Public hospital bed crisis: too few or too misused?

Abstract

• Increasing demand on public hospital beds has led to what many see as a hospital bed crisis requiring substantial increases in bed numbers. By 2050, if current bed use trends persist and as the numbers of frail older patients rise exponentially, a 62% increase in hospital beds will be required to meet expected demand, at a cost almost equal to the entire current Australian healthcare budget.

• This article provides an overview of the effectiveness of different strategies for reducing hospital demand that may be viewed as primarily (although not exclusively) targeting the hospital sector – increasing capacity and throughput and reducing readmissions – or the non-hospital sector – facilitating early discharge or reducing presentations and admissions to hospital. Evidence of effectiveness was retrieved from a literature search of randomised trials and observational studies using broad search terms.

• The principal findings were as follows: (1) within the hospital sector, throughput could be substantially improved by outsourcing public hospital clinical services to the private sector, undertaking whole-of-hospital reform of care processes and patient flow that address both access and exit block, separating acute from elective beds and services, increasing rates of day-only or short stay admissions, and curtailing ineffective or marginally effective clinical interventions; (2) in regards to the non-hospital sector, potentially the biggest gains in reducing hospital demand will come from improved access to residential care, rehabilitation services, and domiciliary support as patients awaiting such services currently account for 70% of acute hospital bed-days. More widespread use of acute care and advance care planning within residential care facilities and population-based chronic disease management programs can also assist.

• This overview concludes that, in reducing hospital bed demand, clinical process redesign within hospitals and capacity enhancement of non-hospital care services and chronic disease management programs are effective strategies that should be considered before investing heavily in creating additional hospital beds devoid of any critical reappraisal of current models of care.

What is known about the topic? There is a growing demand for inpatient care in Australia, with presentations to public hospital emergency departments increasing by 4.9% per year over the last 5 years and admission numbers increasing by 3.6% per year. Increasing numbers of hospital beds may give only short-term reprieve in lowering bed occupancy rates if little attention is giving to improving hospital efficiency by internal process redesign or by decreasing demand for acute hospital beds by improving capacity of the non-hospital sector to manage sub-acute illness and chronic disease.

What does this paper add? This article provides a narrative meta-review of the evidence of effectiveness of various reform strategies. The key findings are that, within the hospital sector, patient throughput could be substantially improved by: outsourcing public hospital clinical services to the private sector where appropriate; implementing whole-of-hospital reforms, which that facilitate more flexible and dynamic bed management (especially where it relates to systems of care for acutely ill patients); separating acute from elective beds and services; increasing the numbers of day-only admissions; and curtailing ineffective or marginally effective clinical interventions. However, the potentially biggest gains in hospital productivity will come from improved access to residential care, rehabilitation services and domiciliary support for hospitalised patients who no longer require acute inpatient care, combined with decreased need for hospitalisation as a result of population-based chronic disease management programs led by primary care agencies, and acute care and advance care planning within residential care facilities.

What are the implications for practitioners? A public debate must start now on how the healthcare system and the role within it of hospitals should be re-configured in managing future population healthcare needs in a sustainable way. In the meantime, all hospitals must consider implementing reforms with potential to improve their productivity and reduce access block for those who really need acute hospital care.