Aging, patient-bed management and overcrowding in the medical departments

BACKGROUND Hospital overcrowding (HO) profoundly affects the whole hospital system, reducing productivity and efficiency. The aging population and the increased prevalence of chronic-degenerative diseases, susceptible to acute exacerbations, make the elderly as frequent users of the emergency room (ER). There is a general agreement that the current disease-oriented and episodic model of care does not adequately cope with the complex needs of older patients. Hospital admission and discharge do not sufficiently link with primary care and other community resources, such as long-term care facilities and outpatient clinics.
AIM OF THE STUDY To evaluate, using a simple dedicated software, the activity data of nine hospitals of Local Health Authority of Bologna (Italy) (ER accesses, hospital admissions, average length of stay - LOS) and the impact of a patient and bed management net in which managers, doctors and nurses share their operational skills to improve patient flow in medical and geriatric wards.
RESULTS Data show that 24% ER accesses concern people > 75 years old; 51% admissions concern people > 75 years old; half of these admissions are from ER frequent users (FU = ‰¥ 3 ER accesses/ year). Only 15% admissions of younger people are from ER frequent users. Each of > 75 years old frequent users produces an average of 2 admissions/year. At the end of the first year of this experience, ER accesses and admissions rose more than 8%. In our model of bed-management (patient and bed management net-software matching hospital capacity with admission, escalation measures) LOS was shortened by an average 0.5-1 day to a range from 0,5 to 1 day.
DISCUSSION HO is due to mismanagement of chronic diseases (CD). Further actions are needed in primary health care to avoid unscheduled hospital due to CD. Applications for admission to hospital should be administered in the real context of the needs, developing both measures to face the contingent situation (setting temporary additional beds in one of the highest step of escalation measures) and post-discharge case management for selected high risk-FU patient profiles.
CONCLUSIONS Our experience shows that an organizational model with a simple software is effective only to manage patient flow for relative small variations. Biggest peak of admissions requires strong link with primary care and other community resources, by systemic administration of health, particularly in frail people, with not scheduled hospital readmissions, for which hospital-centred care is not ever the best choice. Further research in initial ER assessment of FU is needed, by an identification of the high risk patient's profile and its appropriate setting allocation.