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Overcrowded hospitals may risk adverse
events on busiest days
Study finds that efforts to improve efficiency may compromise patient
safety
BOSTON - April 23, 2007 - Hospitals that operate at or over
their capacity may be at increased risk of adverse events that injure
patients, according to a study led by investigators from Massachusetts
General Hospital (MGH) and Brigham
and Woman's Hospital (BWH). The report in the May issue of the
journal Medical Care suggests that efforts to meet two primary
challenges facing hospitals today - reducing costs and improving
patient safety - may work against each other.
"While financial and political pressures to make health care
more efficient are leading to increased hospital occupancy and greater
patient turnover, patients and policymakers are quite rightly demanding
that health delivery systems be made safer," says Joel Weissman,
PhD, of the MGH Institute
of Health Policy, the report's lead author. "Our study
suggests that pushing efficiency efforts to their limits could be
a double-edged sword that may jeopardize patient safety."
In order to examine their hypothesis that increased workload could
raise the likelihood of adverse events, the investigators examined
data from four hospitals in two states - two large urban teaching
hospitals and two suburban teaching hospitals - over the 12 months
from October 2000 through September 2001. To compile patient care
information they reviewed patient charts and billing records on
almost 25,000 patients, selecting 6,841 for comprehensive review,
and analyzed that data against information on hospital workloads
and staffing patterns, with a focus on variations within each hospital.
From the nearly 7,000 records receiving detailed review, 1,530 adverse
events - defined as preventable injuries not resulting from patients'
underlying medical condition - were identified. The most common
such events were wound infections and adverse drug events. At three
of the four hospitals, the rate of adverse events did not appear
to increase at times of peak workload. But at the fourth - a major
urban teaching hospital with consistently high occupancy rates,
exceeding 100 percent for more than three months - workload increases
and higher patient-to-nurse ratios were associated with more adverse
events.
"While we looked at only four hospitals, which limits the ability
to generalize these findings, the hospital where we found a relationship
between working conditions and adverse events was disproportionately
crowded for much of the study period," says study co-author
Eran Bendavid, MD. "That suggests hospitals operating at the
high end of their capacity may need to examine safety systems with
an eye towards coping with periods of high stress." Formerly
with the MGH Institute of Health Policy, Bendavid is now at the
Center for Health Policy at Stanford University.
"This study helps quantify the impression that many clinicians
have and confirms that systems perform poorly when they are overloaded,"
says study co-author David Bates, MD, MSc, of the BWH Division
of General Medicine and Primary Care. "Future research
should address approaches for distributing workload and examine
the effectiveness of strategies to improve safety in high-workload
situations."
Additional co-authors of the Medical Care report are Jeffrey Rothschild,
MD, MPH, and Francis Cook, PhD, BWH; Peter Sprivulis, MBBS, PhD,
University of Western Australia; Scott Evans, PhD, Peter Haug, MD,
and Jim Lloyd, University of Utah; Yevgenia Kaganova, PhD, Melissa
Bender, MD, and JoAnn David-Kasdan, RN, MS, MGH Institute of Health
Policy; Leslie Selbovitz, MD, Newton-Wellesley Hospital; and Harvey
Murff, MD, MPH, Vanderbilt University Medical Center. The study
was supported by grants from the Agency for Healthcare Research
and Quality, U.S. Department of Health and Human Services.
Massachusetts General Hospital, established in 1811, is the original
and largest teaching hospital of Harvard Medical School and conducts
the largest hospital-based research program in the United States,
with an annual research budget of nearly $500 million. Brigham and
Women's Hospital is an international leader in basic, clinical and
translational research on human diseases, involving more than 800
physician-investigators and renowned biomedical scientists and faculty
supported by more than $400 million in funding. MGH and BWH are
founding members of Partners HealthCare System, a Boston-based integrated
health care delivery system.
Media Contacts: Sue
McGreevey, MGH Public Affairs
Kevin Myron, BWH Public
Affairs
MGH Physician Referral Service: 1-800-388-4644
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