Operation capacity: how one hospital system improved access and outcomes for patients

Safe care delivery is the goal of every hospital. This can be challenged by high occupancy rates, because overcrowded hospitals can lead to a mismatch between supply and demand for the hospital’s resources. This may include beds, nurses, physicians, and equipment. Strain on clinical staff can also affect their ability to perform. Negativity, churn, burnout, and conflict may all result.¹

The COVID-19 pandemic exposed and amplified the inadequacies and vulnerabilities of America’s health care system. This was further underscored by the triple pandemic of 2022–2023, which added outbreaks of influenza and respiratory syncytial virus infections in the United States.

Currently, the capacity of many hospitals continues to fall short of the needs of the communities they serve. This is especially true in regions of the country with growing populations. Other factors that contribute to capacity issues include aging populations, increasing numbers of people with chronic conditions, costly infrastructure, and medical technology investments.²

Effective hospital capacity management is central to the success or failure of a hospital. In its absence, long wait times, overcrowding, high error rates, poor communication, and low patient satisfaction are likely. On the other hand, when managed well, enhanced patient care, quality, operational efficiency, and health care system resilience can all be achieved.³

One of the most visible examples of inadequate hospital capacity is admission wait times. When availability of beds is an issue, those requiring admission often stay on stretchers in emergency departments (EDs) for days on end. This then overcrowds EDs and challenges them in providing optimal care for patients. For example, delays in antibiotic administration and pain control medications have been reported. Even worse, higher than average mortality rates have been documented.⁴

Large hospitals are said to operate most efficiently at occupancies of 85%. Above that percentage, less favorable outcomes for patients tend to occur. Some may be efficient at up to 90% occupancy, but higher occupancies often contribute to delays in finding beds for patients and increased pressures on medical staff.^5–10

Another issue has arisen with the specialization of services. Selected areas of hospitals may focus on different afflictions, injuries, and degrees of suffering. For example, there are intensive care units, specialized burn units, cardiac telemetry units, trauma surgery units, maternal care units, and dialysis units. Not every floor of a hospital is ideal for every patient, and this specialization of health care can be disadvantaged by overcrowding. Caring for those with cardiac conditions, for example, may require different expertise than caring for those with kidney disease. Admitting a patient with a heart condition to a nephrology floor therefore may result in suboptimal care.¹¹

Another contributor to bed shortages is the daily variation in admissions and discharges. Admissions for elective surgical procedures are more commonly requested on Mondays, when peak arrivals from emergency admissions also occur. Discharges are also more likely to occur at the end of the workweek; thus, bed availability is more common at the end of the week, especially on weekends.

Health care systems that include multiple geographically separated hospitals may improve care by transferring patients from a full-capacity location to one with more availability. Coordination between hospitals, however, can be challenging, particularly when separate financial statements encourage competition between administrative staffs. In these instances, there may be pressures to operate with high occupancy rates. Indeed, the separate quality, operational, and financial goals of individual hospitals in a system can limit the effectiveness of capacity management.

Controlling the demand for hospital services through triage of emergency admissions, transfer of patients, or cancellation of elective procedures all have potential disadvantages. These include financial implications, adverse patient outcomes, and staffing issues.

Adding bed capacity by expanding current facilities or building new hospitals is another option for cramped capacity. New construction, however, is not a ready alternative and requires significant capital investment. Furthermore, simply adding more hospital beds may only create more space in which to manage inefficiently.

Recognizing that health care systems are complex and that decisions related to capacity management are high stakes, Baylor Scott & White Health (BSWH) has undertaken a concerted and multifaceted effort to improve the delivery of services to its patients. Results have been significant and have demonstrated the potential capability, commitment, and responsiveness of collaborative hospitals and health care workers. In addition, BSWH has witnessed an improved capacity to care for patients without adding any additional beds. Multiple strategies have been implemented that, collectively, have made a significant impact in this program labeled Operation Capacity.

Operation capacity strategies

Discharge lounge

When patients are discharged from a hospital by their physician, it is common for them to remain in their hospital room for 4 to 6 hours awaiting prescriptions, discharge instructions, or transportation. To release their bed for other patients once discharge orders are received, they are transferred to another area of the hospital. In this new lounge, discharged patients comfortably rest in reclining chairs, enjoy snacks and beverages, and receive necessary counseling and support from hospital nurses.

Same-day admissions

Traditionally, patients requiring surgical procedures have been admitted the day before a scheduled operation. Same-day admissions have reduced bed utilization. Not surprisingly, many patients prefer sleeping in their own beds the night before a surgical procedure.

Ambulatory surgery centers

Scheduling operations, when appropriate, at outpatient or short-stay facilities increases bed capacity for general hospitals. BSWH has acquired and opened these types of facilities, which has increased bed capacity in the traditional hospitals.

Inpatient care managers

Social workers and registered nurses are part of a team that analyzes and attempts to predict which services may be required for admitted patients. Trained to facilitate preauthorizations, protocols, and specific plans for management of patients, they utilize proactive, data-driven, multidisciplinary approaches to identify potential mismatches between supply and demand for hospital resources. They can also facilitate timely transfers to skilled nursing or rehabilitation centers when appropriate.

Enhanced recovery after surgery

Protocols involving multimodal perioperative care pathways have improved surgical outcomes in many ways. Pioneered by Dr. Henrik Kehlet from Denmark and popularized by Dr. Ken Fearon of Scotland and Dr. Olle Ljungqvist of Sweden, Enhanced Recovery After Surgery efforts review surgical techniques and protocols, focusing on analgesia, intravenous fluids, feedings, and early mobility after surgery. For example, the injection of local anesthetic within the musculofascial planes of the abdominal wall reduces the need for narcotics after abdominal procedures. Another strategy allows oral caloric solutions until 2 hours prior to surgery to provide nutrients that may hasten recovery. Minimizing intravenous fluids during surgery has also been found to reduce edema at surgical sites. As a result of these and other Enhanced Recovery After Surgery protocols, lengths of stay have been shortened. Costs have also been reduced, and bed capacity has increased. These protocols have been taught and monitored throughout all surgical procedures in the BSWH system.^12–14

Nurse telephone consultation

Trained registered nurses have been made available by telephone 24 hours a day for medical consultation. They offer advice regarding health issues and also provide guidance on where best to be seen when face-to-face evaluations are indicated. This has frequently resulted in appropriate self-care at home, directed serious conditions to EDs, and steered patients with less significant needs to urgent care centers. Studies at BSWH have shown that when patients initially contemplated admission to EDs, the nurse telephone consultations have appropriately redirected them to less intensive settings 74% of the time, saving patients money and reserving space for more critical cases.

Extended workday weeks

Hospital bed occupancy is commonly much lower on weekends than on other days of the week. Seven-day workweek strategies can spread inpatient health care delivery services from 5 days of the week to 7. This strategy, which requires altering the work habits of providers and staff, is challenging and continues to be addressed. Each department of a hospital typically has its own culture and history, which requires understanding and negotiation.

Hospital-in-the-home program

When patients require hospitalization, many cases can be appropriately managed in their own homes with provider and nursing oversight. These programs are almost always favored by patients and their families. When patients are cared for at home, their physical deconditioning and disability from prolonged bed rest are reduced, because they are more likely to stay active. Besides increasing bed capacity in the hospital and improving patient satisfaction, hospital-in-the-home programs have been found to decrease the number of falls and reduce the total cost of care.

Early discharge

Traditionally, patients have been discharged in the late afternoon, although little benefit typically accrues to the patient on the final day of their hospital stay. Coordinating and encouraging physicians to complete early discharge orders has opened up more beds for new admissions.

Radiology services coordination

A standardized radiology council has been able to develop and enforce criteria for imaging studies with more consistency and more timely results. Standardization of software, policies, protocols, patient journeys, self-scheduling, data metrics, and artificial intelligence applications have all contributed to these efforts. An initial barrier to efficient and timely interpretation of radiology studies was a lack of bidirectional access between radiologists and imaging data. Consolidation of computerized data into a single system has reduced transfer and download wait times. The radiology council has also been able to standardize and align the work of six disparate radiology groups, which has resulted in increased efficiency and more consistent readings. These strategies optimize current bed capacity and assist with staff resources and supply chain issues. Patient satisfaction is also higher when wait times are diminished.

Urgent care centers

In addition to existing urgent care centers, the health care system acquired 40+ independent centers scattered around the state. Patients with less acute needs can now be serviced away from traditional emergent care departments. These centers are often more convenient for patients and allow the major hospital emergency centers to focus on and optimize care for those most in need.

Oncology urgent care center opportunity

An urgent care center for oncologic emergent care on one of the hospital campuses has experienced low volumes. Allowing noninfected emergent care patients to access this center has reduced admissions to the main emergent care department.

Dedicated beds for minor illnesses that present to the ED

So-called minor emergencies, such as nonacute upper respiratory illnesses and minor cuts/abrasions, can be triaged and managed more efficiently by a less acute division of the ED. Adjacent to the ED, this complementary division has opened up ED beds for more complicated cases.

Community care clinics

Traditionally, indigent and uninsured patients present to EDs with complicated, advanced diseases or injuries. These patients can also be “frequent fliers,” who return due to lack of follow-up or inadequate care of chronic illnesses. Community clinics have been established to care for these needy patients and have been shown to reduce readmissions and improve their overall health. Subsidizing these clinics has resulted in reduced admissions to EDs, thus benefiting the system financially and improving the care of these patients.

Multiuse areas

Surgical suites often have dedicated areas for preoperative evaluation that are busier in the morning hours. Postoperative recovery areas, on the other hand, are full in the afternoons but often vacant in the mornings. Combining these has freed up space in the hospitals for other purposes.

Readmission avoidance

Following hospitalization, most patients benefit from outpatient follow-up with their admitting physician or primary care provider. Fulfillment of these visits can be challenging. Scheduling timely posthospital outpatient visits at the time of discharge, along with computerized patient reminders sent to patients’ outpatient calendars, has improved compliance. As a consequence, readmission rates have been reduced from 12.5% toward the goal of 2.15%.

Insurance preauthorization

Insurance companies have a variety of requirements for elective procedures that must be met prior to hospitalization. Teams of experts in this area have minimized last-minute delays, which had needlessly delayed and left open previously scheduled hospital beds and rooms.

Transitional, intermediate-care hospital beds

Traditionally, hospitals have had intensive care beds and regular beds. Intensive care patients often improve to the level that they no longer require the full intensity of care yet are not quite ready for the less intensive monitoring that occurs on regular hospital floors. Dedicated intermediate-care beds help to move patients through the system, opening up more intensive care beds and allowing for a smoother transition.

Primary care access

Enhanced access to primary care providers is also a goal of Operation Capacity. Many, if not most, areas of our country are stressed due to inadequate primary care access. Advanced care providers, such as physician assistants and advanced nurse practitioners, can improve the efficiency and capacity of primary care providers. Teamwork approaches that delegate tasks to medical assistants are also helpful. Scribes have been shown to lessen the workload of providers, as have artificial intelligence computer systems. Improving the work of primary care providers has been found to benefit the management of patient panels and reduce the need for some hospitalizations.

Follow-up studies

When hospitalized patients are stable yet awaiting additional consultations with specialists, trained staff are available to schedule those consultations in an outpatient setting. The patients can therefore be discharged earlier, freeing up bed space and allowing patients to return home sooner.

Summary

Our Operation Capacity strategies have produced the following results:

• More timely admissions

• More efficient use with less overcrowding of our ED

• Diminished stress on employees

• Enhanced customer satisfaction

• Quality, safety, and financial improvements

The strategies outlined in this article, though individually having minimal impact, collectively have added significant capacity with much less strain on staff and have produced much more timely, gratifying, and positive results. To date, the hospital system has added 174 “virtual beds” without the disruption and costs of new construction.

Hospitals can anticipate increasing demand, especially in growing markets. Surges will intermittently add to the demand for health care services. These may result from seasonal illnesses, epidemics and pandemics, natural disasters, accidents and injuries, an aging population, and limited access to primary care services. Increased flexibility and effective contingency planning are necessary to mitigate and minimize the adverse consequences of limited capacity.

It has been written that optimizing the efficiency of discrete pieces of a system in isolation often minimizes or even negatively impacts the results for the system as a whole. On the other hand, multifaceted, coordinated approaches allow for more success, more flexibility, and more resilience to changing health care challenges.¹⁵

Disclosure statement/Funding

The author reports no funding or conflicts of interest.