Hospital indicators after implementation of bed regulation strategies: an integrative review

Objectives: to analyze the scientific evidence available in literature on hospital indicators after implementation of bed regulation strategies. Methods: this is an integrative review conducted with studies available in five databases and in the reference database of the Center for Study and Research in Nursing Services Management in October 2019. Articles on hospital bed management, available in full in English, Spanish or Portuguese, without temporal delimitation were included. Results: 1,118 eligible articles were found, of which 37 were duplicated. Among 1,081 pre-selected studies, 112 studies were eligible and 11 articles were included. Six studies addressed the emergency services. Three addressed hospital indicators in general, another focused on a psychiatric ward and one analyzed the indicators of two hospitals administered differently. Conclusions: the studies focused on emergency services, demonstrating the importance of organizing these services for health institutions.


INTRODUCTION
Demand for health care in hospital services increases exponentially; however, the same is not the case with availability of resources. This causes hospital managers to have to work with rationalization of resources to assist the population (1)(2) .
Faced with the high demand for health services, there is insufficiency of hospital beds, culminating in delay in admission of patients in the emergency room, cancellation of elective surgeries, inappropriate use of beds and failure to flow transfers between care units, causing repercussion in intensive care units (ICUs) (2)(3) .
These problems contribute to increased hospital stay, decreased bed turnover, as well as the number of surgical procedures, among others, which may compromise the quality of health care (4) .
Health care institutions have invested in implementing patient flow management systems, which allow demand to be taken care of through the addition of capacity, increasing the efficiency in the use of hospital beds, reducing the waiting time for hospitalization and optimizing surgical scheduling (1) . In this regard, it is noteworthy that implementing these systems contributes to monitoring and planning hospital occupation, enabling the optimization of admission processes up to discharge (3,5) .
In Brazil, the Ministry of Health published two Ordinances to manage the high demand for health care. The first is Ordinance 1,663/2012, which provides for the SOS Emergencies Program, proposing strategies for organizing emergency services, with the objective of making assistance more agile and effective. In this Ordinance, the Internal Bed Regulation Committee (NIR -Núcleo Interno de Regulação de leitos) is presented as a management tool for the organization of emergency services (6)(7) .
On the other hand, Ordinance 3,390/2013 provides for the Brazilian National Hospital Care Policy (PNHOSP -Política Nacional de Atenção Hospitalar), which organizes the Health Care Network (RAS -Rede de Atenção à Saúde) that mentions NIR as a service responsible for institutional coordination, which should manage hospital beds centrally, and act with an interface between institution and corresponding Regulatory Centers (7) .
Still in this context of tools and strategies for reorganization of services, the system designated as bed management emerges, which is an important part of planning operational capacity, controlling and efficient using resources. This system allows the accommodation of patients from emergency services without compromising the assistance to elective demand (2)(3) . This management organizes the allocation of new admissions to vacant beds based on real-time knowledge of the hospital census and the demands for hospitalization. Additionally, it allows assessing and carrying out actions that optimize the entire hospitalization process until hospital discharge (8) .
These strategies proposed by the Ordinances and management tools aim to improve the planning and control between bed supply and demand, allowing the maintenance of the viable occupancy rate for the use (3,8) and provision of assistance to the population without increasing human and structural resources.

OBJECTIVES
To analyze the scientific evidence available in literature on hospital indicators after implementation of bed regulation strategies.

Ethical aspects
Considering that this study is an integrative review without involvement of human beings, there is no need for approval by a Research Ethics Committee.

Study design
This is an integrative review, in which there is meeting, assessment, and synthesis of research results on a given theme.

Methodological framework and steps
To carry out this research, the following steps were taken: review protocol preparation, primary study search, data extraction, assessment of included articles, interpretation of results, and review presentation (9) .
To formulate the research question, PICO strategy (acronym for patient, intervention, comparison, outcomes) was used. The research question was: what scientific evidence is available in literature on hospital indicators related to the implementation of a service or bed regulation strategies? For the first item of the strategy, P stands for indicators; I represents service and bed regulation strategies. The two other elements of the strategy, C and O, were not used, considering that no comparison was defined nor the desired result.
Articles addressing the theme in hospital bed management, available in English, Portuguese or Spanish and available in full were included. Gray literature, secondary studies, literature review and tertiary studies were excluded from the study, and there was no temporal delimitation due to the scarcity of studies.
Study which were: quality indicators health care, health information management, bed occupancy, hospital administration, organization and administration, benchmarking. The keywords used in these searches were: global trigger tool healthcare, healthcare global trigger tool, quality indicators healthcare, administration hospital, hospital organization and administration, organization and administration hospital, benchmark, benchmarking Health Care, department of bed occupancy, access to health services, regulation and supervision of health. In addition to the controlled descriptors, the term "bed management" was used in all studies. Chart 1 shows the search strategies performed in the databases.
To assess the level of scientific evidence of all studies, we used the type of study informed by the authors of the studies included in the sample and the concept of classification into seven levels was used: level 1 -systematic review or meta-analysis of randomized clinical trials; level 2 -well-delineated randomized clinical trials; level 3 -well-delineated clinical trials without randomisation; level 4 -well-delineated cohort and case-control studies; level 5 -systematic review of descriptive and qualitative studies; level 6 -descriptive or qualitative study; level 7-evidence from the opinion of experts (10) .
Analysis of results was performed descriptively, presenting the synthesis of each study, highlighting the authors, database, level of evidence, objectives, indicators and the main results of the studies included in this review.

RESULTS
In the first phase of analysis, after reading all titles and abstracts (n=1,118), 37 were excluded because they were duplicated in the MEDLINE and WOS databases, another 969 because they were not related to the chosen theme (n=921), 29 case studies and 19 studies. In the second analysis, by reading the full article (n=112), 101 studies were excluded, of which 85 did not answer the research question and 16 were not found in full.
As for the 16 studies not available in full, it is noteworthy that the researchers sought them through the Federated Academic Community (CAFe -Comunidade Acadêmica Federada) of three educational institutions and also through Bibliographic Commutation (COMUT -Comutação Bibliográfica), and the studies were excluded only after not succeeding in these attempts.
Chart 2 below presents the main findings of studies included in this review.
It was found that the studies included in this review focused on bed regulation strategies, as well as on improving the quality and efficiency of services, especially beds. All studies showed evidence level 6 (3.11-20) .
As for the type of institutions, it was found that most were public (n=6) (3,13,16,(18)(19)(20) , three others also had the university character (14)(15)17) , one study included public and private hospitals (12) and another did not specify the character of the institution (11) .    Demonstrating the results of the implementation of a project to reduce length of stay and occupancy rates of the Leadenhall ward.
Average length of stay, occupancy rate, number of beds occupied per day, number of admissions per week and readmission rate in 28 days.
In the first year, the average length of stay decreased from 47 to 30 days. The occupancy rate went from 77% to 55%. The number of admissions did not change, but the number of occupied beds decreased due to the reduction of the average length of stay and stable admission and readmission rates.
SAJADI et al. (12)  Assessing the impact of a streaming model, previously validated in metropolitan emergency services, on selected performance indicators in a regional emergency service.
Percentage of emergency patients admitted to an inpatient bed within 8 h of emergency patients not admitted with a length of stay of less than 4 hours of emergency patients who left without being seen by a doctor or nurse.
After 12 months the streaming was implemented, there was a 9% increase in emergency care. Approximately 47% of the visits were allocated to the gold stream (complex treatment), while 53% were allocated in the blue stream (less complex treatment). After the intervention (streaming), the service in less than 8 hours increased on average 0.30% per month, representing a net reversal in the trend of 0.62% per month (p=0.008). After the intervention, the upward trend in 4 hours was reversed, increasing on average 0.20% per month, representing a net reversal in the trend of 0.54% per month (p=0.004). There was no significant trend in the indicator "not waiting for care" of the doctor or the nursing team after the intervention.

DISCUSSION
A health system, like any other system in society, constantly changes, and may have its stability threatened. Therefore, it is necessary to make adjustments and improvements concomitantly. It is in this sense that tools, programs and services that reorganize care flow in health institutions emerge in order to organize and improve the quality of care and the overall result (12) .
These strategies are presented as an alternative to meet the high demand in the face of insufficient resources in most hospital institutions (1) . From the Brazilian perspective, they are presented as a measure to overcome the reduction in the number of beds, considering that between 2008 and 2013 the Unified Health System (Sistema Único de Saúde) presented 11,938 fewer hospital beds (21) . However, they are also related to the use of the maximum capacity of available resources, considering that the inefficient use of beds impacts hospital revenue (22) .
Maximum capacity is not only related to the number of beds available, but to the ability to manage them regarding the admission, treatment and discharge of adequate patients (23) .
Five Australian studies included in this review specifically address regulatory strategies in the emergency service (13,(15)(16)(19)(20) , demonstrating the relevance of this theme in the country. The first Australian survey included in this review addressed ESEP, introduced in 1995, with the aim of contributing to improving the delivery of care, infrastructure and bed management in Victoria state emergency services. It addressed the team's perception of the changes in the indicators after the implementation of ESEP, demonstrating that, in general, the strategy presented positive results regarding waiting time, access to beds and potential factors of change (20) .
It is observed that in Australia the emergency service is an important focus of study and attention of health institutions, because it is known that overcrowding and inadequate patient flow are able to delay care, contributing to exposure to avoidable risks (16) . In 2000, another strategy appears in the Australian literature, the Victorian Patient Management Task Force, which addressed the flows of Victoria's metropolitan hospitals in general, discussing above all the emergency services (24) . Then, at Bendigo Health, the streaming model appears, which replaced the traditional emergency service risk classification system and was the focus of the study conducted by Kismann et al. (19) . In this study, the authors found that the percentage of patients who required hospitalization and were referred to a bed in less than 8 hours increased as well as the percentage of patients who were seen within 4 hours and were discharged (19) .
Subsequently, in 2012, NEAT, another strategy established in hospitals, aimed at organizing care and improving hospital indicators related to emergency services (16) . Sullivan et al. (16) described NEAT development and implementation processes in a Brisbane tertiary hospital; in addition, it assessed the effects of this reform on patient flow and indicators. In another Australian study, the authors implemented an emergency service care prediction tool called PAPT, which was used in two hospitals with distinct capabilities and served as a decision-making tool for bed management, initially for the two institutions in the study and subsequently made available to all 31 public hospitals in Queensland that use the Emergency Department Information System (15) .
The Australian institution Canberra and Health Services (CHS), after the introduction of NEAT, developed a hospital intervention supported by management to improve emergency service quality indicators (13) . In this regard, it is observed that Australia has implemented strategies in emergency services, in order to organize patient care flow and improve quality of care.
In Brazil, care flow organization and improvement of quality of care in emergency services began with the Reception with Risk Stratification, contemplated in the HumanizaSUS policy of the Ministry of Health. This strategy was implemented to classify patients who needed emergency care according to their risk or degree of suffering, organizing the queues of this service, usually overcrowded, ensuring that the most urgent cases do not get worse in the queue due to lack of adequate care (25) . Changes after the introduction of the ESEP: ambulance diversion rates, emergency waiting time, access to the bed, perceived general change and factors that aid or delay change.
One hundred one employees participated in focus groups. Participants noticed an improvement of 20% in waiting times and 0.5% in access to the bed. In statistical analysis of real changes in access to the bed, there was a tendency for improvement; however, it did not show statistical significance. Most respondents (43%) reported that there was improvement over the 3 years with ESEP. The factors cited as capable of bringing improvements were changes in the profile team, managing patient flow through the emergency service, changes in administrative policies, changes in work practices and changes in the number of employees. There was considerable disparity between the perceptions of managers and employees of the emergency service as well as the hospital type in relation to the change and the perceived contribution of ESEP. 8 of Hospital indicators after implementation of bed regulation strategies: an integrative review Maldonado RN, Savio RO, Feijó VBER, Aroni P, Rossaneis MA, Haddad MCFL.
Also on specific developed strategies in the emergency sector, in Saudi Arabia, the King Faisal Specialist Hospital and Research Center Saudi Arabi, together with the departments of informatics, emergency and information technology, conducted a training program for emergency service nurses regarding accessibility to information related to patient length of stay, which demonstrates a variety of measures and/or strategies with a common objective of improving care and hospital indicators (14) .
Studies that addressed hospital bed regulation strategies in general (3,(11)(12)18) presented basically the same indicators: length of stay, number of patients or care, occupancy rate.
Care flow organization in Brazil was initiated in emergency services and expanded through PNHOSP, in which RAS were organized and NIR was defined (7) .
Subsequently, the publication of the manual of implementation and implementation of NIR by the Ministry (26) clarified the role of the service in hospital institutions, highlighting the three pillars of action: regulation practice, articulation with RAS and monitoring of indicators. Furthermore, it addressed the human resource necessary for the activities.
Although there are public policies and strategies regarding organization of care and regulation of beds implemented in Brazil, many studies that specifically addressed this theme were not found. This scarcity of research makes it difficult to compare indicators between institutions with similar profiles, especially not demonstrating the effectiveness of implementing NIR.
In Iran, since 2013, a new reform has been initiated in the country's health system, called HTP, which includes several programs interventions in primary and hospital care SAJADI et al. (12) . This plan, in relation to hospital care, developed seven programs, aiming to increase access to the health service. Among these actions were the reduction of hospital costs, availability of professionals and specialized care, improvement of hospitality, incentive to natural delivery, financial support to patients most in need and improvement of the quality of outpatient care (27) . A first study that assesses the effectiveness, efficiency and productivity of this plan showed that the turnover rate, average length of stay and occupancy rate improved, which may be related to the improvement of hospital efficiency after implementing HCTP. However, the authors stated that this was not an objective of the plan, but it was a finding that should not be ignored and deserves more detailed studies (12) .
HTP began in 2003 in Turkey and emerged as a reorganization of the country's health system, culminating in an agreement of a global budget for all hospitals of the Ministry of Health. Moreover, later, the Social Security Institution (SSI) developed aggregate values for inpatients and outpatient services through a coding system. This program was successful, especially in relation to increased productivity due to advances in technology and technical efficiency; however, in socially and economically disadvantaged institutions, there was no improvement in productivity (18) .
It was found that all strategies and programs (3,(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) presented in the studies included in this review presented positive results in part of the indicators addressed. Among the indicators that showed improvement, we highlight length of stay, occupancy rate, mortality rate, and length of care.

Study limitations
In addition to limiting the number of studies on the subject, it was observed that the level of evidence of these studies is low, demonstrating the need for research with methods of level of scientific evidence considered higher. Another limitation was the inclusion of a Brazilian study not located in the selected databases, which was part of the reference database organized by NEPGESE, demonstrating the scarcity of national studies.

Contributions to nursing, health, and public policies
Although most studies assess the indicators mentioned above, it is noteworthy that health institutions present numerous others that could be analyzed, allowing the expansion of service assessment.

CONCLUSIONS
This integrative review showed that strategies and/or services related to bed regulation are more frequently related to emergency services. However, there was a scarcity of literature on the subject, especially at the national level, considering that most of the articles in this review are international, mainly from Australia.
Despite the scarcity of national studies on the subject, it is believed that this is not related to specific national problems or characteristics, considering that Brazil has a public health system presenting a large number of public health institutions as well as the hospitals presented in the studies of this review. Furthermore, the country presents several programs aimed at organizing care flow and improving hospital indicators. Therefore, it is believed that Brazilian institutions are developing strategies and services on the subject, however, they are not described in the literature.