Hospital

• 1. Introduction

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  The word "hospital" once meant a place of hospitality. Its Latin root, hospes, signified a stranger or foreigner, and so a guest. From that same root grew host, hostel, and hotel. For centuries the building that carried this name had little to do with curing the sick. During the Middle Ages, a hospital might be an almshouse for the poor, a hostel for pilgrims, or a school. How did a guest-chamber for travelers become an institution of surgery, intensive care, and X-rays? Who paid for the first ones, and who staffed them before there were professional nurses? And why, in a country like the United States, would the number of these institutions shrink from 6,933 to 5,534 in the space of a few decades? The Royal Hospital Chelsea, established in 1681, still uses the old meaning of the word. It was built not to heal soldiers but to house them in retirement.

• 2. A Taxonomy Of Care

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  The general hospital is the best-known type, also called an acute-care hospital. It handles many kinds of disease and injury and normally keeps an emergency department, sometimes labeled "accident & emergency," to meet immediate threats to health. Some hospitals, especially in the United States and Canada, run their own ambulance service. Larger cities may hold several hospitals of varying sizes. A district hospital is typically the major health care facility in its region, carrying large numbers of beds for intensive care, critical care, and long-term care. In California the term means something more specific. There it names a class of facility created shortly after World War II to address a shortage of hospital beds in local communities. District hospitals remain the sole public hospitals in 19 of California's counties. They are formed by local municipalities and governed by boards elected by those communities. In 2012, California's district hospitals provided $54 million in uncompensated care. A specialty hospital is dedicated to one or a few related medical specialties. Subtypes include rehabilitation hospitals, children's hospitals, geriatric hospitals, and psychiatric hospitals. In Germany such a facility is called a Fachkrankenhaus, with Fachkrankenhaus Coswig, a thoracic surgery center, as one example. In India they are known as super-specialty hospitals, set apart from multispecialty hospitals that combine several fields. A clinic, smaller than a hospital, generally provides only outpatient services, though some keep a few inpatient beds. The line between the two rests on one ability: a hospital can admit and care for inpatients overnight.

• 3. The Economics Of Specializing

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  Narayana Health's cardiac unit in Bangalore shows how focus can cut cost. It holds 3,000 beds and performs 3,000 pediatric cardiac operations every year, the largest number in the world for such a facility. Its surgeons are paid a fixed salary rather than a fee per operation. So as the volume of procedures climbs, the hospital captures economies of scale and lowers its cost per procedure. Each specialist also grows more efficient by repeating a single procedure, much like a production line. Hospitals are classified as general, specialty, or government depending on their sources of income. Modern ones draw funding from private payment, health insurance, public expenditure, and charitable donation. In the United Kingdom, the National Health Service, founded in 1948, delivers care to legal residents free at the point of delivery, with emergency care free to anyone regardless of nationality. Limited resources push such systems toward waiting lists for non-crucial treatment, which sends those who can afford it toward private care for faster access. In the United States, hospitals typically operate privately and sometimes on a for-profit basis, as with HCA Healthcare. Prices are billed through a chargemaster, and may fall lower within healthcare networks. Law requires hospitals to treat patients in life-threatening emergencies regardless of ability to pay. Privately funded hospitals that admit uninsured emergency patients absorb direct financial losses, as seen in the aftermath of Hurricane Katrina.

• 4. From Almshouse To Laboratory

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  In early India, Fa Xian, a Chinese Buddhist monk who traveled the country around AD 400, recorded healing institutions. The Mahavamsa, a sixth-century chronicle of Sinhalese royalty, credits King Pandukabhaya of Sri Lanka, who reigned from 437 to 367 BC, with lying-in-homes and hospitals called Sivikasotthi-Sala. A hospital and medical training center stood at Gundeshapur, a city of the Sassanid Persian Empire founded in AD 271 by Shapur I. In ancient Greece, temples to the healer-god Asclepius served as centers of medical advice and healing, and they spread into the Roman Empire. Rome itself had no public healthcare, but military hospitals called valetudinaria served soldiers and slaves within the forts. After the First Council of Nicaea in AD 325, construction of a hospital in every cathedral town began. Among the earliest were one by Saint Sampson in Constantinople and another by Basil, bishop of Caesarea. By the twelfth century Constantinople held two well-organized hospitals, staffed by doctors who were both male and female, with specialized wards for different diseases. The earliest general hospital in the Islamic world rose in Baghdad in 805 under Harun Al-Rashid. By the end of the 15th century Córdoba alone had 50 major hospitals. The Islamic bimaristan treated the poor, required medical licenses for doctors, and was forbidden by law to turn away patients who could not pay. These hospitals were funded by waqfs and state money. In England, the dissolution of the monasteries in 1540 by King Henry VIII abruptly ended the church's support of hospitals. Only by direct petition from the citizens of London were St Bartholomew's, St Thomas's, and St Mary of Bethlehem's, known as Bedlam, endowed by the Crown. This was the first instance of secular support for medical institutions. The voluntary hospital movement followed in the early 18th century, with Westminster Hospital founded in 1719 and Guy's Hospital in 1724, the latter from the bequest of the merchant Thomas Guy. When the Vienna General Hospital opened in 1784 as the world's largest, it gradually became one of the most important research centers.

• 5. Designing For Recovery

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  The Royal Naval Hospital at Stonehouse, Plymouth, pioneered a design using "pavilions" to slow the spread of infection. John Wesley visited in 1785 and wrote, "I never saw anything of the kind so complete; every part is so convenient, and so admirably neat. But there is nothing superfluous, and nothing purely ornamented, either within or without." In 1787 the French government sent two scholar administrators, Coulomb and Tenon, who had toured most of Europe's hospitals. They were impressed, and the pavilion design spread across France and the continent. Dutch architectural historian Cor Wagenaar has been blunt about how far the result strayed. He called many hospitals "built catastrophes, anonymous institutional complexes run by vast bureaucracies, and totally unfit for the purpose they have been designed for." Many modern hospitals, he notes, are the product of continual and often badly managed growth over decades, with utilitarian sections bolted on as finances dictate. Instead of making patients feel at home, he argues, they produce stress and anxiety. Research by the British Medical Association points the other way. Good hospital design can shorten a patient's recovery time. Exposure to daylight reduces depression, and single-sex accommodation protects privacy and dignity. Looking out a window onto nature or a hospital garden lifts mood and lowers blood pressure. Open windows in patient rooms have shown beneficial outcomes through better airflow and increased microbial diversity. These ideas reach back to the late eighteenth century, when architects first employed fresh air and the healing powers of nature, an inheritance now driving the shift from communal wards to individual rooms.

• 6. The Modern Reckoning

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  In the United States, hospitalizations peaked in 1981 at 171 admissions per 1,000 Americans, served by 6,933 hospitals. The rate then fell by more than 10 percent, and the count of hospitals dropped to 5,534 by 2016. Occupancy rates slid from 77 percent in 1980 to 60 percent in 2013. More complex care became available at home or in physicians' offices, and the public increasingly saw hospitals as life-threatening rather than therapeutic. In 2013 the Centers for Medicare & Medicaid Services introduced a "two-midnight" rule for inpatient admissions, then dropped it in 2018. Microhospitals, holding between eight and fifty beds, are now expanding across the country. The World Health Organization reported in 2011 that being admitted to a hospital was far riskier than flying. Globally, a patient's chance of suffering a treatment error was about 10 percent, and the chance of death from an error about one in 300. In developed countries 7 percent of hospitalized patients acquire at least one health care-associated infection, rising to 10 percent in developing countries. In the United States, 1.7 million such infections are acquired each year, leading to 100,000 deaths, worse than Europe's 4.5 million infections and 37,000 deaths. In England, the Care Quality Commission turned its attention to hospital food in 2020 after seven patient deaths from listeria linked to pre-packaged sandwiches and salads in 2019. The COVID-19 pandemic pushed hospitals out of their own walls. Across the British NHS, virtual wards let patients be managed at home, monitoring their own oxygen with a saturation probe and supported by telephone. West Hertfordshire Hospitals NHS Trust managed around 1,200 patients at home between March and June 2020 and planned to keep the system for respiratory patients. Mersey Care NHS Foundation Trust began a COVID Oximetry@Home service in April 2020, monitoring more than 5,000 patients a day in their homes. The Catholic Church remains the largest non-government provider of health care in the world, running about 5,500 hospitals, 65 percent of them in developing countries, and by its own 2010 count managing 26 percent of the world's health care facilities.