COVID-19: How Hospitals Can Create Better Inpatient Bed Capacity through Math

COVID-19: How Hospitals Can Create Better Inpatient Bed Capacity through Math
Dr. Pallabi Sanyal-Dey, Associate Professor of Medicine at UCSF & Director of Client Services at LeanTaaS

Since the beginning of the COVID-19 pandemic, key elements of hospital operations such as managing inpatient bed capacity, and access to ventilators and PPE have taken center stage. The general public got a crash course on what hospitals need in order to function successfully when disaster hits, and daily news and discussions were centered around ICU bed capacity as cases accelerated across the country.

The nightmarish predictions and reality led to the development of creative measures to help meet such catastrophic needs such as popup temporary screening and triage sites, non-medical and medical spaces being repurposed for COVID units, increased patient transfers to hospitals that had more space, and mathematical models to predict upcoming numbers of new COVID-19 cases. 

With the latest surge of COVID-19 cases (see figure 1), some states have or will begin opening up field hospitals (Wisconsin, Texas) while others are considering transfers to other locations (both in and out-of-state), and even the concept of ‘rationing care’ has surfaced. 

1Figure 1. The Covid Tracking Project

This public health crisis intensified what happens when hospitals and healthcare providers run out of the right space and resources. As alarming as it has been to watch this play out, the reality is that these capacity and resource challenges are not unique to the pandemic; they happen often in hospitals across the country, just on a different scale. Bed capacity is something hospital leaders manage every day – only 1 of 3 hospital beds are available on any given day in the U.S., per research by the Robert Wood Johnson Foundation 2.  Of course, there’s further variation when looking at urban versus rural regions. Many systems are forced to go on ‘diversion’ (patients will literally be re-routed to other hospitals) when the reality is that they are bursting at the seams. 

Clearly, the pandemic has been devastating, yet it has (finally) propelled healthcare toward innovation and adoption of technology that was much needed in order to improve access to and utilization of quality and cost-effective care. Although the waves continue, organizations are starting to answer the following questions: What newly applied practices do we keep from the pandemic moving forward as we head into additional COVID-19 waves and the flu season? Can we more vigorously apply lessons of the past and present to tackle our future needs? Are our incentives aligned such that the solutions we pursue can be sustained and still “keep the lights on”?

Delayed access to care and, even worse, lack of access to care, have been among the most devastating consequences of the capacity crises during the pandemic.  Though many of our systems started to transition back to their usual state of affairs by July, other factors in addition to the current surge continued to highlight the ongoing need for creating and sustaining ‘good patient flow’.

Under “normal” circumstances, daily chaos is anticipated and actually expected, as hospitals experience the inability to move patients from the emergency room (ER) or operating room (OR) due to a “lack of beds” in the hospital. While this inevitably requires hospital leadership to ‘do something’ about it, it is a scenario that plays repeatedly throughout the day, every day.  

The chaos that comes from the lack of visibility into available beds, let alone appropriately available levels of care, can have negative downstream impacts not only on the patients but also on the frontline staff. Patients are subject to suffering the consequences of inappropriate levels of care, poor clinical outcomes, and/or poor provider/patient experiences.3 Staff are subject to the stress of caring for patients for whom they are not necessarily appropriately trained to care for.

Despite the known implications, this lose:lose cycle continues. These “risks” plus the impact of significant revenue losses from the pandemic highlight the urgent need to address poor, inefficient patient throughput. We are at a critical point where healthcare systems must do what is necessary to improve existing practices when it comes to bed management.  

Some examples of improvement include: 

– Create machine learning models for all locations and patient movements within the hospital, and adjust space and schedules accordingly

  – Place patients using sophisticated demand-supply model

  – Make data-driven internal transfer decisions

  – Right-Sized unit capacity

  – Look hard at the degree of specialization to pool capacity where possible

  – Smooth the patient flow from the OR

Take a magnifying glass to internal operational workflows – Identify practices that work, areas where support is needed, especially when it comes to discharge planning, and whether or not there are financial implications.

– Improve provider workflow

– Don’t let “a dime hold up a dollar”: take a hard look at staffing, hours of operations, and transportation

– Use predictive discharge planning to focus on case teams and social services

Identify clinical workup that can be prioritized according to disposition, treat outpatient setting 

– Prioritize discharge patients in queues for labs/clinical procedures

– Transition some procedures to outpatient

With the recent surge of COVID-19 cases across the nation and the impending flu season, hospitalizations will continue to rise.  Although health systems will be able to resurface earlier crafted emergency plans from previous surges, set up incident command centers more quickly, and have a more stable supply inventory, they will likely continue to manage their bed capacity through a very manual process.  It is imperative that we start to do things differently to achieve better outcomes!

Implementing operational change and deploying new but proven technologies that incorporate both artificial intelligence and lean principles will increase patient access, improve provider, patient, and staff experience, and, of course, smooth inpatient capacity. As a result, terms such as chaos and crisis can, in time, become things of the past. 


References:

1. The Covid Tracking Project Nov. 10, 2020. Retrieved from https://covidtracking.com/data/charts/us-currently-hospitalized

2. Blavin F., (March 1, 2020). Hospital Readiness for Covid-19: Analysis of Bed Capacity and How It Varies Cross The Country The Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2020/03/hospital-readiness-for-covid19-analysis-of-bed-capacity-and-how-it-varies-across-the-country.html

3. Mohr et al., Boarding of Critically Ill Patients in the Emergency Department. Critical Care Medicine 2020; 48(8): 1180–1187

4. Agrawal S., Giridharadas M., (2020) Better Healthcare Through Math: Bending the Access and Cost Curves. Forbes, Inc. 


About Dr. Pallabi Sanyal-Dey

Dr. Pallabi Sanyal-Dey is the director of client services for ‘iQueue for Beds’ Product at LeanTaaS, a Silicon Valley software innovator that increases patient access and transforms operational performance for more than 300 hospitals across the U.S. Dr. Sanyal-Dey is also a visiting associate professor of medicine, providing career mentorship to trainees at the University of California, San Francisco Medical Center (UCSF) where she attends on the internal medicine inpatient teaching service. Prior to joining LeanTaaS, Dr. Sanyal-Dey was at UCSF, as an assistant clinical professor and an academic hospitalist at Zuckerberg San Francisco General Hospital where she directed clinical operations for the Division of Hospital Medicine, and oversaw the faculty inpatient services.


CommonHealth App Connects to 230 Health Systems to Share Health Data – including COVID Test and Vaccine Status

CommonHealth, a Free Mobile App for Patients to Share Health Data - including COVID Test and Vaccine Status - Connects to 230 US Health Systems

What You Should Know:

– CommonHealth has connected to 230
health systems in the United States, allowing patients to gather, manage and
share their health and test data, including COVID test and vaccination status. By
the end of this month, CommonHealth will connect to more than 340 health
systems

– CommonHealth extends the health data
portability and interoperability model pioneered by Apple Health to the 55
percent of Americans with Android devices (85 percent globally)


The Commons Project, a nonprofit public trust established to build digital platforms and services for the public good, today announced that the CommonHealth app has now connected to 230 health systems in the United States, allowing patients using those health systems to gather, manage and share personal health information – including COVID test and vaccine status – on Android devices for free. CommonHealth enables broader and more equitable participation in remote consultations with doctors, telemedicine, innovative care models, next-generation health services, and research.


CommonHealth App Development Background

Developed in collaboration with UCSF, Cornell Tech, and Sage Bionetworks with a team of clinicians, public health experts, technologists, scientists and privacy advocates, CommonHealth is operated by The Commons Project. CommonHealth was first deployed at UCSF Health and underwent substantial testing and user experience research in multiple diverse populations in San Francisco. CommonHealth is the first and only platform designed to allow users of the Android operating system to collect and manage their health data on their mobile devices in a similar way that Apple Health Record operates on iOS.

Already integrated with LabCorp, which
operates one of the largest clinical laboratory networks in the world,
CommonHealth allows individuals to store their COVID test results and vaccination
status, in addition to any health record. CommonHealth plans to integrate with
an additional 110 health systems in December, connecting to more than 340
health systems before the year ends.

Earlier this year, the Center for Medicare and Medicaid (CMS) rolled out new patient health record sharing rules that will require hospitals and physician offices to send standardized medical information, such as lab test results, vaccination records, and imaging tests, directly to third-party apps, like CommonHealth, by July 2021.


Why It Matters

“The COVID pandemic has accelerated the need for the safe sharing of health data as medical consultations go online and individuals are required to demonstrate COVID test and vaccination status in order to travel, work, study and undertake other social activities,” said JP Pollak, co-founder and chief architect at The Commons Project. “CommonHealth extends the privacy-centered data portability and interoperability model pioneered by Apple Health to the 55 percent of Americans who have Android devices.”


Availability

CommonHealth is a shared public service that is always free
for users and is available for download on Android devices via Google Play: https://play.google.com/store/apps/details?id=org.thecommonsproject.android.phr

FDA Grants AppliedVR Breakthrough Designation for Virtual Reality Chronic Pain Treatment

FDA Grants AppliedVR Breakthrough Designation for Virtual Reality Chronic Pain Treatment

What You Should Know:

– FDA awards AppliedVR Breakthrough Device designation for
treating treatment-resistant fibromyalgia and chronic intractable lower back
pain

– AppliedVR’s EaseVRx program helps patients learn self-management skills grounded in evidence-based cognitive-behavioral therapy (CBT) principles and other behavioral methods.


AppliedVR,
a pioneer advancing the next generation of digital medicine, today announced
its EaseVRx product received Breakthrough Device designation from the U.S. Food
and Drug Administration (FDA) for treating treatment-resistant fibromyalgia and
chronic intractable lower back pain. EaseVRx is now one of the first virtual
reality (VR) digital therapeutics to get breakthrough designation to treat
conditions related to chronic pain.

What is the FDA Breakthrough Device Program?

The FDA Breakthrough Device Program helps patients receive more timely access to breakthrough technologies that could provide more effective treatment or diagnosis for life-threatening or irreversibly debilitating diseases or conditions. 

Clinical Trial Results/Outcomes

AppliedVR achieved this milestone after successfully
completing the first randomized controlled trial (RCT), evaluating VR-based
therapy for self-management of chronic pain at home. The RCT, which was
published in JMIR-FR,
found that a self-administered, skills-based VR treatment program for treating
chronic pain was feasible, scalable and was effective at improving on multiple
chronic pain outcomes – each of which met or exceeded the 30-percent threshold
to be clinically meaningful. On average, participants noted:

– Pain intensity reduced 30 percent;

– Pain-related activity interference reduced 37 percent;

– Pain-related mood interference reduced 50 percent;

– Pain-related sleep interference reduced 40 percent; and

– Pain-related stress interference reduced 49 percent.

EaseVRX Program Background

AppliedVR’s EaseVRx program helps patients learn self-management skills grounded in evidence-based cognitive-behavioral therapy (CBT) principles and other behavioral methods. The program was designed by AppliedVR, in partnership with the top pain experts and researchers, to improve self-regulation of cognitive, emotional, and physiological responses to stress and pain. AppliedVR has already been shown to be an effective treatment for acute pain in hospital settings

Why Virtual Reality Is An Effective Approach for Pain
Management

Lower back pain is one of the most common
chronic conditions that people face worldwide and represents one of the top
reasons why people miss work. Additionally, it’s an extremely
costly problem for insurers, especially as they look to cut costs related to back surgery. Recent research indicated that, when combined with neck pain,
lower back pain costs nearly $77 billion to private insurance, $45 billion to
public insurance, and $12 billion in out-of-pocket costs for patients.

Chronic pain more broadly also is a difficult and costly
problem that has contributed to many other major health problems in the U.S.,
including the opioid epidemic. A previous Johns Hopkins study in the Journal of
Pain found that chronic pain can cumulatively cost as high as $635 billion a year — more than the annual costs of
cancer, heart disease and diabetes — and lower back pain has been one of the most common reasons for prescribing opioids.
Cognitive behavioral therapies like VR are now seen by many providers as an
effective alternative or complement to pharmacological interventions that can
support their larger treatment tool belts.

“Since 1980, the American Chronic Pain Association has advocated a multidisciplinary approach to pain management—using a combination of medical and behavioral techniques to address pain,” said Penny Cowan, founder and CEO of the American Chronic Pain Association. “Virtual reality has the potential to be an important resource in this approach, helping people with pain to think differently about their conditions and learn strategies to reduce suffering and improve quality of life.”

Future Clinical Trials

AppliedVR is currently engaged in many other trials,
including feasibility studies with multiple well-known payers and with the
University of California at San Francisco (UCSF) to study how digital therapeutic platforms, including
virtual and augmented reality, can be used to improve care access for
underserved populations. AppliedVR also is advancing two clinical trials with
Geisinger and Cleveland Clinic to study VR as an opioid-sparing tool for acute
and chronic pain – specifically the company’s RelieVRx and EaseVRx platforms.
The National Institute on Drug Abuse (NIDA), part of the National Institutes of
Health (NIH), recently awarded $2.9 million grants to fund the trials.