Irate Physician: “My patient needs admission immediately. I don’t give a damn if the hospital is full; discharge somebody, she’s too sick to wait”

Harassed Registrar: “But Doctor there are absolutely no beds”

Irate Physician: “Well b****y well find one! Right now! I’m sending her in”.

During the early and mid nineties the Canadian hospital system suffered dramatic cutbacks in funding and major reductions in bed numbers. At that time in Edmonton, Alberta five collaborating hospitals provided pediatric inpatient care. Of the total of 130 beds approximately two thirds were in the tertiary care University Hospital and the remainder were divided among several secondary level units in general hospitals.

All beds were managed as a single system-wide unit. Resident coverage was largely confined to the University hospital creating a strong incentive for pediatricians to admit their patients there if possible. Under increasing pressure we evolved a triage system which allowed us to maintain bed occupancy of more than 100% (as calculated on a once a day midnight bed census) and which effectively ensured that children requiring the specialty facilities of the tertiary center; received them.

Early approaches failed. First, we asked the senior resident on call to assume bed control responsibilities but it rapidly became clear that this was unfair and ineffective. Few residents possessed the diplomatic experience or authority to deal with senior pediatricians and their often forceful requests.

Next we appointed a paid fulltime bed control physician who nobly performed the task for nearly a year before the stress of daily altercations with colleagues became unbearable. Our final successful approach involved the appointment of a small group of senior (thick-skinned and hard-nosed) pediatricians to act as bed control officers, rotating on a weekly basis, and paid a reasonable stipend. To avoid the emotive “control” we called them Triage physicians.

We established a daily bed status report run by senior nursing staff. Each hospital phoned a central office early each morning and reported the number of empty beds and the number of expected discharges within the next 24 hours. This information was collated by senior nursing staff into a system wide report, which included anticipated elective surgical admissions and which was updated at noon and five pm. Increased same-day surgery greatly reduced the impact of elective surgical admissions. The system-wide bed status was provided to the triage officer whose approval was required for all admissions and their location.

To avoid unnecessary bureaucracy, we introduced a “triage threshold” so that the triage officer only became involved when five or fewer empty beds were available. In-patient stay was tracked and a further responsibility of the triage officer, with the help of nursing and resident staff, was to identify patients whose discharge was delayed and, with consultation with the responsible physician, facilitate a solution.

Admissions expected to be short, i.e. less than 24 hours, were admitted to a small observation unit and underwent an abbreviated admission procedure. Such patients were transferred to full admission status if their condition failed to improve in the allotted time span.

The key elements of this bed control system included:

1) A bed status information system, updatable several times a day;
2) An empowered and financially rewarded triage officer, preferably a senior physician with sound clinical judgment and strong diplomatic skills;
3) The tracking of In-patient stay with identification and rapid resolution of reasons for delayed discharge;
4) The provision of short-stay beds;
5) Control of the system by “frontline” medical and nursing staff, and
6)Frequent feedback to the whole medical staff about the need for, and the intrinsic fairness of the system.

Some navigational notes:

Copyright (c)Roy Johnston, Peter Millard, 2005, for e-version; content is author's copyright,