What Do You Do When The Hospital Is Full?

The occupancy rate of a hospital is the percentage of available staffed beds that are currently occupied by patients. As the number of COVID cases surges this month, we are about to see our country’s hospitals more fully occupied than ever before.

The need to improve hospital financial efficiency has led many hospitals to try to keep their average occupancy as high as possible, often 90% or higher. But if the occupancy rate is too high, then inefficiencies arise that can be just as detrimental to hospital finances as when occupancy rates are too low. One danger of keeping the average occupancy rate too high is that the hospital cannot accommodate unexpected surges in admissions. This has been a significant problem for hospitals across the U.S. during the various case surges during the COVID-19 pandemic and will be even more so in the next few weeks.

What is occupancy? Most hospitals use the “midnight census” to track their occupancy rate. This is the number of patients in a bed at midnight each day. This metric works well for hotels since there is a defined check-out time in the morning and check-in time in the afternoon each day. However, this number can be misleading for hospitals because hotels, hospital admissions and discharges occur at continuously throughout the day and night with the result that the hospital census at noon is almost always higher than the census at midnight as morning admissions start to pile up while afternoon discharges are still occupying beds. As a consequence, a hospital may have 15% empty beds at midnight but have no empty beds at 2:00 PM. Therefore, the midnight census is useful from a financial standpoint but real-time census is more important from an operational standpoint.

It takes more than just a room with a bed… Not only do you have to have a physical place to put patients, but you have to have the nurses, doctors, pharmacists, and respiratory therapists to take care of them. During the COVID pandemic, at any given time, large numbers of these healthcare workers were unable to work due to having COVID themselves, having to isolate because of a COVID exposure, or having to stay home to take care of  child who was unable to attend school due to COVID. A single nurse can only safely take care of so many patients and if that number of patients is exceeded, then patient care can suffer. Moreover, nursing contracts and nursing units often place a limit on the number of patients a nurse can take care of and a limit on the number of hours per week a nurse can work. When the hospital lacks the personnel to care for patients, it has to “block-out” rooms from use.

Not all hospital beds are equal. Hospitals will try to group similar patients on a single nursing unit. This allows nurses to develop expertise in managing specific types of patients, for example, cardiac, pediatric, psychiatric, post-surgical, and maternity. This also creates better efficiency for the doctors so that, for example, a surgeon does not need to go to 7 different nursing units to round on his/her 7 post-op patients. But as nursing units become more and more specialized, it becomes less desirable to admit one kind patient to a different kind of unit. So, for example, having a lot of open beds in the addiction medicine ward does not really help you if you are trying to find a bed for a post-op neurosurgery patient and all of the surgical nursing units are full. Most hospitals will have a lot of “med-surg” units that can accommodate general medical patients or surgery patients.

What happens when there are no beds?

The need to accommodate the constant flow of admissions has resulted in hospitals putting a lot of resources into capacity management. Smaller hospitals often utilize a “nursing supervisor” who keeps up-to-date information on which patients are projected to be discharged and which patients are awaiting admission. Larger hospitals will utilize a admission control center staffed by multiple nurses whose sole responsibility is directing the flow of hospital admissions and patients being transferred from other hospitals; this is called “bed placement”. In most hospitals, the electronic medical record will facilitate this process by having dashboards that list open beds and beds occupied by patients who will be discharged later that day.

But what happens when all of the beds are full and there are more projected admissions than discharges for the rest of the day? That is when the hospital medical director generally gets involved. Here are the some of the available options:

1. Expedite discharges. This is usually the first action taken and involves contacting all of the hospitalists and other attending physicians to ask them to hasten discharges. Most of the time, this only results in moving otherwise planned admissions up by a couple of hours but even that can help free up a few beds to help decompress admission bottlenecks. Simply having a discharge order does not ensure that an empty bed will be created, however. Nursing and case management can also expedite discharges by arranging earlier transportation home, by locating nursing homes with available beds, and by using “discharge suites” where discharged patents can wait for their rides.
2. Focus on long-length-of-stay patients. Every hospital has a group of inpatients that have been admitted for many weeks or months. Often, these are patients who are difficult to get placed in nursing homes because they are uninsured or because they have behavioral problems. By creating  multidisciplinary workgroup to identify and overcome the barriers to discharge of these patients, desperately needed hospital beds can be opened up.
3. Board admitted patients in the emergency department. There are a lot of reasons why boarder patients are undesirable (see my previous post). But in the short run, this is often the easiest way to accommodate a surge in admissions. If the number of boarders in the ER becomes too high, then the ER becomes congested and unable to provide care for regular emergency patients.
4. Board post-surgical patients in the post-op recovery unit. Most patients recover in the recovery unit and then go to a regular hospital room to spend the night (for outpatient surgeries that require overnight observation) or spend several nights (for elective inpatient surgeries). Keeping patients in the recovery room longer can allow extra time needed to get other patients discharged and get those rooms cleaned and ready for the post-op patients. However, at some point, the recovery unit becomes full creating a bottleneck in patient flow in the operating rooms. One solution to this is multi-use space that can serve as pre-op beds in the morning and post-op beds in the afternoons. However, if patients remain in the recovery area into the evening or night, then you have to have the nurses to care for those patients and this either means keeping the post-op recovery area nurses overtime or “floating” nurses from other floors to the recovery area.
5. Stop accepting hospital transfers. This is a tactic that only works for larger referral hospitals that normally have transfers comprise a significant percentage of their admissions. These transfers are usually patients with complex medical or surgical conditions coming from small hospitals that are not equipped to manage them and so these patients still need to be transferred somewhere. If all of the other referral hospitals in the area are also full, this can mean that the patient in a small hospital may need to be transported to a hospital in a far-away city or even another state. During the first surge in COVID cases in January 2021, it was not uncommon for me to get a call about transferring a patient with respiratory failure from a physician in a town such as Defiance, Ohio who had already had his patient turned down for transfer from all of the referral hospitals in Toledo, Dayton, Cincinnati, and Cleveland.
6. Put the emergency department on divert. When the emergency department goes on divert status, emergency squads are directed to take patients to other emergency departments. This is undesirable from a community standpoint because it can result in delays in caring for critically ill patients by having the squads travel to emergency departments that are further away. There are a lot of reasons why an emergency department might go on divert: too many patients backed up in the waiting areas, a bolus of cardiac arrest or trauma patients that temporarily requires all of the available ER staff to manage, a hospital power failure, too many inpatient boarders in the ER, etc. During the COVID surges, there were days when all of the hospitals in Columbus were at full inpatient capacity and all of the emergency departments went on divert – when this happens, the agency that oversees regional trauma care institutes “city-wide divert”. In this situation, the region’s emergency squads go to hospitals on a rotational basis so that all hospitals share the excess patients equally.
7. Cancel elective admissions. This mainly affects surgeries – both elective inpatient surgeries (such as spine surgery) and outpatient surgeries that require an overnight stay (such as knee replacement surgery). Hospital leaders hate to do this because these surgeries are very financially lucrative. The result is replacing a surgery patient that the hospital can make money on with a medical patient that the hospital can at best hope to break even on. In addition, by canceling surgeries, the surgeons and anesthesiologists are idle and the hospital usually ends up paying the salaries for these highly-paid physicians since they cannot earn their income in the operating room.
8. Open up new beds. In a crisis, hospitals can convert many areas of the hospital into emergency-use patient care areas: decommissioned nursing units, the endoscopy suite, the sleep lab, the cardiac cath lab recovery area, etc. There is an inherent inefficiency to using these areas for inpatients as they are not equipped to care for inpatients and the normal nurses for these areas are unaccustomed to regular inpatient care. Also, when these areas are used for inpatients, they cannot be used for their normal purposes and this results in canceling  elective procedures.
9. Create new space. When the hospital has maximized available space within the building, the next step is often to create temporary hospital space . During the initial surge in COVID cases, we erected a large tent in the parking lot adjacent to the emergency department to do triage and care for low-acuity emergency room patients. The Ohio National Guard helped to convert the Columbus Convention Center into a several hundred bed hospital area for low-acuity inpatients (that we fortunately never needed to utilize). Other hospitals converted parking garages, college dormitories, and hotel rooms into temporary patient care areas.
10. Ration healthcare. This is usually done only as a last resort. Although often discussed in the U.S. during COVID surges, it was rarely, if ever implemented in our country. But in underdeveloped nations, this is a fact of daily life. If there are only 3 ventilators in a hospital with no others within several hundred miles, then the doctors have to choose which three patients get to use the ventilators. Even in developed countries, such as Italy, the first surge of COVID resulted in rationing of ventilators and ICU beds to only those patients felt to be most likely to survive.

Where do you find more doctors and nurses?

When hospitals start opening up new beds or new space for inpatients, those beds are only useful if there are doctors, nurses, and other staff available to cover them. During January 2021, we staffed new COVID ICU areas with anesthesiologists, hospitalists, trauma surgeons, and emergency medicine physicians rather than critical care internists. Recovery room nurses, addiction medicine nurses, and cardiac cath lab nurses were sent to staff med-surg nursing units and ICUs. We brought in general internists and family physicians who normally worked in outpatient clinics to function as hospitalists. CMS made an emergency allowance that residents and fellows in training could be temporarily credentialed as attending physicians and were allowed to bill for inpatient services. Many hospitals turned to recently retired physicians and nurses. “Traveler” nurses and locum tenens physicians (frequently from out of state) were often brought in to help with inpatient care.

Currently in Ohio, the governor has deployed the National Guard to the most crowded hospitals to assist. The problem with the National Guard is that most of the doctors and nurses in the National Guard are already tied up caring for patients in their own hospitals during the current COVID surge and so the only members of the National Guard available to help are non-healthcare workers who can only assist with support activities in hospitals.

Keeping up morale

When hospitals run out of beds and operate at full capacity (or over full capacity), it puts enormous strain on the mental health of the healthcare workers: Nurses who are caring for patients with conditions that they are not familiar with. Doctors who are taking care of more patients than they normally manage in a day. Everyone exhausted from working extra shifts. Angry patients and families lashing out at healthcare workers. Experiencing mounting numbers of deaths. All of these contribute to burn out. Even if the hospital administrators can open new physical beds, those beds are useless if the healthcare workers call-off work or quit due to burnout. Also, a toxic doctor or nurse may provide a needed warm body in the short run but will poison the workplace for other doctors and nurses in the long run. Fortunately, there are some things that medical directors can do.

1. Communicate. This is probably the single most important tool that medical directors have to combat staff burnout. Times of crisis create information vacuums and unless hospital leaders communicate regularly, that vacuum will be filled by rumors and conspiracy theories. In-person town hall meetings, virtual Zoom meetings, daily website posts, and emails all have their roles and it is best to use a combination in order to ensure the largest audience possible.
2. Be a cheerleader. More than any other time, during high capacity periods, medical directors and other hospital leaders need to get out of their offices and get into the patient care areas. It is essential that you are visible to the doctors and nurses and show that you are there to serve them. Look for excuses to give compliments. Show up at code blues, STEMI alerts, and trauma alerts. And don’t forget about the night shift staff.
3. Recognize burnout. Knowing the signs of burnout can allow you to intervene early when burnout is still reversible. The worst thing you can do is to deny that burnout exists.
4. Offer help. Counselors and other mental health professionals can help build resilience in the healthcare workers and making them freely available to hospital staff is a must.
5. Offer accommodations. This could be as simple as allowing staff to do non-standard length shifts so that they can be home to take care of children. It could include reserving a block of hotel rooms for nurses who live out of town to stay in order to avoid long-distance commutes.
6. Offer perks. Minor services  such as paying the cost of grocery delivery, Uber rides, baby sitting costs, and laundry services are relatively inexpensive for hospitals but can go a long way toward preventing burnout during times of healthcare worker stress from high inpatient capacity. Periodically buying pizza and cookies is a small measure but shows the staff that you are thinking about them.
7. Pay them. Overtime compensation and bonuses are powerful prevention against disgruntlement. When the hospital is full for prolonged periods of time, it is probably losing money from canceled surgeries, etc. But this is why hospitals maintain a certain number of days cash on hand and the hospital should not be afraid to use those reserves.

U.S. hospitals are about to fill up

As of January 14, 2022, the United States is seeing not only the highest number of daily cases of COVID-19 than at anytime in the pandemic (red line in the graph above) but we are also seeing the highest number of patients hospitalized with COVID (yellow line in the graph above). From experience, we know that hospitalizations do not peak until 2-3 weeks after case numbers peak so our hospitals are only going to become more full before the end of this month. The good news is that the percent test positivity peaks about a week or so before the case numbers peak and the most recent data from the CDC suggests that the percent test positivity is just starting to come down (yellow line in the graph below). If this trend continues, then we should see the case numbers begin to fall within the next week or so.

But COVID does not affect different parts of the country at the same time and many cities and states may not see the peaks in case numbers and hospitalizations for several weeks.

Regardless, we are about to see our nation’s hospitals more full of patients than ever before and each hospital needs to develop plans for how it will get through the next month.

January 16, 2022