Empty pediatric units force flexibility Pressure from insurers, medical changes lower child-patient counts

July 07, 1996|By M. William Salganik | M. William Salganik,SUN STAFF

Most days, Shannon Stevens, a nurse at St. Joseph Hospital in Towson, works in the pediatric unit. But some days, there are not enough pediatric patients to keep the three nurses on her shift busy, and she gets moved to the newborn intensive care unit. (The hospital gave her extra training so she could work there.) And, sometimes, "When the census drops, we'll take turns taking time off," she says.

St. Joseph is typical of Maryland's community hospitals in finding itself many days with single-digit patient counts in its pediatric unit. The number and length of pediatric hospitalizations is continuing to drop, under pressure from managed-care insurers and as a result of advances in such areas as immunizations and home health care.

On an average day, about two-thirds of Maryland's licensed pediatric beds are empty. And while legislators and regulators fret over the costs of excess capacity in adult units -- where about three in eight beds are empty -- there has been less attention to pediatrics, in part because pediatric cases account for only about 5 percent of Maryland's hospital admissions.

The problem of empty pediatric beds is greatest in the community hospitals. In Maryland and nationally, as the simpler cases are cared for on an outpatient basis and only the more complex cases are leading to hospital admissions, pediatric patients are more likely to go to academic medical centers and specialized children's hospitals.

St. Joseph, licensed for 35 pediatric beds, had 5.6 patients on an average day in the first six months of 1995, the period covered by the most recent report from the state's health planning agency. Average pediatric patient counts for other community hospitals are similar: St. Agnes in Baltimore, 7.8 (37 licensed beds); Anne Arundel Medical Center in Annapolis, 5.2 (25 beds); Harford Memorial in Havre de Grace, 2.7 (26 beds); Franklin Square in Baltimore County, 8.4 (29 beds).

The low patient counts are raising questions of quality and efficiency nationally. And while neither quality nor cost has been a hot issue in Maryland, it is clear that the hospitals are scrambling to keep staffing levels adequate.

"It requires a lot of flexibility on the part of the nursing staff," says Dr. Michael Burke, chairman of pediatrics at St. Agnes. "The census can go from three or four to 10 or 12 in 24 hours. In the winter, we can have 20 patients, and it can go down to five or six a few days later."

In addition to cross-training nurses so they can work as needed in different pediatric areas, hospitals need "a pool of staff not committed to regular hours," says Karen Reichert, director of maternal-child nursing at St. Agnes. This may mean paying some nurses to be "on call," but gives the hospital a chance to "flex up" its staffing when it has more patients.

This can add to costs. St. Agnes, St. Joseph and GBMC have above-average daily room charges for pediatrics compared to other Maryland urban and suburban hospitals, but they have below-average daily charges for adult medical/surgical stays.

On the other hand, the academic medical centers, Johns Hopkins and University of Maryland, are the highest cost hospitals for adults, but have below-average daily room rates in pediatrics. The two maintain the largest pediatrics units and highest pediatric occupancy rates in the state. (Under Maryland's state rate-setting regulations, charges are based on costs in each area. While pediatrics can be a money-loser at hospitals in other states, it is generally a break-even proposition in Maryland.)

Nationally, some experts worry about whether hospitals caring for so few children at a time can provide enough services oriented to young patients. "The real question in my mind is: Can they provide quality care?" says Lawrence W. McAndrews, president of the National Association of Children's Hospitals and Related Institutions.

"When children are really sick," McAndrews asks, "are you doing them a service by putting them in a unit that may have only two or three or four patients?"

These concerns, so far, have prompted "a fair amount of talk and not a heck of a lot of action," says Dr. James Shira, chairman of the Committee on Hospital Care of the American Academy of Pediatrics. Shira, who is a professor of pediatrics at the University of Colorado School of Medicine, said his committee has been studying the issue but has yet to issue recommendations.

In Maryland, there is no push to close the smaller pediatric units.

"There was a debate 10 or 15 or 20 years ago, and some hospitals eliminated their pediatric units entirely," says Calvin Pierson, president of the Maryland Hospital Association. "Now, there's been some reversal; hospitals are saying they need to have comprehensive services for the community. There's not much talk lately about closing units."

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