Percent Bed occupancy rate in a selected specialized tertiary care hospital in Dhaka city

Background and Aims: Providing a necessary care for a sick person outside home 'in hospes or hospital' dates back to nearly 300 century BC. In the present day hospital care facilities has been taken an institutional shape both in public and private sector. A hospital bed is both a scarce and expensive commodity in healthcare. Administrators running hospitals are in a dire need of objective measures and methods for efficient management of their limited financial resources. Bed utilization rates can be of immense help in realistic and effective decision making. The present study was undertaken to explore utilization of bed in a specialized tertiary care hospital in the Dhaka city. Methods: Hospital records of the year were reviewedage, gender, disease profile, duration of hospital stay, outcome of treatment were recorded and bed occupancy rate was calculated. Data were presented as number, percentage and/ or mean SD, as appropriate. The dada were managed by Statistical Package for Social Science (SPSS) for Windows Version 10. Results: The results showed in the year 2001 total number of admissions were 13,305 of which 9953 (74.8%) were male and 3352 (25.2%) female. Average monthly admission was 1109. Maximum number of admissions (1304) was observed in the month of September of that year. Male admission rate was higher than female admission throughout the year. Among all the admission 27.2% were of road traffic accident cases. Among the admitted patients there was 57.3% discharge with advice, 1.9% death, 14.6% discharge on request bond, 12.7% discharge on request. Of all the admission there 12.5% found to be absconded. Bed occupancy rate was 79.75% and average length of stay in the hospital 18.47 days. Conclusions: The present data suggest that (i) in terms of bed occupancy rate the NITOR found to run in optimal capacity which, however, might be attributed to the relative high rate of ascendance and discharges on requests; (ii) average length of stay of patients appeared to be relatively longer and (iii) the management need to look into the issue and take appropriate measures to reduce patients unwanted long duration of stay and make the tertiary care hospital improve the quality of services.


Introduction
Care of a sick person outside home was initially linked to religious place which later has taken the shape organized institution like the preset day over the course of hundred of years 1.However, in early sixties of the past century a definition was suggested by a WHO Expert Committee as 'A hospital is a residential establishment, who provider short term and long term medical care consisting of observational diagnostic therapeutic and rehabilitation' 2. Healthcare is accepted as the basic rights of the citizen to ensure perfect functioning of body and mind 3. Healthcare service in a country spans as primary, secondary and tertiary care level 4. In addition to that there are specialized care centre(s) like cardiac, thoracic and neurosurgery specialties.Healthcare structure in Bangladesh outlined as (i) Home and community level filed workers; (ii) Union level: H and F. W.C/U.S.C-this is the first static health facility; (iii) Thana health complex (THC)-the primary referral hospital; (iv) District Hospital-the secondary referral level hospital (5) Medical College Hospitals and Specialized Institutes-constitutes tertiary referral level hospitals 5.A functional referral system belied to be necessary for obtaining maximum benefit of the healthcare system, which, however, is observed to be lacking so far.
In evaluating the utilization of a hospital its bed occupancy rate is generally calculated.A number of investigators have attempted to work out bed occupancy in different tiers of hospitals of Bangladesh.Wide variations in the rate of bed occupancy in Upozilla (Thana), District and Medical College Hospitals were observed [5,6].The lowest, 50% bed occupancy was observed in the Upozilla hospitals and the highest, 100 percent, in Medical College Hospitals [5,6] .This observation suggested that Medical College Hospitals are extremely burdened in the face of underutilization of primary level hospitals in the Upozillas.Specialized hospitals were understood to serve as the referral centers and help achieve the goal of dealing with special cases.There are five specialized tertiary level of public hospitals in Bangladesh which is 250 to 600 bedded.National institute of Traumatology, Orthopedics and rehabilitation is 500-bed hospital which deals with huge number of patients with orthopedic problems all over the country.The present study was undertaken to evaluate bed occupancy of the NITORE in a year and explore the disease profile it dealt for that particular time.

Materials and Methods
This retrospective descriptive type of study evaluated patients' records of National Institute of Traumatology, Orthopedics and Rehabilitation (NTTOR), Dhaka-1207, for the period of January to December 2001 after obtaining permission from the respective authority.All the hospital admission records were accessed, counted the number and cross checked with hospital records.A total number of 13305 hospital records were reviewed, variables compiled and finally ana-lyzed.Only complete records were considered for evaluation.Variables considered were age, gender, disease profile and duration of hospital stay, outcome of treatment and bed occupancy rate of the hospital.Month wise duration (days) of hospital stay of patients was the aggregate of number of days spent by them during the course of treatment.Bed occupancy rate was calculated as following [7]: Hospital bed occupancy rate = [No of in-patients hospital beds occupied/Average number of hospital beds] x 100

Statistical methods
Data were presented as number, percentage and/ or mean SD.The dada were managed by Statistical Package for Social Science (SPSS) for Windows Version 10.

Results
A total of 13305 patients were admitted from January to December for the year 2011.Month wise total number of admission found to swing around the mean value through out the year.Number of patients admitted during May to November, 2001 were higher than that of the mean.Male admission was higher than female through out the year (Table I).Proportion of admitted male patients were 74.8% (9953 out of 13305) compared to female 25.2% (3352).
Mean SD duration of hospital stay in days was 12801 714.Month wise aggregate days of hospital stay in May to August showed upward trend (Table I).
Mean SD occupancy on the basis of clinical profile was 5.6 5.1.Of the total 79.75 (average) month wise occupancy bony fractures constitute about 47.22%, Club foot and others 7.33%.Patients of road traffic accidents attributed to about 21.69 of total 79.75 occupancy (Table IV).
Month wise bed occupancy of the year 2001 was shown in the table III.Mean ( SD) bed occupancy for the studied year was 79.76 4.26.In the month of May the rate was the highest (84.25%) in the face of lowest in December (72.17).Number of admission and bed occupancy for the year 2001 was explored on the basis profile of the clinical conditions and gender (Table III).
Age wise distribution of admitted patients for the year was shown in table II.It was shown that 46.6% of sthe admitted patients for the year were between age group 25 to 40 year.The proportion of patients for both male and female were almost similar for the three clusters from 25-38 years (Table II).
Number of days occupied by one patient was worked out.Number of discharges were 646 77 in the year 2001 (Table V).Month wise the distribution was found to vary between 569 in December to 772 in August 2001.The distribution was appeared to be normally distributed.Table IV also demonstrated month wise total number of days patients stayed in the hospital bed and yearly mean ( SD) was 12128 709.Monthly distribution of total hospital stay (days) was also normally distributed except relatively lower in April (Figure I).Mean SD number of days a patient in the hospital was 18.66 1.4.The distribution of values was also found to be consistently similar through out the year (Table V).

Outcome of admission of patients in NITOR in
2001 was shown in table VI.Only 57.3% admitted patients discharged with advice after recovery.Proportion of admitted patients were discharged on request bond was 14.6%, discharge on request 12.7% and only 1% was referred to other institutes.It was observed that 12.7% of the admitted cases were absconded (Table VII).
Number of discharge with advice and deaths, total duration (days) of those patients stayed in the hospital and number of days one patient stayed in the hospital were demonstrated in the table VI.Total number (Mean SD) of deaths and discharge was 563 503.Total number of discharges and deaths in male was three times compared to those of female counterpart.
Duration (Mean SD) of total hospital stay for all the clinical conditions was 10396 9286.Mean total duration of hospital stay of male patients was almost three times of the female counterpart.Mean SD duration (days) of hospital stay of one patient was 18.5 0.1 (Table VI).
Percent Bed occupancy rate in a selected specialized tertiary care hospital in Dhaka city

Discussion
A total of 13305 patients were admitted in 2001 of which 9953 were males (74.8%) and 3352 were females (25.2%).Male patients were more than female through out the year.The pattern was compared to a study conducted on a thana health complex (THC) in Abhoynagor 8.The main bulk of admitted patients were the victim of different kind of injuries.The male female ratio of admission was 52.57% and 47.43% respectively 5. The average monthly admission of patients in NITOR for the year 2001 was 1109 patients which appeared to be much higher compared to available data 9,10.In multidisciplinary district hospital average monthly admission was found to be 4850 11.The high rate may be attributed to the fact of focus of the NITOR as a specialized orthopedic hospital and also of the awareness of healthcare seeking population.The male female disproportion may have substantiated the view that men substantially travel more involved in outdoor risky jobs.
Nearly fifty percent of admitted patients were between 25-39 years of age.Interestingly male female proportion of admission in the three age clusters of the range was similar (Table II).Patients from RTA accounted for 27.2% of admission for the studied year.Women in increasing are getting involved in jobs which mean they are also traveling more like that of male counterpart.Substantial number of hospital admission found to be the result of RTA then justifies the nearly similar proportion of male female among the admitted patients for the study period in particular 25-39 years age range .
Bed occupancy rate (%, mean SD) was 79.76 4.26 which is very much within the suggested range, 70%-80%, mentioned in the book of hospital organization and management as an indicator for safe and effective care patients according to DGHs 12.The bed occupancy rate we have observed was much higher than that of the THC (45.09%) 8,12.There is, however, lacking of data regarding bed occupancy rate in any tertiary care hospital in Bangladesh perspectives.A Bangladesh Health Services Report in 1989, based on district hospitals, has shown that percent bed occupancy rate to approaching nearly hundred, however, according to operational definition a reasonable rate is around 80% 9,12,13.Average length of stay of patients in the hospital was 18.5 0.1 (mean SD, Table VI).Hospital bed occupancy rate in different training hospitals in Turkey was found to be around 82-85% and average length of stay from 9-15 from 1990-1999 [14].In different district hospital in Srilanka bed occupancy arte was found to be varying from 25% to 74%.In most of the cases it was between 50-60% 15.In a tertiary care hospital in Goa, India bed occupancy rate in the Orthopedic Ward was found to be 97.4% where average length of stay in the hospital of a patient was 10.1 days 16 which is much higher that the present study.However, percent bed occupancy rate in an orthopedic ward was about 68-76 from 2007 to 2009 [17] that was almost similar to the present study.This strongly suggests that percent bed occupancy rate is ranging around the standard value with other hospitals which however might have contributed by high rate of absconding and cases and discharges on requests.The present data suggest that (i) in terms of bed occupancy rate the NITOR found to run in optimal capacity which, however, might be attributed to the relative high rate of ascendance and discharges on requests; (ii) average length of stay of patients appeared to be relatively longer and (iii) the management need to look into the issue and take appropriate measures to reduce patients unwanted long duration of stay and make the tertiary care hospital improve the quality of services.

Conclusions
The achievement and maintenance of more effective bed utilization meant developing a better balance between beds and demand.Bed occupancy rate and average length of stay were found to be about 80% and 18.5 days average length of stay was not satisfactory, so turn over of the patients is not good and Bed occupancy rate 80%.There should be system of proper supervision, monitoring and evaluation of hospital performance by higher authorities and to determine the problems which in turn should solved for the effective and efficient utilization of hospital beds.