A method for bed control in ICU (Intensive Care Unit)
for quality and safety assurance of healthcare
Takahiro Yoshida1, Shogo Kato2
Satoko Tsuru3, Yoshinori Iizuka4
1 The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8656, JAPAN
tyoshida@tqm.t.u-tokyo.ac.jp
2 The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8656, JAPAN
kato@tqm.t.u-tokyo.ac.jp
3 The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8656, JAPAN
tsuru@tqm.t.u-tokyo.ac.jp
4 The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8656, JAPAN
iizukay@tqm.t.u-tokyo.ac.jp
ABSTRACT
Recent reforms in healthcare social system have led to changes such as reduction in the period of inpatient hospitalization and rapid
turnover of sickbeds. In this situation, it is essential to improve the method of “bed control” for the best use of healthcare resources, that
is, how the medical staff can allocate the limited healthcare resources to each patient appropriately.
A previous study developed a method for bed control; however, it did not address bed control for severely diseased patients admitted to
ICU (intensive care unit). The present study describes a method for ICU bed control.
A survey was carried out in a hospital with about 1,000 beds to identify the issues regarding ICU bed control. On the basis of analysis of
these issues, 4 bed control modules were developed, including “control of bed availability,” “control of existing patients in ICU,”
“control of incoming patients to ICU with vacant beds,” and “control of incoming patients to ICU with unavailable beds.” We elaborated
these modules to resolve the identified issues and developed a method of bed control in ICU for quality and safety assurance in
healthcare. Further, this method was presented to the hospital staffs for their review to determine its effectiveness in actual clinical
situations.
Keywords: ICU bed control, quality and safety assurance in healthcare, bed control module
INTRODUCTION
Background
In Japan, recently, there is a considerable debate on the need for the quality assurance in healthcare. A medical care reformation was
implemented in 2002. Since then, the average period of inpatient hospitalization has decreased from 23.8 days to 17.1 days, and the
number of sickbed has decreased from 8,738 to 6,717 (from 2002 to 2008)[1]. This resulted in a rapid turnover of sickbeds. As a result,
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the number of inpatients who are highly dependent on medical treatment increased in acute hospitals. Thus, it becomes essential to
determine how to allocate the limited medical and human resources to each patient appropriately.
Sickbed is not just a bed where the patients lie down but where they receive medical treatment. By considering the attributes of
inpatients, medical staffs allocate these patients to the sickbed in the hospital. For example, nurses allocate severely diseased patients to
the sickbed that is near to the staff workstation.
They much say the importance of bed control. Most of them are, however, provide advice to use the resources, and there are hardly any
specific methods. This is why the bed control has complex relationships with many elements, and the principle is not clear.
Previous study
In a previous study[2], Nitta developed a support system for bed control in hospitals for quality and safety assurance. In this study, the
concept and method of bed control was established. We thought that the bed control in ICU had common concept as base, and introduced
in this study that concept; as will hereinafter be described in detail.
Problems
The previous study focused on general beds. These beds comprise a majority of beds in a hospital. There are also other types of beds in a
hospital, for example, beds in an ICU. ICU has some prominent features.
1.
It employs a considerable amount of medical and human resources in the hospital.
2.
It is used only for severely diseased patients who require intensive medical treatment and constant nursing.
3.
Medical staff can always actively treat and nurse patients admitted in ICU. Moreover, they possess a high level of technical
skills.
4.
It has a very high running cost. ICU beds are 10 times more costly than general beds.
5.
The number of ICU beds is limited.
From these features, it is clear that the attributes of patients admitted in ICU are different from those of patients put on general beds;
hence, we need to establish a different method for bed control in ICU. In addition, there have been some recent incidents wherein
severely diseased patients were refused admission into some hospitals because of no availability of beds and were kept in a high-risk
situation for a long time.
OBJECTIVE
To solve the abovementioned problem, the ultimate purpose of this study is to develop a method for bed control in ICU for quality and
safety assurance in healthcare.
In this study, we aim to
• survey and analyze the present situation and issues regarding ICU bed control in hospital A
• develop an ICU bed control model to allocate each patient to ICU appropriately
In the future, we aim to develop a comprehensive bed control system, which includes all the beds in a hospital, i.e., ICU, high care unit
(HCU), general beds, and so on.
THE CONCEPT OF BED CONTROL
Here, we introduce the concept of bed control. This concept comprises 4 parts as shown in Figure 1.
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1.
To clarify the needs of a patients according to his/her attributes
To figure out what information is necessary to allocate and control the bed for each patient according to the characteristics of
age, sex, severity of disease, ADL (Activities of Daily Living), etc.
2.
To clarify the function of a bed
To figure out what information is necessary for each bed to accept patients, i.e., equipment, positioning, requirement of a
private room, etc.
3.
To develop a logic for deciding a bed
To figure out how to decide a bed function that is tailored to patients on the basis of information of points 1 and 2.
4.
To develop the bed control process
To figure out how to allocate each patient to the bed and to adjust the actual hospital work appropriately by considering point
3.
2.We figure out what
information is
necessary for each
bed to accept patients
1.We figure out what
information is necessary
to allocate and control
the bed for each patient
Concept
The needs
of a patient
according
to his/her
attributes
Matching
The function
of a bed
Bed deciding
4.We figure out how to
allocate each patient to the
bed and to adjust the actual
hospital work appropriately
3.We figure out
how to decide the
bed function that is
tailored to patients
Figure 1- Conceptual diagram of bed control
DEVELOPING THE MODEL
Investigation of the issues of bed control for severely diseased patients in hospital A
To clarify the actual status and issues of bed control in details, we interviewed healthcare workers concerned with the nursing of severely
diseased patients.
• Case hospital: Hospital A (this is a regional core hospital)
This hospital has approximately 1,000 sickbeds and 11 ICU beds.
• Method: We filled the data for the discussion of bed control for severely diseased patients in a form of 5W (what, why, where, who, and
when) and considered that the issues of bed control originated from the section of “why.” We collected and classified these issues from
the forms.
Table 1 shows the contents of analyses. Table 2 shows the collected issues.
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Table 1- Contents of analyses of discussion data (partial view)
Department
ICU
Dabel
What happened
additional work because
of inappropriate
personal error
imformation and
cooperation
prediction
Recovery beds
Why it happened
An example for solving
increase in risk by
ambiguity in the comparative
criteria
inappropriate
criteria
comparative assessment
no imformation on beds
bed functions
ambiguity in the function of beds
that will be unoccupied
decrease in the
occupancy rate because
of difference in the
number of sickbeds used
during the day
Where it happened
to(2)
from
to
・develop the rogic of comparative criteria for severity
incoming
ICU
ICU
general bed
・clarify the function of bed
・clarify the arributes of patients for bed control
ICU
general bed
in
error made by the doctor
・the immidiate imforming about changing
・develop a work flow chart to share imformation
each bed
absence of prediction for
dispersion
abcence of a control method
depending on the prediction
・define the optimum state from the past state
・find the elements that cause differences
・control patients in accordance with the differences
recovery bed
ambiguity in the comparative
increase in risk by
criteria
criteria
inappropriate
personal error
difference in criteria between Dr.
comparative assessment
and Ns
horizontal migration of
structure
problem of bed position
patients not possible
addition work involved in
work
ambiguity in migration procedure
migration of patients
criteria
a delay in accepting
ambiguity in criteria and the
cooperation patients
problem of cooperation
difference in criteria for
difference in criteria between
criteria
accepting emergency
nurses
patients
difficulty to adjust beds
criteria
ambiguity in criteria
in emrgency
a difficulty to decide the
bed functions bed for newly entering
fuzziness of criteria
patients
cooperation
fuzziness of criteria to
use the available beds
cooperation
ambiguity in bed available
unshared imformation at night
states at night
absence of shared criteria
・develop outgoing criteria for existing patients
・develop incoming criteria for incoming patients
・develop criteria for using beds of other departments
・control avoiding the full bed state
recovery bed general bed
・set the combined department in the same floor
recovery bed surgical bed
・develop a simple work flow chart
recovery bed surgical bed
・develop criteria for using beds of other departments
incoming
recovery bed
・develop share criteria
recovery bed
・develop incoming criteria for incoming patients
・clarify the definition of the available beds
recovery bed
・develop share criteria
general bed recovery bed
・develop share criteria of using beds
・clarify the function of bed
general bed recovery bed
・developing a system to unify bed states
recovery bed
Table 2- The collected issues of bed control for severely diseased patients
Classification
criteria
bed functions
patient needs
prediction
shortage of resources
unavailability of bed
cooperation
work
personal error
structure
environments
Explanation
the problem
the problem
the problem
the problem
the problem
the problem
the problem
the problem
the problem
the problem
the problem
caused
caused
caused
caused
caused
caused
caused
caused
caused
caused
caused
by
by
by
by
by
by
by
by
by
by
by
ambiguity in criteria for deciding beds for patients
fuzziness of the bed function for accepting patients
fuzziness of attributes of patients
absence of prediction for dispersion of number of available beds
shortage of human and medical resources
unavailability of the beds (full bed)
lack of cooperation between departments
lack of work ethics
personal error
the structure of the hospital
the particular environments of the bed and various situation
We interpreted these issues as the function of a process model for ICU bed control. In Table 2, the issues represented in gray are beyond
the scope of this model.
Classification of the types of patients
We interviewed nurses who worked in ICU and figured out the entering and leaving paths of patients admitted in ICU. We classified the
types of these patients. Figure 2 shows the paths of patients, and Table 3 shows the content of classification of these patients.
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hospital
emergency
entering
accept
judgment
Emergency room
other
hospital
ICU
HCU
operation
room
planned
entering
general ward
discharge
Figure 2- The paths of patients
Table 3- Classification of types of patients
Type
patients in ICU
inside palnning patients
outside planning patients
inside emergency patients
outside emergency patients
Definition
patients who are currently exist in ICU
patients who are planned to enter ICU from inside the hospital
the patients who are planed to enter in ICU from outside the hospital
the patients who are unplaned to enter in ICU from inside the hospital
the patients who are unplaned to enter in ICU from outside the hospital
Setting the control modules
As shown in the previous subsection, bed control involves a large number of complex factors. It is very difficult to appropriately control
all these classified patients in the same process. Therefore, we set 4 control modules (module 0~module 3) similar to cells according to
the simplistic flow of bed control shown in Figure 3.
First, we set module 0 to clarify the ideal state of ICU for bed occupancy. Second, with regard to the ideal state, we set module 1 to
control the existing patients in ICU. Third, we set modules 2 and 3 as bed availability and bed unavailability (unavailable), respectively,
to control the patients entering ICU.
We developed the processes and contents for these control modules to solve the issues described in Table 2 and to control each
classified patient as described in Table 3. These modules are explained in details in Results.
other hospital
entering control
available
unavailable
ICU
Module3
Module2
Module1
existing control
general
wards
ideal state
Module0
outgoing control
Figure 3- The simplistic bed control flow in ICU
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RESULTS
Figure 4 shows the constructed model as a method for bed control in ICU for quality and safety assurance in healthcare. The explanation
of each module is given below.
Module1: Control of existing patients in ICU
Module0:Control of bed availability
Past state of
ICU beds
Applicability
assessment
Date of
patient
schedule
Module3: Control of incoming patients
in ICU (unavailable)
outside
Date of
patient
attributes
inside
Treatment
capability
Other
hospital
ICU
not
ICU High
cared
general
bed
ICU
“Pushed out”
capability
NG
OK
Entering ICU
Treatment
capability
Other
hospital
NG
Sorting
State
of ICU
ICU
inside and outside
Patients planned
to enter ICU
Patient
Rejection
Applicability
assessment
Date of
ICU
function
outside
Patients unplanned
to enter ICU
NG
Yes
High cared
general
bed
Module2: Control of incoming patients in ICU (available)
Patients unplanned
to enter in ICU
NG
not
ICU
Patients
in ICU
The number of vacant
ICU beds and the state
to beds to save
inside
ICU
Goal state
The capability
of each hospital
Patient
rejection
OK
Suitability
assessment
Entering ICU
NG
not
ICU
High cared
general bed
Applicability
assessment
not
ICU
ICU
Emergency?
No
Yes
High
cared
general
bed
To emergency path
Deciding schedule
Entering ICU
State
of ICU
Figure 4- The constructed model as a method for bed control in ICU
Module 0: control of bed availability
Module 0 analyzes the past state of ICU and clarifies the ideal state of ICU in the hospital by considering the capability of the hospital to
accept patients.
•The beds with the past state:
This is the date of the past state of ICU. It includes the day the patient entered ICU, the period of stay in ICU, etc. By analyzing this
parameter, we can determine the number of available ICU bed to save, for example, 4/1 - save 2 available beds.
•The capability of each hospital:
This includes the medical and human resources available with the hospital in order to accept new entering patients. It determines how to
save the available beds. If the medical staff can transfer the existing patients in ICU to other wards at any time, then the beds occupied by
such patients become available. However, if the medical staff cannot perform such transfer, they must save the unoccupied bed as the
available bed. In other words, this defines the concept of available bed.
Module 1: control of existing patients in ICU
Module 1 controls the patients who currently exist in ICU with no new entering patients, with regard to the determined ideal state in
module 0. Here, we should determine the suitability of patients for ICU admission. Next, we clarified the elements based on the concept
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of bed control (Figure 1), such as the date of patient attributes, the date of ICU bed function, and suitability assessment.
•The date of patient attributes:
On the basis of the concept of bed control, we clarified the items for assessing patients to determine suitability for admission in ICU.
We extracted important requirements for ICU bed control from an earlier study and broke down them into the assessment items, as
shown in Table 4.
Table 4- The assessment items for a patient
Requirements
association
with medical
staff
to treat
association
with medical
equipment to
treat
Patient's needs
Assessment items
severity
severity
fear of worsening of the condition
pace of worsening of the condition
fear of relapse
fear of the risk factor
degree of the major complaint
degree of complication
infection
high
high
high
high
high
high
high
high
expertise of the using equipment
only ICU
prediction
risk factor
major complaint
complication
infection
medical
resources
Evalution
mid
high
prediction of period
mid
mid
mid
mid
mid
mid
low
low
low
low
low
nothing/low
low
low
nothing/low
nothing/low
the day ○～the day ○
•The date of ICU bed function:
On the basis of the concept of bed control, we clarified the items of ICU bed function. In the same manner as described above, we
extracted important requirements for ICU bed control from an earlier study and broke down them into the items of bed function, as
shown in Table 5. This enabled us to define the bed function.
Table 5- The items of the bed function
Requirements
association
with medical
staff
to treat
association
with medical
equipment to treat
Resources
treatment
Function items
expertise of treatment
the frequency of
distance from the workstation of
medical intervention medical staff
required equipment
expertise of using equipments
available state
Evalution
high
near
high
available not available
•Suitability assessment:
By considering the results of assessment (Table 4), we classified the weight of these items and developed a suitability assessment
flowchart to judge whether the patient is suitable for admission to ICU. The outputs are “technical bed,” “inevitable admission,”
“preferable admission (ranks A~E),” and “high cared general bed.” The higher the rank of the patient, the greater was the requirement for
admission in ICU; thus, patient with Rank A has greater requirement for admission in ICU than patients with rank E.
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START
infection
high
technical
bed
low/nothing
having “high”
at least 1?
Yes
inevitable
admission
No
severity is mid
severity is low
pace of worsening mid
of condition
pace of worsening
of condition
low
mid
degree of
complication
A
degree of
complication
low
mid
mid fear to
B
fear to worsening low
of the condition
worsening
of the condition
mid
low
mid
fear of
relapse
C
risk factor,
complaint
are
considered
here
low
Yes
D
Dr indication
other risk
mid
E
fear of
relapse
low
Yes
F
Dr indication
other risk
No
No
preferable
admission
high cared
general bed
low
inevitable
admission
preferable
admission
high cared
general bed
Figure 5- The suitability assessment flowchart
Module 2: control of incoming patients to ICU (available)
Module 2 controls the new entering patients in ICU in the case of bed availability. The case of bed unavailability in module 3 is discussed
later.
Case 1: For patients planned to enter ICU
First, the suitability assessment is performed in the same manner as that in module 1. If the patient requires ICU admission, we judge
whether it is an emergency. If it is an emergency, the patient is treated as an inside unplanned patient. If it is not an emergency, the
schedule to enter ICU is determined by considering the state of ICU.
Case 2: For patients unplanned to enter ICU
First, it is assessed whether the patient can be treated in hospital A. If not, the inpatient is sent to another hospital, and the outpatient is
refused admission to the hospital. If the patient can be treated in hospital A, the suitability assessment is performed in the same manner as
that in module 1.
Module 3: control of incoming patients to ICU (unavailable)
Module 3 controls the new entering patients in ICU in the case of bed unavailability.
Case 1: For patients planned to enter ICU
In the case of these patients, the medical staff can delay the schedule of patients entering ICU. Therefore, there is no process involved in
this case for the staff.
Case 2: For patients unplanned to enter ICU
First, in the same manner as that in module 2, it is assessed whether the patient can be treated in hospital A, and the suitability
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assessment is performed. For outpatients, the staff considers the possibility of “pushed out.” “Pushed out” is to accept the new entering
patient by immediately transferring the existing patient in ICU to other bed in the case of unavailability. This approach has some risk,
which must be considered. If possible or in the case of inpatients, the staff compares the suitability output of each existing patient in ICU
(“inevitable admission,” “preferable admission rank C,” etc.), transfers the least number of existing patients, and accepts new patients.
DISCUSSION AND FUTURE PLANS
In conclusion, in the present study, we developed a method for bed control with a focus on ICU, in particular, those ICUs that employ a
considerable amount of medical and human resources.
The nurses of hospital A were interviewed, and the bed availability was confirmed because there is no general direction for studying bed
control. The rough framework of this model was not very different from the actual criteria, and it is able to deal with issues such as
differences in criteria, bed functions, patients’ needs, and bed unavailability. Further studies are required to include some omitted
elements (deliria, opinion of the family, etc.) to decide bed availability and involve the conceptual framework of a doctor.
In addition, this model did not address some issues. With regard to the prediction of issues, this model is just a framework, and further
studies are required to develop a more accurate analyzing method. With regard to the shortage of resource, the quality and quantity of
nursing care should be evaluated. Evaluation of the amount of work performed by nurses and doctors can enable us to clarify the shortage
of resources in the social world.
This model generally aims to serve as a base for ICU bed control. Nonetheless, we need to separate and recognize the general part and
the customized part for each hospital.
In conclusion, in the future, further studies are required to apply the model in actual clinical situations. Thus, the following points must
be addressed:
•We must refine the suitability assessment of the items and logic of flowchart on the basis of investigation of the actual method of
work.
• We must refine the method and principle in module 0 more finely, i.e., how to analyze and determine.
If the model progresses, then, it has the possibility to apply the unsolved issues of Table 2, “cooperation” and “work”. Moreover, by
combining this model with the model for general beds, we can develop a unified model of the hospital for quality and safety assurance in
healthcare.
REFERENCES
[1]
Health, Labour and Welfare Ministry, (2005): -iryo shisetsu (seitai･doutai) tyosa･ byoinn houkoku no gaikyo-(Medical facilities (static and dynamic)
investigations･General condition of hospital report) (in Japanese), http://www.mhlw.go.jp/toukei/saikin/hw/iryosd/05/index.html
[2]
Japan Association for Medical Informatics･ Nursing departmental Association, (2008, 7): -9th nihon iryo zyoho gakkai kango gakujutsu taikai
ronbunsyu- (Japan Association for Medical Informatics Society･ Nursing Science Society thesis collection) (in Japanese)
ACKNOWLEDGEMENT
This study was supported by a grant from the Japan Ministry of Health, Labor and Welfare (No.19143101）and the Japan Standard
Association.
Special thanks are extended to Ms. Inoue and Ms. Moriyama of the Iizuka Hospital for their invaluable contribution to this study.
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