Surge capacity: analysis of census fluctuations to estimate the number of intensive care unit beds needed

How Do Health Systems Address Patient Flow When Services Are Misaligned With Population Needs? A Qualitative Study

BACKGROUND

Patient flow through health services is increasingly recognized as a system issue, yet the flow literature has focused overwhelmingly on localized interventions, with limited examination of system-level causes or remedies. Research suggests that intractable flow problems may reflect a basic misalignment between service offerings and population needs, requiring fundamental system redesign. However, little is known about health systems' approaches to population-capacity misalignment, and guidance for system redesign remains underdeveloped.

METHODS

This qualitative study, part of a broader investigation of patient flow in urban Western Canada, explored health-system strategies to address or prevent population-capacity misalignment. We conducted in-depth interviews with a purposive sample of managers in 10 jurisdictions across 4 provinces (N = 300), spanning all healthcare sectors and levels of management. We used the constant comparative method to develop an understanding of relevant strategies and derive principles for system design.

RESULTS

All regions showed evidence of pervasive population-capacity misalignment. The most superficial level of response - mutual accommodation (case-by-case problem solving) - was most prevalent; capacity (re)allocation occurred less frequently; population redefinition most rarely. Participants' insights yielded a general principle: Define populations on the basis of clusters of co-occurring need. However, defining such clusters demands a difficult balance between narrowness/rigidity and breadth/flexibility. Deeper analysis suggested a further principle: Populations that can be divided into homogeneous subgroups experiencing similar needs (eg, surgical patients) are best served by narrow/ rigid models; heterogeneous populations featuring diverse constellations of need (eg, frail older adults) require broad/ flexible models.

CONCLUSION

To remedy population-capacity misalignment, health system planners should determine whether clusters of population need are separable vs. fused, select an appropriate service model for each population, allocate sufficient capacity, and only then promote mutual accommodation to address exceptions. Overreliance on case-by-case solutions to systemic problems ensures the persistence of population-capacity misalignment.

Quantifying Supply of Home Health Services for Public Health Emergencies

The number of persons seeking medical treatment during a public health emergency could quickly overwhelm the capacity of hospitals and emergency rooms. The amount of surge capacity home health care could provide during a public health emergency is unknown. The purpose of this research is to quantify the surge capacity of the home health sector in four emergency scenarios. According to the model developed, routine demand will exceed scenario capacity for almost all home health agencies in all pessimistic cases for the four scenarios discussed. However, home health agencies have the surge capacity to contribute to the provision of care for patients during times of demand under routine operating conditions as well as in conditions where demand may be moderately increased.

Critical care bed growth in the United States. A comparison of regional and national trends

RATIONALE

Although the number of intensive care unit (ICU) beds in the United States is increasing, it is unknown whether this trend is consistent across all regions.

OBJECTIVES

We sought to better characterize regional variation in ICU bed changes over time and identify regional characteristics associated with these changes.

METHODS

We used data from the Centers for Medicare and Medicaid Services and the U.S. Census to summarize the numbers of hospitals, hospital beds, ICU beds, and ICU occupancy at the level of Dartmouth Atlas hospital referral region from 2000 to 2009. We categorized regions into quartiles of bed change over the study interval and examined the relationship between change categories, regional characteristics, and population characteristics over time.

MEASUREMENTS AND MAIN RESULTS

From 2000 to 2009 the national number of ICU beds increased 15%, from 67,579 to 77,809, mirroring population. However, there was substantial regional variation in absolute changes (median, +16 ICU beds; interquartile range, -3 to +51) and population-adjusted changes (median, +0.9 ICU beds per 100,000; interquartile range, -3.8 to +5.9), with 25.0% of regions accounting for 74.8% of overall growth. At baseline, regions with increasing numbers of ICU beds had larger populations, lower ICU beds per 100,000 capita, higher average ICU occupancy, and greater market competition as measured by the Herfindahl-Hirschman Index (P < 0.001 for all comparisons).

CONCLUSIONS

National trends in ICU bed growth are not uniformly reflected at the regional level, with most growth occurring in a small number of highly populated regions.