plan suggested was to hold a number of orthopedic beds Sunday night. This would guarantee their availability for the high volume of orthopedic patients coming in on Monday. The orthopedic nursing staff could then be transferred to the ED to help out with patients boarding there, rather than moving those boarders to the orthopedic unit. The chief nursing officer felt this was unsatisfactory because the nurses from orthopedics would not be comfortable taking care of these patients. The same patients, mind you, who would have been placed on the same orthopedic unit to be cared for under the usual scenario. So, what happened? The beds were held, and the orthopedic nurses were sent home leaving the boarded ED patients to be cared for by the ED nurses.

This demonstrates the disconnect in hospitals on resource utilization and management of the overall system. Another method of attempting to manage excess ED boarders is to place patients in the hallways of the med/surg floors. The idea is that if the staff have to care for a patient in the hallway, they will be more motivated to discharge a patient so the hallway patient will get a bed—Nice theory. In reality, this is difficult to implement. Why? Patient types considered eligible for hallway placement have multiple restrictions. No telemetry, no oxygen, no patient requiring isolation, no patient with gastrointestinal issues, etc. The list goes on and on. I always viewed the placement of patients in hallways as simply removing the crowding problem from the ED to the floors, not fixing it.

Some organizations have designed Rapid Admitting Units (RAU’s) to care for these patient types. These units can be expanded or contracted based on need and are staffed predominantly with reallocated staff, who often come from areas in which beds are being prepped for the very patients they are caring for in the ED. This approach is only possible with centralized bed assignment and staffing control. It also requires a broad understanding of the entire organization’s needs, beyond any individual area of the hospital.