by John Dao

Hospitals across the country struggle with the difficult task of planning for unpredictable swings in patient volumes in some of their busiest departments. Sudden increases in patient volumes above the typical range, also known as “peak periods,” can have a dramatic impact on not only the department experiencing the peak, but also on other downstream departments throughout the hospital.

The emergency department (ED), for example, serves as one of the most important portals of entry for patients, yet hospitals consistently report not having enough exam room capacity to handle patient demand during peak periods.

When the ED runs out of exam room capacity, wait times spike, and patients go to other hospitals – or worse, return home without treatment. In addition, the ED may go on divert status which effectively shuts off the flow of incoming patients until the existing patient queue is reduced.

In each of these scenarios, the hospital is negatively impacted in a variety of ways.

• Inpatient volumes are diminished as potential admissions are diverted to other competitor hospitals.
• Ancillary volumes are reduced as lab tests and diagnostic imaging volumes go unordered.
• Patient satisfaction declines as wait times go up.
• Overall community perception suffers as the ED is a significant community “touch point.”

The ED is not the only department that must cope with wide swings. Other hospital service lines that typically deal with great variation in patient census include obstetrics (OB), pediatrics, and general inpatient beds.

The simple fact that it is impossible to gauge the exact time when a mother will go into labor adds unpredictability and census peaks into the OB service line. Typically, when the OB department peaks, multiple mothers will present at the same time creating capacity shortages in triage areas, labor delivery rooms, and C-section rooms. During these peak periods, physicians and staff are stretched to the limit trying to accommodate the unpredicted rise in census. It is these stressful peak periods the physicians and staff will always remember when planning for future growth or additional capacity. However, as the rate of scheduled C-section deliveries continues to rise, swings in OB census may not be as great as they were in the past.

Pediatrics is another service line that often sees spikes in patient census. Many hospitals have built dedicated pediatric beds or wings to separate this unique patient population from other adult patients. Unfortunately, many of these hospitals have found these dedicated beds or units difficult and expensive to staff during the summer months and other low pediatric census periods. Conversely, these same hospitals often discover they do not have enough pediatric beds during high-census periods, such as the winter cold and flu season.

Common pitfalls for peak census predictors

Hospitals located in rapidly-growing cities or areas of higher population density often experience census peaks in their general inpatient beds. One of the most common drivers of peaks in inpatient census is observation patients and other outpatients that reside in an inpatient bed. These are typically patients who are not formally admitted but need a bed for extended recovery (e.g., from a surgical procedure) or other extended observation (e.g., for chest pain). Many hospitals do not accurately plan for these types of patients, and this can lead to bed shortages.

For example, many hospitals make the mistake of planning staffing and estimated bed need around an average daily census (ADC) statistic. This number, however, is often calculated based on a midnight census as opposed to a midday or peak-period census count. For hospitals that utilize a significant number of their inpatient beds for observation or outpatients, planning around a midnight census can create serious bed and staffing shortages.

How can a hospital better plan for these “unpredictable” peaks to ensure adequate facility and staff capacity? The first response is to consider whether or not your peaks are truly unpredictable. When it comes to peak periods, past trends often provide a good indication of what the future will hold.

Seasonality, for example, can often have a dramatic impact on census. During the winter, illnesses such as the flu and pneumonia often push inpatient census to peak levels. Hospitals located in lake-and-cabin areas often see volume spikes in the summer months that are directly related to the influx of vacationers to their service area.

A more universal example is provided by EDs, which typically see their greatest patient volumes on the weekends and in the evenings, when most other health care options are closed. By tracking and analyzing detailed historical volumes, peak census patterns become apparent and easier to predict and accommodate.

Better peak planning: A step-by-step approach

In order to implement a better peak planning methodology, it is important to focus on one particular department and then expand the methodology to other departments. The ED often serves as a good “pilot” department, as the ED typically tracks patient visit data to a greater detail than inpatient areas such as OB and pediatrics.

The first step in the process is to understand which key utilization statistics your information system currently tracks. Most EDs track common utilization indicators such as patient volume by day, month, and year. Unfortunately, that is often where the tracking ends. This level of data does not provide ED administration with enough information to analyze and effectively plan for peak periods.

In order to define when peak periods impact the ED, it is important to not only track the daily, monthly, and annual volumes but also hourly volume/census information as well. If the system does not track hourly volumes, actual hand tallies tracking hourly visits may be used as an extremely rough approximation of hourly census.

The second step in the process is to analyze your historical ED volume and identify your peak periods. Based on your data, answer the following questions:

• Which hour of the day is busiest?
• Which day of the week is busiest?
• Which month of the year is busiest?

Once these peak periods have been identified, the next step is to compare these peak volumes to average patient volumes for the same time periods. The peak period patient volumes will obviously be higher than the average volumes and thus a “peak factor” can be easily calculated by dividing the peak census by the average census. The table below provides an example.

Predicting your “Easter Sunday”

The last step in the ED peak planning process is to use the information gained from the analysis above to calculate how many ED exam rooms would be required during your busiest peak period. In order to do this, you will need to make several assumptions around operational factors that include average visit time and average occupancy rate. The end goal is to identify the estimated patient volumes and associated exam room/staffing needs when your “Easter Sunday” hits.

Once the above analysis is complete, the obvious question remaining is “Do we need to have enough exam room capacity for our Easter Sunday?”

From a fiscal and practical stand point, it is difficult to rationalize the additional expense of building enough physical capacity to handle the busiest peak periods. However, it is possible to build flexibility into your ED to accommodate the busiest periods.

For example, a great way to build in additional ED exam room capacity to handle the peak periods is to place the ED adjacent to a department that has similarly sized treatment/patient rooms. Observation units or surgical prep/recovery areas often have patient rooms that are similar in size and makeup to an ED exam room.

In addition, areas like surgical prep/recovery are typically closed during traditional ED peak periods, and thus the space is available and unused. If the ED was physically adjacent to these rooms, additional ED capacity could be added quickly during peak periods by simply opening up and overflowing patients into the adjacent department (assuming staff availability). This added flexibility and capacity could dramatically improve how peak periods impact your ED by adding exam room capacity, reducing the need to go on divert, and improving overall ED as well as hospital flow.

Population swings are here to stay

Peak periods and dramatic volume swings are endemic to the health care industry. The most successful health care organizations are those that can successfully plan for and benefit from these peaks rather than being paralyzed by them.

The principles as introduced in this article can be applied to many different areas and settings within your hospital or clinic. If applied correctly, the findings from these analyses can set your organization along the pathway towards successful peak planning.

John Dao is a health care manager for Partners Healthcare Consulting (“Partners”), a service of Wipfli LLP. His consulting career has spanned a wide breadth of hospital and ambulatory settings, ranging from large academic hospitals and integrated delivery systems to small regional hospitals. John can be reached at (952) 548-3377 or jdao@wipfli.com.