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Journal of the Academy of Hospital Administration

Utilization of Beds in A Tertiary Care Hospital

Author(s): E. Ravi Kiran*, K.Vijaya**

Vol. 15, No. 2 (2003-07 - 2003-12)

Abstract:

Key Messages:

Average length of stay of the hospital was optimum.

Bed occupancy rate of the hospital was low.

Turn over interval was excess in positive.

Efficient month by month analysis of bed utilization is the most important measure.

Keywords : Average length of stay, Bed occupancy rate, Bed turnover interval, Bed turnover rate.

Introduction

The availability of hospital bed has always been a problem in developing countries. The availability of beds is perhaps the most important single factor in determination of the hospital utilization in country 1. In India, shortage of hospital beds in a huge problem, the average bed population ratio being 6.8 / 10,0002. Moreover the cost of construction of a new bed is also to an extent of Rs. 50,000 to Rs. 100,000 added to its huge maintenance cost3. This situation is further deteriorated by population explosion, increasing the flow of patients and rising demand for hospitalization. On the other hand, hospital facilities may not be fully utilized due to a multitude of factors, including medical and social customs.

The term "hospital utilization" devotes the manner in which a certain community makes use of its hospital resources. The role of the hospital can be fully studied only by taking into consideration all aspects of hospital service, that is by including the services to the community on an out-patient as well a sin-patient basis. However, the concept of "hospital utilization statistics" is relatively less known in our country.

The term "hospital utilization" utilization" denotes the manner in which a certain community makes use of its hospital resources. The hospital utilization statistics are also known a "patient movement statistics"4.

Various indices are utilized in the assessment of hospital utilization Hospital bed utilization indices will provide trends and pattern of hospital utilization. Davis and Macula (1996) have described various indices which are:

  1. Indices related to the hospital
  2. Average length of stay (ALS)
  3. Bed occupancy rate (BOR)
  4. Bed turnover interval (BTI)

Indices related to the populations

  1. Admission Rate (AR)
  2. Hospitalization rate per person (HC)
  3. Bed occupancy rate (BC)
  4. Bed/population Index (B/P)
  5. However in this study only hospital related indices were studied taking into account also Bed turn over rate (BTR)

The manner in which a certain community utilizes the hospital bed and the extent of such utilization are influenced by many factors that depend on the social, economic, educational and cultural characteristics of the people and on the attitudes and special habits of the medical profession.

In view of such considerations, competitive studies on hospital utilization must be interpreted with caution, as a wide divergence in utilization may be found among countries without its meaning that this divergence reflect any difference in the quality or efficiency of the medical services. Nevertheless, because of the rising cost of hospital care, such studies are valuable in pointing out the way in which the economy may be affected without influencing the quality of care.

The following are some of the factors that affect the utilization of hospitals. Availability of hospital beds, Methods of payment for hospital services, Age of population, Service coverage and bed distribution, Availability of extramural medical services, Hospital "bottlenecks", Medical customs and social patterns, Supply of physicians, Research and training, Existence of proprietary hospitals, Housing, Morbidity, Internal organization1.

Materials and Methods

A descriptive study was carried out from January to March 2003 in a 492 bedded tertiary care teaching hospital to study the utilization of beds. Data concerning inpatient admission, duration of stay, discharge, death and hospitalized patient days for the entire year 2002 was collected from the medical record section and was entered in a pre-designed proforma. The Data collection was restricted to Medicine (179 beds), Surgery (41 beds), Orthopaedics (41 beds), Ophthalmology and ENT wards combined (36 beds) and the entire hospital in toto and hospital bed utilization indices were calculated for those selected ones. The indices that were estimated were:

Average Length of Stay (ALS) = H / (D=d)
Total number of bed-days in a year = H
Number of discharges and deaths D+d in the same year

Bed Occupancy Rate (BOR) = (N / B) x 100
Average number of beds occupied x 100
Bed Complement

Annual Number of Hospitalized = H / (B x 365)
patient days x 100 = H
Bed complement x 365 B x 365

Turnover Interval (TOI) = (B x 365) - H / (D = d)
Bed complement X 365 - patient days = B x 365 - H
Deaths + discharges D + d

Bed Turnover (BTR) = (D = d) / B
No. of discharges including deaths = D + d
for a period B
Bed complement

N = Daily average of beds occupied
D = Discharges
B = Bed complement
d = Deaths
H = Hospitalized patient day

Observation and Discussion

It was observed that the number of inpatient admissions during the year 2002 was 11,440; of which males constituted 6,405 (56%) and females constituted 5,035 (44%) in number.

Average length of stay in the Medicine Department was in the range of 6-12 days. Bed occupancy rate was highest (50.13%) in the month of June which is less than optimum. It was also much less in most of the months. Turn over interval was very high throughout the year with the maximum (13.2) in the month of January. This shows that the beds remain vacant for a long period. Bed turnover rate was very low throughout the year.(TABLE-I)

Table-I: Monthly Statistics of the Department of Medicine

Month Admissions Discharge Hospital Bed Average ALS BOR TOI BTR
  + Deaths Days Occupancy          
January 207 231 2,497 80.5 10.8 44.9 13.2 1.3
February 250 205 2,379 84.9 11.6 47.4 12.8 1.1
March 148 269 2,663 85.9 9.8 47.9 10.7 1.5
April 259 263 2,420 80.6 9.2 45.0 11.2 1.5
May 252 279 2,618 84.4 9.3 47.1 10.5 1.6
June 224 232 2,342 78.0 10.0 43.6 13.0 1.3
July 277 334 2,782 89.7 8.3 50.1 8.2 1.9
August 367 378 2,302 74.2 6.0 41.1 8.5 2.1
September 338 347 2,368 76.3 6.8 44.0 8.6 1.9
October 273 271 2,453 79.1 9.0 45.6 11.4 1.5
November 270 286 2,229 74.3 7.7 41.5 10.9 1.6
December 247 251 2,384 76.9 9.4 42.9 12.6 1.4
Dept. of Medicine (including Skinard VD, Oncology, Geriatrics and Paediatrics

Average length of stay in the Surgery Department was in the range of 6-12 days through the year except in July when it was 2.7 days. Bed occupancy rate was highest (113.7) in month of January which is more than the optimum and lowest (4.1) in the month of July. For the rest of the year it was more or less in the optimal range. Turn over interval was negative in the month of January indicating that Bed occupancy rate was over 100%. Bed turnover rate was lowest (1.9) in months of November and December. (TABLE-II)

Table II

Month Admissions Discharge Hospital Bed Average ALS BOR TOI BTR
  + Deaths Days Occupancy          
January 131 131 1,446 46.6 11.0 113.7 -1.33 3.19
February 97 113 961 34.3 8.5 83.7 1.6 2.7
March 101 107 1,079 34.8 10.0 84.8 1.7 2.6
April 103 108 970 32.3 8.9 78.8 2.4 2.6
May 101 113 1,071 34.5 9.4 84.2 1.7 2.7
June 98 130 841 28.0 6.4 68.3 2.9 3.1
July 117 110 307 9.7 2.7 24.1 8.7 2.6
August 81 93 1,040 33.5 11.1 81.8 2.4 2.2
September 102 96 1,165 30.6 12.1 94.7 1.1 2.3
October 89 104 1,088 35.0 10.4 85.6 1.7 2.5
November 77 81 875 29.1 10.8 71.1 4.3 1.9
December 87 81 1,015 32.7 12.5 79.8 3.1 1.9
Dept. of Medicine (including Skinard VD, Oncology, Geriatrics and Paediatrics

Average length of stay in the Orthopedics Department was in the range of 9-13 days. This may be due to the fact that Orthopedic cases are hospitalized for a large period since healing of fractures takes a long time. Bed occupancy rate was more than optimum in the month of March and was optimum in most of the months except in May and June. Turn over interval was negative in the month of March and more than 2 in most of the months. Bed turnover rate was lowest (1.8) in months of January, February and June. (TABLE-III)

Table-III Monthly Statistics of the Department of Orthopaedics

Month Admissions Discharge Hospital Bed Average ALS BOR TOI BTR
  + Deaths Days Occupancy          
January 92 77 1,044 33.6 13.5 82.1 2.9 1.8
February 97 77 1,055 37.6 13.7 91.8 1.2 1.8
March 114 114 1,485 47.9 13.0 116.8 -1.87 2.7
April 99 114 1,139 37.1 9.9 92.6 0.7 2.7
May 88 86 851 27.4 9.8 66.9 4.8 2.0
June 66 77 843 28.1 10.9 68.5 5.0 1.8
July 112 101 1,049 33.8 10.3 82.5 2.1 2.4
August 104 104 1,095 35.3 10.5 89.0 1.6 2.5
September 91 102 1,053 35.1 10.3 82.8 1.7 2.4
October 94 91 1.003 32.3 11.0 78.9 2.9 2.2
November 95 98 1,031 34.3 10.5 83.8 2.0 2.3
December 95 108 1,084 34.9 10.0 85.3 1.7 2.6
Dept. of Medicine (including Skinard VD, Oncology, Geriatrics and Paediatrics

Average length of stay in the Ophthalmology and ENT Departments throughout the year was fluctuating between 5-11 days except in April when it was 4 days. Bed occupancy rate was less than the optimum. This can be attributed to the acute nature of the cases and treated mostly on an out-patient basis. Turn over interval was also high throughout the year. Bed turnover rate was highest (3.3) in month of February. (TABLE-IV)

Table-IV: Monthly Statistics of the Department of Eye & ENT

Month Admissions Discharge Hospital Bed Average ALS BOR TOI BTR
  + Deaths Days Occupancy          
January 75 65 455 15 7 40.7 10.1 1.8
February 113 119 586 21 5 58.1 3.5 3.3
March 86 89 443 14 5 39.6 7.1 2.4
April 83 82 368 12 4 44.3 8.6 2.3
May 88 92 511 16 6 45.7 6.5 2.6
June 71 69 271 9 9 24.2 11.7 1.9
July 108 102 418 13 11 37.5 6.8 2.8
August 62 69 261 8 7 23.4 12.3 1.9
September 63 60 300 10 10 27.2 13.0 1.7
October 109 108 538 18 10 48.2 5.3 3.0
November 76 79 324 10 9 30.0 9.5 2.2
December 103 95 465 15 10 41.7 6.8 2.6

Overall Average length of stay was optimum. Overall Bed occupancy rate of this teaching hospital, was low. The overall Turn over interval was in excess of positive. This clearly suggests that there is an excess of beds in relation to the patients. Thus, there is an underutilization of hospital in-patient facilities. This is possibly due to the fact that this teaching hospital is a speciality hospital. Admissions are selective for different departments. This leads to overall low admissions. Increased segmentation in the hospital leads to decreased utilization of the hospital.

A study titled, "Using length of stay and inactive days in the hospital to assess appropriateness of utilization in Barcelona, Spain" by Alonso MA et al was carried out as a retrospective evaluation of the medical records of patients admitted to Hospital Universitari del Ma, a teaching hospital with 440 beds located in Barcelona, Spain in two periods; 1988 and 1990. The average length of stay was 11.7 days in 1988 and 9.5 in 1995. This study compares favourably with our study where the average length of stay was between 8-10 days. It also concurs with Anand T R who in his treatise on hospital services and management, where length of stay in any ward should be 6-10 days6. Similar observations were made by Tripathi in his study where average length of stay was 6.55-8.76 days7. However it differs form the observations made by Saha J. B. et al in the study where the overall length of stay found in the study (14.02 days) is considerably higher than Indian optimum8. Bed occupancy rate of this teaching hospital was found to be low in this study and it ranged between 50-60 % which differs with that made by Anand in his treatise where he reported a Bed occupancy rate of 80-90% as optimal6. It also differs with the observations made by Cohan who reported a Bed occupancy rate in an American Hospital to be 67-77 %9.
(TABLE-V)

Table-V: Monthly Statistics of the Entire Hospital

Month Hospital Discharges ALS BOR TOI BTR
  Days + Deaths        
January 8,693 909 10 57 6.6 1.8
February 7,810 919 9 57 6.4 1.8
March 8,917 980 9 59 6.4 1.9
April 8,102 898 9 54 7.5 1.8
May 8,073 964 8 53 7.4 1.9
June 7,371 864 9 50 8.5 1.7
July 8,929 1,089 8 59 5.8 2.2
August 7,585 1,030 7 50 7.1 2.0
September 8,023 980 8 54 6.8 1.9
October 8,405 1,000 8 55 6.8 2.0
November 7,408 902 8 50 8.1 1.8
December 8,043 914 9 53 7.8 1.8

Conclusion

It was found in this study of utilization of hospital beds that though the Bed occupancy rates were on an overall low, certain months in certain wards had a rate over 10% suggestive of less number of beds which appears to be paradoxically high in other months. Large number of small and big nursing homes, teaching hospitals concentrated in this small geographical area are to some extent responsible for a low be occupancy. A month by month statistical analysis would enable the administrators to plan ahead for meeting this contingency and do the necessary corrective measures for a particular ward or for a particular season. Turn over interval was in some instances was very high certain wards is again reflective of the nature of the cases or excess of beds.

This study provides an insight that to get the best out of a hospital bed in any hospital, the hospital authorities should formulate its policies taking into account the local community requirements, socio-economic status, marketing strategies and use all hospital resources to the fullest potential.

References

  1. Llewellyn- Davies R, Macaulay HMC. Hospital Planning and Administration, WHO Monograph series No. 54, Geneva. New Delhi: JaypeeBrothers, 1995:6-35.
  2. Park.K. Park?s Text Book of Preventive and Social Medicine. 17th ed. Jabalpur:.M/s. Banarasidas Bhanot, 2002:616.
  3. Thapa V, Saha JB, Lahiri SK, Sarkar GN. An evaluation of bed management in a rural hospital adjacent to Indo- Nepal border in West Bengal. Ind. JI. Pub. Hlth. April - June 200;46;2:57-60.
  4. Background and reading material for training course of Diploma in Health Administration-Paper-III. Academy of Hospital Administration. New Delhi 2000:10-20.
  5. Alonso Ma, Anto JM. The Appropriateness Evaluation Protocol Group of the Hospital Universitari del Mar using length of stay and inactive days in the hospital to assess appropriateness of utilization in Barcelona, Spain. Journal of Epidemiology and Community Health. 1996;50:196-201.
  6. Anand TR. Hospital Services and Management Methods.Background and reading material for training course on Hospital Management. 1982:6.
  7. Tripathi GD. Maximum utilization of Hospital beds. NIHAE Bull. 1997; 10; 3:215, 315-321.
  8. Saha JB, Mitra J, Mondal A. Length of stay of in-patients of a Gynecological ward in a sub-divisional hospital in West Bengal. Ind. Jl. Pub. Hlth. 1991;35:3,71-74.
  9. Cohan CF. Hospital expenses rise faster than overall CPI. Hospital. 1980; 54:59-62.

* Assistant Professor, Deptt. Of Community Medicine,
Kasturba Medical College, Mangalore-575001

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