Length of stay and readmission rate are key indicators of the health of a hospital. A practitioner of medicine, or of administration, needs to be able to interpret and apply these data to keep the facility operational, says James S. Newman, MD, MHA, of Mayo Clinic College of Medicine and Science, Hospital Internal Medicine, Rochester, MN. 

To better understand these data, he says it is essential to  have an inherent knowledge of how a facility operates at baseline, what causes dysfunction, and how it can be prevented and remediated.

"Understanding the flow of patients through the hospital, from the time they arrive in the emergency department, through discharge, is key to managing the census, maintaining efficiency, and preserving access," Dr. Newman writes in a commentary article where he presents a model (framework) – the Heart of the Hospital – as a guide for hospital census management.   

Patients are admitted to the hospital and ultimately discharged. The point of entry to the hospital is from various sources including the emergency department, scheduled admissions for surgery, chemotherapy, or procedures, and transfers from other facilities. When the patients are discharged, they are ejected into various locations from home to post-acute care facility, with hope of avoiding readmission. 

"Reducing both the preload and the afterload, as well as increasing the efficiency of myocardial contractility, can improve the cardiac function in a patient with congestive heart failure. In the same way, we can envision hospital census management as the outcome of admission, discharge, and efficiency," the author points out.

When a hospital has a smoothly functioning census management system, the author says, it can better withstand large volume aberrations such as seen with an influenza outbreak with associated increased admission volumes. In particular, the author highlights the importance of managing patient flow at the emergency department – a major source of hospital volume.  

"Aside from ambulance diversion, which is an extreme intervention, efforts such as improved outpatient availability, or 'smoothing' the operating room schedule to have more even admissions across the week, can help control emergency department flow," according to the author, noting that the addition of a social worker to the ED can help arrange home services and durable medical equipment, facilitate follow-up, and generally avoid unnecessary admissions.

Hospital transfers can also have a considerable impact on census volumes. Admission guidelines can be developed to avoid admitting patients who will receive no benefit from transfer. Also, elective transfers can be deferred during periods of high census.

Process improvement strategies and staffing analysis can lead to improved efficiency of the flow through the facility. One simple strategy, according to Dr. Newman, is the initiation of a physician-led, daily census huddle. Key stakeholders from the ED, bed management, admitting services, social work, physical medicine, nursing, and environmental services review projected patient throughput issues and can target efforts to help services that are overloaded to improve bed turnover, or redirect key staff to decrease bottlenecks. 

"As the census rises, hospital leadership may become engaged to address organisational flow and implement a house-wide surge plan to address the evolving emergency," the author says. "By monitoring the hospital vital signs and responding with proper management and process improvement, the  administrative and patient care teams can better maintain the hospital’s health, control the census, and avoid hospital failure."

Source: Mayo Clinic Proceedings


Newman JS (2018) The Heart of the Hospital. Mayo Clin Proc. Article in Press, Published online: 10 October 2018 DOI: https://doi.org/10.1016/j.mayocp.2018.06.017

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