This analysis of 39 children’s hospitals found high levels of occupancy and weekend occupancy lower than weekday occupancy (median difference 8.2%-points). Only 12.6% of scheduled admissions entered on weekends. Thus, weekend capacity is available to offset high weekday occupancy. Hospitals at the higher end of the occupancy thresholds (95%, 100%) would reduce the number of days operating at very high occupancy and the number of patients exposed to such levels by smoothing. This change is mathematically feasible, as a median of 7.4 patients would have to be proactively scheduled differently each week, just under one-tenth of scheduled admissions. Since LOS by day of admission was the same (median 2 days), the opportunity to affect occupancy by shifting patients should be relatively similar for all days of the week. In addition, these admissions were short, conferring greater flexibility. Implementing smoothing over the course of the week does not necessarily require admitting patients on weekends. For example, Monday admissions with an anticipated 3-day LOS could enter on Friday with anticipated discharge on Monday to alleviate mid-week crowding and take advantage of unoccupied weekend beds.26
At the highest levels of occupancy, smoothing reduces the frequency of reaching these maximum levels, but can have the effect of actually exposing more patient-days to a higher occupancy. For example, for 9 hospitals in our analysis with >20% of days over 100%, smoothing decreased days over 100%, but exposed weekend patients to higher levels of occupancy (). Since most admissions are short and most scheduled admissions currently occur on weekdays, the number of individual patients (not patient-days) newly exposed to such high occupancy may not increase much after smoothing at these facilities. Regardless, hospitals with such a pattern may not be able to rely solely on smoothing to avoid weekday crowding, and, if they are operating efficiently in terms of SLOSR, might be justified in building more capacity.
Consistent with our findings, the Institute for Healthcare Improvement, the Institute for Healthcare Optimization, and the American Hospital Association Quality Center stress that addressing “artificial variability” of scheduled admissions is a “critical first step” to improving patient flow and quality of care while reducing costs.18,21,27
Our study suggests that small numbers of patients need to be proactively scheduled differently to decrease mid-week peak occupancy, so only a small proportion of families would need to find this desirable to make it attractive for hospitals and patients. This type of proactive “smoothing” decreases peak occupancy on weekdays, reducing the safety risks associated with high occupancy, improving acute access for emergent patients, shortening wait-times and loss of scheduled patients to another facility, and increasing procedure volume (3–74% in one study).28
Smoothing may also increase quality and safety on weekends, as emergent patients admitted on weekends experience more delays in necessary treatment and have worse outcomes.29–32
In addition, increasing scheduled admissions to span weekends may appeal to some families wishing to avoid absence from work to be with their hospitalized child, to parents concerned about school performance – and may also appeal to staff members seeking flexible schedules. Increasing weekend hospital capacity is safe, feasible and economical, even when considering the increased wages for weekend work.33,34
Finally, smoothing over the whole week allows fixed costs (e.g., surgical suites, imaging equipment) to be allocated over 7 days rather than 5 and allows for better matching of revenue to the fixed expenses.
Rather than a prescriptive approach, our work suggests hospitals need identify only a small number of patients to proactively shift, providing them opportunities to adapt the approach to local circumstances. The particular patients to move around may also depend on the costs and benefits of services (e.g. radiologic, laboratory, operative) and the hospital’s existing patterns of staffing. A number of hospitals that have engaged in similar work have achieved sustainable results, such as Seattle Children’s Hospital, Boston Medical Center, St. John’s Regional Health Center, and New York University Langone Medical Center.19,26,35–37
In these cases, proactive smoothing took advantage of unused capacity and decreased crowding on days that had been traditionally very full. Hospitals that rarely or never have high-occupancy days and that do not expect growth in volume may not need to employ smoothing, whereas others that have crowding issues primarily in the winter may wish to implement smoothing techniques seasonally.
Aside from attempting to reduce high-occupancy through modification of admission patterns, other proactive approaches include optimizing staffing and processes around care, improving efficiency of care, and building additional beds.16,25,38,39
However, the expense of construction and the scarcity of capital often preclude this last option. Among children’s hospitals, with SLOSR close to 1, implementing strategies to reduce the LOS during periods of high occupancy may not result in meaningful reductions in LOS as such approaches would only decrease the typical child’s hospitalization by hours, not days. In addition to proactive strategies, hospitals also rely on reactive approaches, such as ED boarding, placing patients in hallways on units, diverting ambulances or transfers, or canceling scheduled admissions at the last moment, to decrease crowding.16,39,40
This study has several limitations. First, use of administrative data precluded modeling all responses. For example, some hospitals may be better able to accommodate fluctuations in census or high occupancy without compromising quality or access. Second, we only considered intra-week smoothing, but hospitals may benefit from smoothing over longer periods of time, especially since children’s hospitals are busier in winter months, but incoming scheduled volume is often not reduced.11
Hospitals with large occupancy variations across months may want to consider broadening the time horizon for smoothing and weigh the costs and benefits over that period of time, including parental and clinician concerns and preferences for not delaying treatment. At the individual hospital level, discrete-event simulation would likely be useful to consider the trade-offs of smoothing to different levels and over different periods of time. Third, we assumed a fixed number of beds for the year, an approach that may not accurately reflect actual available beds on specific days. This limitation was minimized by counting all beds for each hospital as available for all the days of the year, so that hospitals with a high census when all available beds are included would have an even higher percent occupancy if some of those beds were not actually open. In a related way, then, we also do not consider how staffing may need to be altered or augmented to care for additional patients on certain days. Fourth, midnight census, the only universally available measure, was used to determine occupancy rather than peak census. Midnight census provides a standard snapshot, but is lower than mid-day peak census.41
In order to account for these limitations, we considered several different thresholds of high occupancy. Fifth, we smoothed at the hospital level, but differential effects may exist at the unit level. Sixth, to determine proportion of scheduled admissions, we used HCUP KID proportions on PHIS admissions. Overall, this approach likely overestimated scheduled medical admissions on weekends thus biasing our result towards the null hypothesis. Finally, only freestanding children’s hospitals were included in this study. While this may limit generalizability, the general concept of smoothing occupancy should apply in any setting with substantial and consistent variation.
In summary, our study revealed that children’s hospitals often face high mid-week occupancy, but also have substantial unused weekend capacity. Hospitals facing challenges with high weekday occupancy could proactively use a smoothing approach to decrease the frequency and severity of high occupancy. Further qualitative evaluation is also warranted around child, family, and staff preferences concerning scheduled admissions, school, and work.