When hospitals operate at full or overloaded capacity, serious problems can arise. The supply of valuable resources, like beds and staff time, can quickly shrink, creating an overtaxed system. Hospital overcrowding is also a safety issue. Patients may be placed in inappropriate locations or may experience long delays in care, which can lead to complications and even fatalities. We spoke with Peter Sprivulis, M.D., recent Harkness Fellow in Health Care Policy (2004-05) and current clinical director of Acute Demand Management for Western Australian Emergency Services, about the problem of overcrowding in Australian and U.S. hospitals and sustainable approaches to the growing demand for acute health care.
How bad is overcrowding in Australian hospitals?
Peter Sprivulis: Overcrowding is recognized as a major problem, particularly in Australian tertiary hospitals, and in all Australian major capital cities. It's a problem that has attracted significant attention, particularly at a state government level. The U.S. cities that I visited—large, metropolitan areas with an aging demographic—had similar problems.
The principal indicator is a statistic called "access block," where we measure the proportion of patients who take longer than eight hours from arrival at a hospital emergency department (ED) to move to an inpatient bed. In most Australian tertiary hospitals, well over 20 percent of patients take more than eight hours to be moved to a bed. At that level, it is usually associated with problems of reduced capacity in EDs; the patients consume space and staff resources. This results in difficulty seeing new cases and in diverting patients to alternative EDs.
What happens in overcrowded hospitals?
Sprivulis: Most large hospitals—between 400 and 500 beds—operate most efficiently given occupancy of 85 percent. Slightly larger hospitals can operate efficiently at up to 90 percent. But when occupancy levels get higher, it becomes difficult to match patients to appropriate areas of care. And that results in two things: delays in finding beds for patients and an increased pressure on staff. This can lead to delays in care, patients placed in locations not ideal for their care, and an increase in adverse events. And when there are delays in care for people with acute conditions—people coming in with emergencies—those delays may be fatal. My research indicates increased mortality associated with high occupancy status, particularly when that's associated with evidence of poor flow in the ED.
So, it's a safety issue, in addition to a workflow issue. Aside from mortality, what else can happen to patients under crowded conditions?
Sprivulis: Because it's a systems issue, overcrowding tends to affect the entire range of medical conditions treated in hospitals. Any patient requiring acute intervention has an increased risk of delay. In addition, patients assigned to inappropriate locations are less likely to have signs of deterioration identified early and treatments initiated properly. If a person with a surgical condition is cared for in a medical ward, the staff on that ward are less likely to pick up signs of early postoperative problems. In any walk of life, if you overload a system, it will fail to function effectively. What we're seeing in hospitals is the equivalent of a traffic jam.
What are the primary causes of hospital overcrowding?
Sprivulis: The primary cause is a mismatch between the supply of beds, poor flow of patients through beds, and demand. As demand increases and the bed supply shrinks, flow through hospitals becomes impaired and patients back up in EDs. At the same time, particularly in places like the United Kingdom and Australia and Canada, you have patients waiting not only for ED services, but also elective services.
The most important driver has been the increasing age of patients coming into hospitals. As patients get older, they tend to consume more resources for the same kind of medical conditions. For example, if someone comes in to have their knee replaced at 50 years old, and he is otherwise well, he'll have a short, uneventful medical stay. At 75, with chronic obstructive pulmonary disease, length of stay is likely to be longer and there's more risk of complications. In the past 20 years, expectations have changed. We tend to be more invasive in our approach to older patients. And that typically drives up costs.
Is the nature of overcrowding in Australia the same as in the U.S?
Sprivulis: I was impressed by the similarity of the problem and the similar drivers. There are increasing expectations about access to technology and increased invasiveness of the approach to care for older patients. And this is fine; there are lot of elderly people who will get value from the care they receive. But what we're not having is a realistic debate about how we're going to sustain that increase in demand.
But in Australia, there is not quite same pressure to push elective surgery through hospitals at the expense of acute care. For instance, in winter, we normally ask surgeons to reduce the number of patients likely to have prolonged hospital stays to make space for sick people who come in due to complications from the winter viral season. In the U.S., if a hospital's profitability depends on surgical throughput, management is less inclined to cut that activity. The consequence of doing that is it actually becomes a self-perpetuating cycle: sick patients on the acute side back up in the ED; the ED gets overcrowded; and patients can be diverted to other locations.
What can hospitals learn from your research?
Sprivulis: Hospitals need to think of themselves as systems through which patients flow. Managing that flow correctly is very important in terms of reducing complications and improving safety. The increasing use of interventions upstream is also an important development. In Australia, there are myriad chronic disease management plans used to reduce need for hospitalization and lessen pressure on hospitals. In America, some of the larger health systems are doing similar work. Hospitals can also learn from other industries, like airlines and traffic control. They can learn from standard process engineering principles to streamline the flow of work. Health care must look outside itself for solutions.
September 2005