Bed utilisation trends in selected wards across eight

Bed utilisation trends in selected wards across eight district hospitals in the Cape Town district Leilah Najjaar Student Number: 2006009 A mini-thesis submitted in partial fulfilment of the requirements for the degree of Master in Public Health at the School of Public Health, University of the Western Cape Supervisor: Dr Hanani Tabana November 2018 10 Keywords: Average Length of Stay, Bed Occupancy, Bed Utilisation Rate, District Hospital, Expenditure per Patient Day Equivalent, Overcrowding, Patient Flow, Inpatient Beds, Large District Hospital, Small District Hospital http://etd.uwc.ac.za/ CONTENTS 10 Keywords: i LIST OF FIGURES iv LIST OF TABLES iv DECLARATION Acknowledgements List of Abbreviations Definitions of key terms ABSTRACT CHAPTER 1: INTRODUCTION Global Background South African Context Study Setting 10 Research Problem 12 Purpose of the Study 13 CHAPTER 2: LITERATURE REVIEW 14 Introduction 14 Bed Utilisation 14 Average Length of Stay 16 Factors Affecting Bed Utilisation and Average Length of Stay 17 Patient Flow 17 Overcrowding 17 Inappropriate Admissions 18 Delayed Discharge 19 Expenditure Per Patient Day Equivalent (PDE) 20 Summary of the Literature Review 20 CHAPTER 3: RESEARCH METHODOLOGY 21 ii | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ Aim 21 Objectives 21 Study Design 21 Population and Sampling 21 Data Collection 22 Data Analysis 22 Small vs Large Hospitals 23 Validity and Reliability 23 Ethics Considerations 24 CHAPTER 4: Results 24 Description of the Wards 24 Inpatient Beds per Hospital 25 Hospital Targets 28 Bed Utilisation in the Wards 28 ALOS in the Wards 33 Deaths in Wards 37 CHAPTER 5: DISCUSSION 39 Discussion 39 Limitations 41 CHAPTER 6: CONCLUSION & RECOMMENDATIONS 42 Conclusion 42 Recommendations 42 REFERENCES 43 APPENDICES 47 APPENDIX A: Standardisation of ward names per hospital 47 APPENDIX B: Approval letter 49 APPENDIX C: Approval letter 51 iii | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ APPENDIX D: Approval letter 53 APPENDIX E: Approval letter 55 APPENDIX F: Ethics letter UWC 57 LIST OF FIGURES Figure 1: Share of annual household consumption expenditure by quintiles (2006, 2009, 2011, 2015) Figure 2: Map of City of Cape Town Health Boundaries 11 Figure 3: Proportion of bed distribution across hospital wards in eight district hospitals 27 Figure 4: Bed Occupancy (%) Small District Hospitals April 2016-March 2017 31 Figure 5: Bed Occupancy (%) Large District Hospitals April 2016-March 2017 32 Figure 6: ALOS Small District Hospitals April 2016-March 2017 35 Figure 7: ALOS Large District Hospitals April 2016-March 2017 36 Figure 8: Deaths per ward in large hospitals 38 Figure 9: Deaths per ward in small hospitals 38 LIST OF TABLES Table 1: Summary Population Data 10 Table 2: Burden of Disease, Cape Town 12 Table 3: Number of beds, Average Length of Stay, Bed Utilization Rate [%] (District Hospital) 2015-2016 (MDHS, 2016) 13 Table 4: Small and Large district hospitals 23 Table 5: Number of original wards vs regrouped wards 25 Table 6: Inpatient beds per hospital ward type 26 Table 7: Beds per ward type within each hospital 26 Table 8: 2016-2017 Fin year -Targets for district hospitals 28 Table 9: Number of deaths in wards 37 iv | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ DECLARATION I declare that, “Bed utilisation trends in selected wards across eight district hospitals in the Cape Town district”, is my own work and that it has not been submitted for any degree or examination in any other university, and that all the sources I have used or quoted have been indicated and acknowledged by complete references Leilah Najjaar October 2018 1|Page MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ Acknowledgements I would like to acknowledge and thank my supervisor, Dr Hanani Tabana, for her continued guidance and support in this journey Thank you to the district hospital managers and the information management clerks for granting me access to the data and for being so helpful in clarifying queries with the data Thank you to the information management staff at the district office for granting me access and supplying data for the study Thank you to the Provincial Department of Health and the Health Impact Assessment unit for granting me approval for the study to take place and permission to access the required data To my manager at work, Ms Juanita Arendse, for her support and guidance throughout the study period and for accommodating me with time off to work on my study To my family, especially my husband, Thofier Najjaar and children, Jehaan & Ismaeel, for your continued support and understanding during this time Without your love and support I would not have been able to complete my studies 2|Page MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ List of Abbreviations ADR Adverse Drug Reactions AEP Appropriateness Evaluation Protocol ALOS Average Length of Stay BAS Basic Accounting System BUR Bed Utilisation Rate CEO Chief Executive Officer DHS District Health System DOH Department of Health EC Emergency Centre HIA Health Impact Assessment HIS Health Information System HIV Human Immunodeficiency Virus IMR Infant Mortality Rate IP Inpatient KMC Kangaroo Mother Care LOS Length of Stay MDG Millennium Development Goals MHS Metro Health Services MRSA Methicillin-Resistant Staphylococcus Aureus NDOH National Department of Health NHI National Health Insurance PHC Primary Health Care PDE Patient Day Equivalent SA South Africa SDG Sustainable Development Goals TB Tuberculosis U5MR Under Mortality Rate UWC University of Western Cape WCG Western Cape Government WHO World Health Organization 3|Page MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ Definitions of key terms BUR: Bed Utilisation Rate (BUR) is a measure of the bed occupancy of available beds and therefore indicates how efficiently a hospital is using its available capacity (WCGH, 2017) ALOS: Average length of stay (ALOS) refers to the average number of days that patients spend in hospital (WCGH, 2017) PDE: Patient day equivalent (PDE) is calculated by adding the number of inpatient days plus half the number of day patients plus one-third the numbers of outpatients and emergency room visits It is a unit of measure which allows comparisons between hospitals (WCGH, 2017) District hospital: A hospital which receives referrals from and provides generalist support to clinics and community health centres with health treatment administered by general health care practitioners or primary health care nurses (KZN Dept of Health, 2001) Over and underutilisation: for the purpose of this study over utilisation is BUR above 90% and under utilisation is BUR below 80% This is based on an ideal BUR of between 80% and 90% (Olukoga, 2007) Small district hospital: for this study, all hospitals with an inpatient bed number less than the median of 166.5 beds Large district hospital: for this study, all hospitals with an inpatient bed number more than the median of 166.5 beds 4|Page MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ ABSTRACT Background: The largest focus areas for the department of health is ensuring access to quality healthcare The district health system (DHS) model remains the vehicle used by the district managers to deliver on the health department’s goals, objectives and priority focus areas Strengthening the district health system platform is therefore important to the department to improve access and quality of care to the clients serviced in the province The district hospitals play a fundamental role since they support primary health care (PHC) and serve as the entry point to more specialised care The efficient management of beds in the district hospitals is the key in ensuring access to care and preventing bed blocking Bed Utilisation Rate (BUR) and Average Length of Stay (ALOS) are indicators used to measure the efficiency of hospital beds This study provides a description of the trends in bed utilisation within the inpatient wards of eight district hospitals in the Cape Town metro district in the 2016-2017 financial period Methodology: To analyse and compare wards a quantitative approach was used Inpatient ward activity reports for eight district hospitals were accessed from the department of health’s routine data collection repository A total of fifty-five wards were compared across small and large hospitals for BUR and ALOS during the financial year period April 2016 to 31 March 2017 Data entry was done in MS EXCEL and analyses were done using STATA 11.0 Results: Using the number of inpatient beds the hospitals were divided into small and large district hospitals Large hospitals also had additional wards such as psychiatry, maternity and obstetrics, gynaecology and high care BUR for the wards were mostly in line with the BUR target for the hospital with the exceptions of the emergency centre (EC) and casualty overnight wards that remained high in five of the eight hospitals Paediatrics and neonatal BUR was low when compared with the hospital target Ideal BUR was between 80-90% but the targets set for the hospitals were not necessarily aligned to this Instead, BUR was based on a previous year’s achievement and was found consistent throughout the year and no seasonal trends were noted ALOS for the wards were mainly aligned to the hospital target except for maternity and obstetrics, paediatrics and EC acute wards which displayed shorter ALOS In the medical and psychiatry wards longer ALOS was observed A total of 4286 deaths took place of which 61% occurred in the medical wards Conclusion: Despite some limitations the study aims were met Although the BUR and ALOS were mostly found to be in line with the targets set, further investigation is needed to address some of the causes of high BUR in the psychiatry, EC and casualty overnight wards The 5|Page MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ relationship between high ALOS and mortality in the medical ward must be determined It is recommended that a longer study period, e.g 3-5 years, be conducted to determine trends in ALOS and BUR 6|Page MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ REFERENCES Al-Kandari, F and Thomas, D (2009) ‘Perceived adverse patient outcomes correlated to nurses’ workload in medical and surgical wards of selected hospitals in Kuwait’, Journal of Clinical Nursing John Wiley & Sons, Ltd (10.1111), 18(4), pp 581–590 doi: 10.1111/j.1365-2702.2008.02369.x Benatar, S (2013) ‘The challenges of health disparities in South Africa’, South African Medical Journal, 103(3), pp 154–155 Blum, F C et al (2008) ‘Crowding : High-Impact Solutions’, (April) Borg, M (2003) ‘Bed occupancy and overcrowding as determinant factors in the incidence of MRSA infections within general ward settings’, Journal of Hospital Infection, 54(4), pp 316–318 doi: https://doi.org/10.1016/S0195-6701(03)00153-1 Bruce, N., Pope, D and Stanistreet, D (2008) A Practical Interactive 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Najjaar 2006009 http://etd.uwc.ac.za/ 37 Soria-Aledo, V et al (2009) ‘Associated Factors and Cost of Inappropriate Hospital Admissions and Stays in a Second-Level Hospital’, American Journal of Medical Quality SAGE PublicationsSage CA: Los Angeles, CA, 24(4), pp 321–332 doi: 10.1177/1062860609337252 38 Statistics South Africa (2014) Poverty Trends in South Africa: An examination of absolute poverty between 2006 and 2011, Statistics South Africa 39 Stats SA (2017) ‘STATS SA Mid-year population estimates 2017’, (July) 40 The World Bank (2018) The World Bank In South Africa Available at: http://www.worldbank.org/en/country/southafrica/overview (Accessed: 25 April 2018) 41 Victor, C R (1990) ‘A survey of the delayed discharge of elderly people from hospitals in an inner-London health distric’, Archives of Gerontology and Geriatrics, 10(2), pp 199–205 doi: 10.1016/0167-4943(90)90019-3 42 WCGH (2016) NORTHERN TYGERBERG SUB-STRUCTURE Annual Operational Plan 20162017 43 WCGH (2017) Annual Performance Plan 2017/18 Cape Town 44 Western Cape Government (2013) ‘Healthcare 2030’, pp 1–160 45 WHO (2017) ‘From MDGs to SDGs’ Available at: http://www.who.int/mediacentre/events/meetings/2015/MDGs-SDGsSummary.pdf?ua=1 46 Zimmer, J G (1974) ‘Length of stay and hospital bed misutilization’, Medical Care Lippincott Williams & Wilkins, 12(0025–7079 (Print)), pp 453–462 doi: 10.2307/3762916 46 | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ APPENDICES APPENDIX A: Standardisation of ward names per hospital Original Ward Name Casualty Overnight A General Ward E General ward C Paeds/Neonates Ward D Surgical Overnight Ward Maternity Ward Female Ward Male Ward Paediatric Ward Psychiatric Ward G Ward/Private High Care Kangaroo Mother Care Ward M Maternity and Obstetrics E General Medicine Ward Nursery Ward P Paediatrics Psychiatry Ward A Surgical Male B Surgical Female D Ward EC Acute Ward 6A-Kangaroo Care (&Gynae) 3A-Hospital Maternity Antenatal 3B-Maternity postnatal 1A-Medical/Psychiatry Female 1B-Medical/Psychiatry Male 2A-Intensive Medical/Surgical 4A-Medical 4B-Medical 5A-Private Medical 3E-Baby Room 4C Paediatrics Medical/Surgical 2B-Surgical 5A-Private Surgical 5B-Surgery Ortho & Gynae Overnight Ward EMC EC Majors Adults EC Majors Paeds EC Psychiatric Ward Gynaecology Regrouped Ward Name Casualty Overnight Ward Medical Ward Paediatrics Surgical Ward Casualty Overnight Ward Maternity and Obstetrics Medical Ward Paediatrics Psychiatry Ward Gynaecology High Care Kangaroo Mother Care Ward Maternity and Obstetrics Medical Ward Nursery Ward Paediatrics Psychiatry Ward Surgical Ward EC Acute Kangaroo Mother Care Ward Maternity and Obstetrics Hospital Name Hospital A Hospital B Hospital C Hospital D Medical /Psychiatry Medical Ward Nursery Ward Paediatrics Surgical Ward Casualty Overnight Ward EC Acute Hospital E Gynaecology 47 | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ Kangaroo Care Antenatal Ward Post Natal Ward Medical Ward Medical Ward Nursery Paediatric Ward Female Psychiatric Ward Male Psychiatric Ward Surgical Ward Surgical Ward EC Overnight Adult ICD EC Overnight Medical Adult Ward EC Overnight Paeds ward Gynaecology KMC Antenatal Ward Maternity Post Natal Medical Female Medical Male MPH Carnation Neonatal Ward Paediatric Ward Mental Health Female Mental Health Male Surgical Female Surgical Female Orthopaedic Surgical Male Surgical Male Orthopaedic Emergency Ward High Care Unit Sandes Medical Female Total Sandes Medical Male Total Wright Ward Total Currie Children Currie Surgical Female Currie Surgical Male Emergency Centre Maternity Ward Medicine Paediatric Surgical Kangaroo Mother Care Ward Maternity and Obstetrics Medical Ward Nursery Ward Paediatrics Psychiatry Ward Surgical Ward Casualty Overnight Ward Hospital F Gynaecology Kangaroo Mother Care Ward Maternity and Obstetrics Medical Ward Neonatal Ward Paediatrics Psychiatry Ward Surgical Ward EC Acute High Care Medical Ward Hospital G Paediatrics Surgical Ward EC Acute Maternity and Obstetrics Medical Ward Paediatrics Surgical Ward 84 Hospital H 55 48 | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ APPENDIX B: Approval letter 49 | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ 50 | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ APPENDIX C: Approval letter 51 | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ 52 | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ APPENDIX D: Approval letter 53 | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ 54 | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ APPENDIX E: Approval letter 55 | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ 56 | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/ APPENDIX F: Ethics letter UWC 57 | P a g e MPH Thesis: L Najjaar 2006009 http://etd.uwc.ac.za/