Background: Prior studies have described the negative collateral effects of a hospital’s closure on the efficiency, access, and quality of care delivered at nearby hospitals that bear the brunt of care transfers and patient dispersion. However, few studies have addressed quality at the institution that is closing, as it is closing, and when the closure period is prolonged.
Purpose: We share preliminary observations on the impact of a prolonged hospital closure on inpatient quality and efficiency of care.
Description: In late 2023, our health system implemented a ten-month closure plan for our then 230 bed academic institution, with a final date of operations target in July 2024. A careful choreography of floor closures, diversion of specialty lines, ancillary services, and medical and surgical specialists ensued, including attrition of long-term staff. On July 1, 2024, all trainees (residents and fellows) departed the campus. However, due to complexities of the closure process and external complications, the hospital remained open and continued to operate with an average of 55 occupied hospital medicine/critical care beds. As a result, the hospital medicine division transitioned from an academic care delivery model that included 120 internal medicine residents to one that combined direct care with locum tenens advanced practice practitioner (APP) paired shifts. We took ownership of leading rapid response events and provided care as on-site consultant availability decreased. A robust transfer process within the health system for ED, floor, or ICU patients in need specialty or care escalation was employed. While the hospitalist group remained intact, the ED, ICU and nursing departments were soon mostly staffed with locum tenens, per diem, and moonlighting providers. Given the magnitude of these changes, it was prudent to investigate the impact on quality and care efficiency. Preliminary data suggest that despite the changes, the unadjusted rates for the available metrics of mortality, LOS, and excess days improved [table 1]. Hospital-acquired infection (CAUTI, CLABSI, CDI) rates also improved. While the impact of a steadfast group of experienced hospitalists on quality and throughput cannot be underestimated, a decline in average case mix index by 0.2 from 2023 and a reduction in census likely contributed. However, without risk-adjusted data, the extent of these improvements remains unclear. Comparing available data from Q3-Q4 2024 to similar time periods in 2023 and 2022, the transition to a direct care /APP model did not appear to affect the patient experience domain of ‘doctor communication’ [figure 1]. We postulate that the lower census and care delivery model changes facilitated bedside time with patients and families and streamlined communication. Top box scores for the HCAHPS domain of teamwork (‘staff worked together’) fluctuated while ‘hospital rating’ and ‘willingness to recommend hospital’ scores experienced a downward trend.
Conclusions: The effect of a hospital’s closure on its real-time quality metrics is not often discussed. Based on available unadjusted risk data, we share preliminary observations that an institution can potentially undergo a drastic transformation to its staffing and care delivery without sacrificing quality, efficiency or patient experience. A protective factor may be a carefully maintained core of experienced hospitalists who are already adept at navigating care within the health system.
