title: The Association Between Hospital Capacity Strain and Inpatient Outcomes in Highly Developed Countries: A Systematic Review.
abstract: BACKGROUND
  Increases in patient needs can strain hospital resources, which may worsen care quality and outcomes. This systematic literature review sought to understand whether hospital capacity strain is associated with worse health outcomes for hospitalized patients and to evaluate benefits and harms of health system interventions to improve care quality during times of hospital capacity strain.
  
  
  METHODS
  Parallel searches were conducted in MEDLINE, CINAHL, the Cochrane Library, and reference lists from 1999-2015. Two reviewers assessed study eligibility. We included English-language studies describing the association between capacity strain (high census, acuity, turnover, or an indirect measure of strain such as delayed admission) and health outcomes or intermediate outcomes for children and adults hospitalized in highly developed countries. We also included studies of health system interventions to improve care during times of capacity strain. Two reviewers extracted data and assessed risk of bias using the Newcastle-Ottawa Score for observational studies and the Cochrane Collaboration Risk of Bias Assessment Tool for experimental studies.
  
  
  RESULTS
  Of 5,702 potentially relevant studies, we included 44 observational and 8 experimental studies. There was marked heterogeneity in the metrics used to define capacity strain, hospital settings, and overall study quality. Mortality increased during times of capacity strain in 18 of 30 studies and in 9 of 12 studies in intensive care unit settings. No experimental studies were randomized, and none demonstrated an improvement in health outcomes after implementing the intervention. The pediatric literature is very limited; only six observational studies included children. There was insufficient study homogeneity to perform meta-analyses.
  
  
  CONCLUSIONS
  In highly developed countries, hospital capacity strain is associated with increased mortality and worsened health outcomes. Evidence-based solutions to improve outcomes during times of capacity strain are needed.
authors.affiliation: Division of Pediatric Critical Care, Department of Pediatrics, Oregon Health and Science University, 707 SW Gaines St., Portland, OR, 97239, USA. eriksson@ohsu.edu.
authors.forename: Carl O
authors.initials: CO
authors.lastname: Eriksson
authors.affiliation: Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA.
authors.forename: Ryan C
authors.initials: RC
authors.lastname: Stoner
authors.affiliation: Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA.
authors.forename: Karen B
authors.initials: KB
authors.lastname: Eden
authors.affiliation: Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA.
authors.forename: Craig D
authors.initials: CD
authors.lastname: Newgard
authors.affiliation: Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA.|Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA.|Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA.|OHSU-Portland State University School of Public Health, Portland, OR, USA.
authors.forename: Jeanne-Marie
authors.initials: JM
authors.lastname: Guise
mesh_terms: D003441:Crowding; D019049:Developed Countries; D006760:Hospitalization / Q000706:statistics & numerical data*; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data*; D064887:Observational Studies as Topic; D011785:Quality Assurance, Health Care / Q000592:standards
keywords: Hospital medicine; Patient safety; Quality assessment; Systematic reviews; Variations