HOSPITAL AND HEALTH DEPARTMENT FACILITIES AND NEEDS IN TENNESSEE TENNESSEE DEPARTMENT OF PUBLIC HEALTH NASHVILLE. TENNESSEE 1948 HOSPITAL AND HEALTH DEPARTMENT FACILITIES AND NEEDS IN TENNESSEE TENNESSEE DEPARTMENT OF PUBLIC HEALTH NASHVILLE. TENNESSEE 19 48 FOREWORD Early In 1945 the Tennessee Department of Public Health realized that federal funds might be made available In the near future for hospital construc- tion. The Commission on Hospital Care, a non-government public service commit- tee to study hospital service In the United States, had been established In 1944 by the American Hospital Association. This Commission had conducted a pilot study In Michigan for the purpose of developing forms and procedures Suitable for use In other states. The work of this group was known and their advice was obtained In developing plans for a survey of existing facilities In Tennessee, a necessary step In planning for hospital construction. After consultation with Governor Jim McCord the State Department of Public Health was designated by executive order as the State Agenay to make or have made a hospital survey for Tennessee. A contract was made with the Tennessee Ho.spltal Association, Incorporated, for a detailed survey of hospital facili- ties within the state utilizing the forms known as Hospital Schedules of In- formation and Public Health Department Facilities Schedules of Information prepared by the Commission on Hospital Care of the American Hospital Associa- tion. A Survey Committee of the Tennessee Hospital Association was appointed with the following persons serving on the committee: T. H. Haynes, Knoxville, Chairman C. E. Thompson, Memphis H. H. Miller, Nashville H. G. Ramsey, Memphis Mr. w. N. Walters was appointed director of the survey and a staff was obtained to assist In the conduct of the survey. Mrs. Ruth Ray rendered sta- tistical assistance In collection and assembly of data. The survey was started In November, 1945 and was completed July 1, 1946. The completed schedules of Information regarding hospitals and health facilities were sent to the Commission on Hospital Care for processing. Tabu- lations of hospital schedule data were prepared and returned to Tennessee In September, 1946 for use In the report of hospital facilities. The Director of Statistical Service of the Tennessee Department of Public Health, Dr. Ruth R. Puffer, served as a consultant throughout the survey and was given the responsibility for analysis of the data and preparation of the material for publication. Tennessee Public Acts of 1947, Chapter 16, authorized the establishment of the Division of Hospital Survey and Construction In the Tennessee Department of Public Health. This division was created and Dr, C. C. Demmer was appointed director of the division on February 10, 1947. He has taken charge of this program and has developed an- Integrated plan for construction of hospital and health department facilities. The Public Acts of 1947 also authorized the appointment of an Advisory Hospital Committee to advise and consult with the Department of Health In carrying out the administration of this Act. The mem- bers of this committee are given on page v. The first four chapters of this report were released prior to the first meeting of the Advisory Hospital Committee on September 4, 1947. The plan for development of hospitals and health department facilities as given In Chapter V was presented to the Committee on that date. This report of Hospitals and Health Department Facilities and Heeds in Tennessee received the approval of the Advisory Committee. This report provides the basic data used In developing the present plan for hospital and health department facilities. It Is realized that changes will need to be made from time to time In developing these services for the population of Tennessee. Annual revisions of the plan will be made to take account of changing conditions. The contributions of the many agencies and Individuals Involved In the survey, in processing and analyzing data and In the preparation of the plan, are acknowledged. It Is believed that an outstanding step has been taken for the development of hospital and health department facilities for the population of Tennessee. ROBERT H. HUTCHESON Chairman, Advlsory HospItal Committee Commissioner, Tennessee Department of Public Health November 1, 1947 MEMBERS OF ADVISORY HOSPITAL COMMITTEE R. H. Hutcheson, M.D. , Commissioner, Tennessee Department of Public Health, Nashville, Chai man Sam Breeding, representing Agriculture, Sparta C. E. Brehm, Acting president, university of Tennessee, Knoxville 0. N. Bryan, M.D. , Member, Tennessee public Health Council, Nashville John C. Burch, M.D., representing State Medical Association, Nashville Roy C. Coleson, representing Tennessee press Association, Somerville Nat C. Copenhaver, M.D., Vice-Chairman, Tennessee Public Health Council, Bristol Charles L. Cornelius, representing the Tennessee Bar Association, Nashville Roy 0. Elam, D.D.S., representing the Tennessee Dental Association, Nashville H. J. Foltz, Mayor of Humboldt, representing Tennessee Municipal League, Humboldt T. H. Haynes, representing Tennessee Hospital Association, Knoxville Tom Hitch, representing Agriculture, Maryville 0. W. Hyman, Ph.D., Dean of Administration, University of Tennessee School of Medicine, Memphis Granbery Jackson, Jr., representing the American Institute of Architects, Nashville W. E. Jacobs, Sr., Commissioner, Tennessee Department of Labor, Nashville Maxey Jarman, President, General Shoe Corporation, representing Manufacturers' Associa- tion, Nashville Hayden B. Johnson, Executive Director, Tennessee State planning Commission, Nashville Gilbert King, representing Pharmacy, Chattanooga Mrs. w. W. McCallum, representing the Parent-Teacher Association, Henderson Henry h. Miller, representing the Tennessee Hospital Association, Nashville L. F. Mitchell, Ph.G., Secretary, Tennessee public Health Council, Nashville Oren A. Oliver, D.D.S., Chairman, Tennessee Public Health Council, Nashville Mrs. Ferdinand Powell, Member, Tennessee public Health Council, Johnson City T. R. Ray, M.D., Member, Tennessee public Health Council, Shelbyvllle George D. Roberts, Blount County judge, representing Tennessee County judges' tlon, Maryville 0 • , W. L. Rucks, M.D., Member, Public Health Council, Memphis Lee Sanders, President, Nashville Trades and Labor Council, Nashville William A. Shoaf, Commissioner, Tennessee Department of Public Welfare, Nashville J. M. Smith, President, State College, Memphis J. R. Thompson, Jr., M.D. , Member, Tennessee public Health Council, Jackson R. B. Wood, M. D. , Member, Tennessee Public Health Council, jcnoxvllle Nina E. Wootton, R. N., representing Tennessee Nurses Association, Nashville CONTENTS , Page I. SURVEY OF HOSPITAL FACILITIES IN TENNESSEE ' 1 A. Hospitals and Hospital beds According to Type of Service and Size 2 B. Distribution of Hospitals In Tennessee 3 C. ownership of Hospitals 8 D. Patient Services 8 E. Hospital Expense •. 12 F. Hospital Personnel 13 II. SURVEY OF HEALTH DEPARTMENT FACILITIES IN TENNESSEE 16 A. Distribution of Health Facilities 16 B. Buildings Used by Health Departments 17 C. Personnel of Health Departments 20 D. Services Rendered by Health Departments . . 23 E. Expenditures by Health Departments. ■ 24 III. RELATED RESOURCES 26 A. population 26 B. Financial Resources 29 C. Vital Statistics Data 32 D. Births and Deaths In Hospitals 35 E. Attendance at Birth by Midwives 40 F. Medical," Dental and Nursing Personnel . . 40 IV. HOSPITAL AND HEALTH DEPARTMENT NEEDS IN TENNESSEE . 47 A. General Hospitals 47 B. Nervous and Mental Hospitals 49 C. Tuberculosis Hospitals . 49 D. Chronic Disease Hospitals 50 E. Health Department Facilities 50 F. Personnel 61 G. Educational Facilities 52 H. Financial Consideration ......... 53 V. THE PLAN FOR HOSPITAL AND HEALTH FACILITIES IN TENNESSEE 54 A. Division of Tennessee Into Regions and Areas 55 B. Distribution of General Hospital Beds 58 C. Distribution of Tuberculosis Hospital Beds. 63 D. Distribution of Mental Hospital Beds . . . i . 66 E. Distribution of Chronic Disease Hospital Beds 68 F. Summary of Hospital Beds Needed . 70 G. Distribution of Health Facilities . . 70 H. Method of Administration 71 HOSPITAL AND HEALTH DEPARTMENT FACILITIES AND NEEDS IN TENNESSEE I. SURVEY OF HOSPITAL FACILITIES IN TENNESSEE A state-wide Inventory of hospital and public health facilities was undertaken In November, 1946, to determine the needs of the entire state. A hospital survey commit- tee was appointed and a staff to carry on the survey was employed. The survey commit- tee and staff cooperated with the Commission on Hospital Care sponsored by the American Hospital Association, a non-government pub- lic service committee for the study of hospital service In the United States. The schedules of Information regarding hospital and public health department fac- ilities prepared by the Commission on Hospi- tal Care were used In Tennessee for record- ing of Information, An effort was made to Include all except federal hospitals; In addition to the hospitals and related Institutions listed In "Hospital Service In the United States," published by the Ameri- can Medical Association, local officials were requested to supply information regard- ing hospitals. The schedules were sent out to hospitals providing bed care for the sick. The director and members of the survey staff visited the hospitals and rendered assistance to them In the completion of schedules. The completed schedules were sent to the Commission on Hospital Care for processing. Tabulations of schedule data were prepared and returned to Tennessee for use In a report of hospital facilities. In the present report, selected data from the survey of hospital facilities have been used to show the amount and type of hospital service available to the population of Tennessee. In the 1945 edition of "Hospital Ser- vice In the United States", published by the American Medical Association, there were 111 hospitals and related Institutions listed for Tennessee In 1944. Of these 111 hospitals and related Institutions, 97 were included in the hospital survey and 14 were excluded. The reasons for exclusion of these with the number of beds excluded are given In Table I. TABLE 1 NUMBER OF HOSPITALS AND BEDS LISTED BY AMERICAN MEDICAL ASSOCIATION ACCORDING TO INCLUSION AND EXCLUSION IN HOSP1 ITAL SURVEY REASON FOR EXCLUSION HOSPITALS BEDS NUMBER LISTED BY AM. MED. ASSN. 111 19.866 NUMBER INCLUDED IN SURVEY 97 14.328 NUMBER EXCLUDED FROM SURVEY 14 5.538 FEDERAL HOSPITALS 5 3. 148 INSTITUTIONS FOR DOMICILIARY CARE 4 2.272 HOSPITALS IN INSTITUTIONS 2 52 DATA NOT OBTAINED (UNCOOPERATIVE) 2 26 CLOSED 1 40 For the 97 hospitals listed by Ameri- can Medical Association and Included In the survey there were 14,328 beds. Fourteen other hospitals with 5,538 beds were exclud- ed. These Included five federal hospitals which serve only a Selected group, four Institutions for domiciliary care, and two hospitals Included as parts of Institutions. Data were not obtained from two small hos- pitals with twenty-six beds. One hospital was closed at the time of the survey. Although there were 14,328 beds listed by the American Medical Association for the 97 hospitals, on the basis of the "bed com- plement" that Is the number of beds actually set up and In use at the time of the survey these same hospitals had 14,028 beds, In this report, the number of beds will refer to bed complement. The data given for bed ♦Hospitals and related Institutions are termed "hospitals" In this report. complement were more complete and accurate than for bed capacity. In addition to these 97 hospitals, 48 others with 1,059 beds which were not listed by the American Med- ical Association were Included. A few of these were new hospitals which were not In operation In 1944. The total number of hos- pitals Included In the survey was 145 with 15,087 beds. In addition to these 145 hospitals In- cluded In the survey, there were small hos- pitals and clinics with a few beds which have not been Included. The total number of beds In these small hospitals and clinics was not large. One large known hospital In Oak Ridge In Anderson County was not Includ- ed In the survey. This hospital has served a restricted population group In this In- dustrlal community In which work on the atomic bomb was carried on. A. HOSPITALS AND HOSPITAL BEDS ACCORDING TO TYPE OF SERVICE AND SIZE On the basis of the population of Tennessee In 1944 (3,045,345), there were 5.0 hospital beds per 1,000 population. The 101 general hospitals had 6,229 beds or 2.0 per 1,000 population. The number of hospi- tal beds for nervous and mental patients (6, 748) was slightly larger than the number of general hospital beds. There were 1,091 beds In tuberculosis hospitals, or 0.4 per 1.000 population. The remaining 1,019 hos- pital beds In 28 hospitals were for special services (Table II). In the remainder of •the report, they will be Included in the group "other special." TABLE II NUMBER OF HOSPITALS AND BEOS. WITH BEDS PER 1.000 ACCORDING TO TYPE OF SERVICE HOSPITALS POPULATION BEDS PER 1,000 TYPE OF SERVICE NUMBER PER CENT NUMBER PER CENT POPULATION TOTAL 145 100.0 15,087 99.9 5.0 GENERAL 101 69.7 6,229 41.3 2.0 NERVOUS AND MENTAL 9 6.2 6,748 44.7 2. 2 TU8ERCUL0S1S 7 4.8 1 .091 7.2 0.4 MATERNITY 1 0.7 17 0.1 ♦ CHILDREN 1 0.7 99 0.7 ♦ ORTHOPEDIC 5 3.4 213 1.4 0. 1 EYE. EAR, NOSE. AND THROAT 7 4.8 149 1.0 ♦ CHRONIC AND CONVALESCENT 10 6.9 259 1.7 0. 1 ALCOHOL 1C 2 1.4 34 0.2 • VENEREAL DISEASE * Less than 0.05 beds per 2 1,000 POPULATION I .4 248 1.6 0. 1 Only 25 hospitals had 100 or more beds; 17 had 50 - 99 beds; and the remain- Ing 103, or 71 per cent, had less than 50 hospital beds. The number of hospitals and beds according to size and type of service Is given In Table III. 2 TABLE 1 1 1 NUMBER OF HOSPITALS AND BEDS ACCORDING TO SIZE AND TYPE OF SERVICE TOTAL GENERAL NERVOUS AND MENTAL TUBERCULOSIS OTHER SPECIAL SIZE HOS- HOS- HOS- HOS- HOS- P1TALS BEDS PITALS BEDS PITALS BEDS PITALS BEDS P ITALS BEDS TOTAL 145 15.087 101 6.229 9 6.748 7 1 .091 28 1,019 UNDER 25 BEDS 61 918 46 708 . . . 15 210 25 - 49 BEDS 42 1.433 30 1 .005 4 160 2 72 6 196 50 - 99 BEDS 17 1 .044 10 575 1 50 1 54 5 365 100 - 249 BEDS 13 2.187 7 1.119 1 230 3 590 2 248 250 - 499 BEDS 9 3.197 8 2.822 - 1 375 - - 500 BEDS AND OVER 3 6.308 . . 3 6.308 . . . . Of the 25 hospitals with 100 or more beds, 15 were general hospitals, four were nervous and mental hospitals, four were tuberculosis and two were venereal disease hospitals. B. DISTRIBUTION OF HOSPITALS IN TENNESSEE The distribution of the 101 general hospitals and 44 other hospitals was stud- ied and related to the population of coun- ties and of sections of the state. In Figure 1 the numbers of hospitals according to size are shown by counties. All but two of the hospitals with 100 beds or more were located In the large city-counties of David- son, Hamilton, Knox and Shelby. Of the 17 hospitals with 50 - 99 beds, nine were located in the four large city-counties and eight In smaller counties (Blount, Dyer, Gibson, Green (2) , McMlnn, Roane and Washington) . The remaining small hospitals (103) were found in 51 counties. Forty-one counties had no hospitals. FIGURE 1 DISTRIBUTION OF 101 GENERAL HOSPITALS AND 44 OTHER HOSPITALS ACCORDING TO SIZE BY COUNTIES OF TENNESSEE OTHER HOSPITALS GENERAL HOSPITALS 100 Beds and Ovor 50 - 99 Bods Loss than 5° Bode 100 Bods and Over 50-99 Coda Loss than 50 Beds 3 In Figure 2, the estimated population for 1944 and the urban character of each county are given. In addition to the four large counties with cities of 100,000 pop- ulation and over, there are seven counties with cities of 10,000 - 30,000 and 37 others with cities of 2,500 but less than 10,000 population. The remaining 47 counties have no cities with as mdny as 2,500 people. FIGURE 2 ESTIMATED POPULATION OF COUNTIES IN 1944 AND URBAN CHARACTER OF COUNTIES OF TENNESSEE Counties wfth Cities of 100,000 Population and Over ! Counties with Cities of 2,5^-9,909 Population Counties with Cities of 10,000-99,999 Population Counties without Cities of ?,5C'0 Population GENERAL HOSPITALS - In Figures 3, 4, 5, and 6, the distribution of general hospital beds Is shown. In Figure 3, the reported number of general hospital beds by counties Is given. In only seven counties were there more than 100 beds; In 12 counties there were 50 - 99 beds. FIGURE 3 DISTRIBUTION OF GENERAL HOSPITAL BEDS. BY COUNTIES OF TENNESSEE 100 Reds and Ove; rO - 99 Pod) 1 - i|9 Pods 1 • 4 In Figure 4, the number of general hospital beds per 1,000 population Is shown for the counties. For the State as a whole, there were 6,229 general hospital beds or 2.0 per 1,000 population. This Is far below the recommended figure of 4.5 per 1,000 population. In accordance with the Hospital Survey and Construction Act, (Public Law 725, 79th Congress), 4.5 beds per 1,000 pop- ulation are recommended. In that program, the standard for base areas would be 4.5 per 1,000 population, for Intermediate areas, 4.0 per 1,000 population and for rural areas, 2.5 per 1,000 population. A base area is defined as an area with a teaching hospital of a medical school or an area with at least 100,000 population and one general hospital with complement of 200 or more beds for general use. An Intermed- iate area has a population of at least 25,000, and on completion of hospital con- struction program would have at least one general hospital of 100 beds suitable for use as a district hospital In a coordinated hospital system. A rural area Is the re- malnlng area, no part of which Is Included In a base or Intermediate area. In only the three counties of Davlason, Shelby and Can- non were there as many as 4.0 beds per 1,000 population. Davidson and Shelby have hospi- tal centers serving large areas; in fact, the hospitals of Davidson County are used by residents of nearly all the counties of Middle Tennessee. Memphis Is the hospital center for West Tennessee and for the sur- rounding area of Arkansas and Mississippi, Cannon County, the other county with over 4.0 beds per 1,000 population, has one gen- eral hospital in Woodbury with 42 beds. There were only 13 other counties with 2.0 - 3.9 beds per 1,000 population. These counties with beds per 1,000 population are given below: Campbell 2.2 Cumberland 2.7 Greene 3.3 Hamblen 2.5 Hamilton 2.8 Henry 2.0 Knox 3.8 McHlnn 2.5 Madison 2.2 Marshall 2.4 Roane 3.1 Sevier 2.1 Wilson 2.3 FI GURE 4 GENERAL HOSPITAL BEDS PER 1.000 POPULATION BY COUNTIES OF TENNESSEE ■HBkIi.O Pud* and Ove 2.0 - 3.9 Beds 0.1 -1.9 Bedi Rob* For consideration of the problem by sections of Tennessee, the state, excluding the four large city-counties, has been di- vided Into six sections with each of the three main sections. East, Middle and West, divided Into two sections (Figure 5). For t-he four areas In Middle and West Tennessee, outside of Davidson and Shelby Counties, there were only 0.8 beds per 1,000 popula- tion. In East Tennessee there were 1.3 beds In the Eastern section and 1.5 In the sec- tion between Knox and Hamilton. 5 FIGURE 5 GENERAL HOSPITAL BEDS PER 1.000 POPULATION FOR FOUR LARGE CITY COUNTIES AND SIX SUBDIVISIONS OF TENNESSEE J.d Beds a ltd Ovtr [1.0 - 2.99 Beds Less than 1*0 Bads Since thb hospitals of the four large city-counties, Davidson, Hamilton, Knox, and Shelby, are known to serve the counties adjacent to them, these metropolitan coun- ties and counties adjacent to them have been combined and the hospital beds per 1,000 population obtained. The beds per 1,000 population for these four areas and for the remaining areas of West, Middle and East Tennessee are shown In Figure 6. On this basis, there were only 3.4 beds per 1,000 population for Davidson and adjacent coun- ties, 2.2 for Hamilton and adjacent coun- ties, 2.5 for Knox and adjacent counties, and 3.7 for Shelby and adjacent counties In Tennessee. FIGURE 6 GENERAL HOSPITAL BEDS PER 1.000 POPULATION IN METROPOLITAN AND ADJACENT COUNTIES BY SECTIONS OF TENNESSEE Shelby end Adjacent Counties 5*7 Beds per 1,000 Population Rest of West Tennessee C.9 Beds per 1,000 Population Davidson and Adjacent Counties 3»U Beds per 1,000 Population Rest of Middle Tennessee 0.8 Beds per 1,000 Population Hamilton and Adjacent Counties 2.2 Beds per 1,000 Population Knox and Adjacent Counties 2.5 Beds per 1,000 Population Rest of East Tennessee 1.5 Beds per 1,000 Population 6 NERVOUS AND MENTAL HOSPITALS - There were nine hospitals for nervous and mental pa- tients In Tennessee with 6,748 beds (Table IV). The three large state hospitals, one In Middle Tennessee (Davidson County) with £,000 beds, one In East Tennessee (Knox County) with 1,850 beds and one In West Tennessee (Hardeman County) with 2,458 beds, had 93 per cent of the hospital beds In nervous and mental hospitals. In addition to these three large hospitals, there were two other governmental and five proprietary hospitals for nervous and mental patients. TUBERCULOSIS HOSPITALS - The seven tubercu- losis hospitals* In Tennessee had 1,091 beds, or0.4 per 1,000 population. Two small hospitals, one In Davidson County with 54 beds and one In Greene County with 32 beds, were owned by the state. The four large hospitals were In Davidson, Hamilton, Knox and Shelby Counties, with two owned by the city-county, one by the county and one by a non-profit association. There was one other tuberculosis hospital owned by a non-profit association (Hawkins County). The distribu- tion of these hospltals Is given In Table V. TABLE IV NUMBER OF NERVOUS AND MENTAL HOSPITALS AND BEDS BY COUNTIES COUNTY HOSPITALS BEDS STATE 9 6 .748 DAV IDSON 2 2,045 HAMILTON 1 230 HARDEMAN 1 2,458 KNOX 1 1 .850 SHELBY 4 165 NUMBER TABLE V OF TUBERCULOSIS HOSPITALS AND COUNTY BEDS BY COUNTIES HOSPITALS BEDS STATE 7 1 .091 DAV1DSON 2 274 GREENE 32 HAMILTON 225 HAWK 1 NS 1 40 KNOX 1 145 SHELBY 1 375 The recommended ratio of beds In men- tal hospitals Is 5 per 1,000 population. This Is slightly more than twice as many as Tennessee has at present, 2.2 per 1,000 population. * One small hospital which had thirty beds assigned to tuberculosis patients has been classed general. TABLE VI NUMBER OF HOSPITALS AND BEDS FOR SPECIAL SERVICES, EXCLUDING NERVOUS AND MENTAL AND TUBERCULOSIS HOSPITALS BY Counties EYE. EAR. NOSE CHRONIC AND TOTAL ORTHOPEDIC AND THROAT CONVALESCENT OTHER COUNTY HOS- HOS- HOS- HOS- HOS- PITALS BEDS PITALS BEDS PITALS BEDS PITALS 8EDS P ITALS BEDS STATE 28 1.019 5 213 7 149 10 259 6 398 DAVIDSON 8 167 1 36 . 6 111 1 a 20 HAM 1L TON 7 28 5 - - 2 30 1 25 4 b 230 SHELBY 9 511 4 177 1 63 3 123 1 c 148 SULL1 VAN 1 10 - - 1 10 - - - WASHINGTON 3 46 - - 3 46 ■ - - (a) Alcoholic (b) One hospital each of the following types: maternity, 17 beds; ; children, , 99 beds; al- cohollc, 14 beds; venereal disease, , 100 beds. (c) Venereal disease 7 The desired ratio for beds In tuber- culosis hospitals Is 2.5 times th-e average annual number of deaths from tuberculosis. For the five years, 1940 - 1944, the aver- age annual number of tuberculosis deaths for Tennessee was 2,097 and, thus, the num- ber of recommended beds would be 5,242. This recommended number of beds In tubercu- losis hospitals (5,242) was 4.8 times the actual number (1,091) in Tennessee. OTHER SPECIAL HOSPITALS - Twenty-eight other hospitals were for specific services. The number of these hospitals and beds according to type of service are given In Table VI. The maximum allowance for beds for chronic disease patients is 2 per 1,000 population. C. OWNERSHIP OF HOSPITALS The ownership of hospitals has been classified Into three groups; namely, 1) governmental, which Includes state, city, county and city-county; 2) non-profit which includes church and other non-profit assoc- iations; 3) proprietary which Includes In- dividual, partnership and corporation. The number of hospitals with hospital beds ac- cording to ownership, type of service and size are given In Table VII. TABLE VI 1 NUMBER OF HOSPITALS AND BEDS ACCORDING TO OWNERSHIP. TYPE OF SERVICE’ AND SIZE TOTAL UNDER 50 BEDS 50 - 99 BEDS 100 BEDS AND OVER OWNERSHIP AND HOS- HOS- HOS • HOS- TYPE OF SERVICE P1TALS BEDS P1TALS BEDS P 1 TALS BEDS PITALS BEDS TOTAL 1 45 15.087 103 2,351 1 7 1 .044 25 1 1.692 P ROP R1 ETA RY 80 1 . 770 74 1.442 6 328 - - GENERAL 56 1,210 52 992 4 218 . . NERVOUS AND MEN Tal 4 1 70 3 1 20 1 50 • • OTHER SPECIAL 20 390 19 330 1 60 • - NON-PROFIT 41 3,932 20 649 9 563 1 2 2.720 GENERAL 34 3.385 1 7 533 6 357 11 2,495 TUBERCULOS1S 2 265 1 40 - - 1 225 OTHER SPECIAL 5 28 2 2 76 3 20 6 - - GOVERNMENTAL 24 9,385 9 260 2 1 53 1 3 8,972 GENERAL 1 1 1,634 7 188 - - 4 1 .446 NERVOUS AND MENTAL 5 6,578 1 40 - - 4 6 . 538 TUBERCULOS1S 5 826 1 32 1 54 3 740 OTHER SPECIAL 3 347 ■ F . 1 99 2 248 Over half of the hospitals In Tennes- see (80 or 55 per cent) were proprietary hospitals; 41 (28 per cent) were non-pmfit; and 24 (17 per cent) were governmental hos- pitals. The proprietary hospitals, however, had only 11.7 per cent of the hospital beds. The non-profit had 26 p-er cent and the gov- ernmental hospitals, 62.2 per cent. The proprietary hospitals were small hospitals. Each one of these had less than 100 beds. Only six had 50 beds or more. The non-profit hospitals were larger than the proprietary hospitals, with 12 of the 41 having 100 beds or more. Of the 24 hospi- tals owned by city, county, or state, 13 had 100 beds or more, D. PATIENT SERVICES In this section of the report, select- ed data regarding use of the hospitals are presented. In Table VIII the admissions and patient days are given according to type of service of the hospital. During the period of one year, there were 225,964 admissions to the hospitals. Of these hospital admissions 195,567, or 86.5 per cent, were In general hospitals. The general hospital admission rate was 64.2 per 1,000 population, or 6 per 100. Disregarding readmlssIons, on the average one out of every 16 persons was admitted to a general hospital. * The admission rates to the special hospitals are of Interest. For nervous and mental hospitals, the rate was 1.5 per 1,000 population, for tuberculosis, 0.6 per 1,000 population, for venereal disease, 3.5 per. 1,000 population, and for eye, ear, nose and throat, 3.1 per 1,000 population. TABLE VI 1 1 ADMISSIONS WITH RATES PER 1.000 POPULATION. PAT 1 ENT DAYS, AVERAGE LENGTH OF STAY AND DAI LY CENSUS ACCORDING TO TYPE OF SERVICE OF HOSPITAL TYPE OF SERVICE ADMISSIONS ft. AVERAGE LENGTH AVERAGE DAILY NUMBER RATE PATIENT DAYS ,OF STAY CENSUS TOTAL 225.964 74.2 4.502.307 19.9 12.335 GENERAL 195.567 64.2 1.643.067 8.4 4.502 NERVOUS AND MENTAL 4.662 1.5 2.315.383 496.7 6.344 TUBERCULOS|S 1.683 0.6 323,007 191.9 88 5 OTHER SPECIAL 24.052 - 7.9 220.850 9.2 605 VENEREAL DISEASE 10,685 3.5 64.580 6.0 177 EYE. EAR. NOSE AND THROAT 9.325 3.1 27.709 3,0 76 ORTHOPED1C 2.065 0.7 54.436 26.4 149 MATERNITY 562 0.2 5.022 8.9 14 CHILDREN 1.321 0.4 14.393 10.9 39 CHRONIC AND CONVALESCENT 94 * 54,710 582.0 150 * Less than 0.05 per 1,000. # Admissions to 131 hospitals for which data were given. Fourteen small hospitals with 321 beds were not In operation In 1944 or failed to give the Information for other reasons. The average lengths of stay varied from very long periods for chronic and con- valescent and nervous and mental patients to very short periods for venereal disease and eye, ear, nose and throat patients. The patients remained In general hospitals on the average 8.4 days. The average dally census given In the last column of the table shows the average number of hospital patients on a given day. On the average on a given day there were 12,335 persons in hospitals or 4.1 per 1,000 population. Slightly over half of these patients were In nervous and mental hospi- tals where the rate was 2.1 per 1,000 pop- ulation. The average dally census In general hospitals was 4,502 or 1.5 per'1,000 popu- lation. The numbers jpf births and deaths In these hospitals with rates per 1,000 admis- sions ire given In Table IX. The number of births reported by these hospitals was 31,346 which gave a rate of 136.7 per 1,000 admissions. Nearly all of these births, 31,027 (99.0 per cent), occur- ed In general hospitals and the rate for general hospitals was 158.7 per 1,000 ad- missions or 15.9 per 100 admissions. Thus, probably one out of six admissions to gen- eral hospitals was for obstetrical services. At present in the United States, about one- seventh of all hospital beds are used for obstetrical care. According t-o Information tabulated from birth certificates, 34,200 births were recorded In Tennessee hospitals in 1944. There Is a difference of 2,854 births as stated In the hospital survey and from birth certificates. Some of the survey reports may not have been for the calender year 1944. Also, births occurring In some of the small hospitals or clinics and those In the 9 TABLE IX BIRTHS AND DEATHS WITH RATES PER 1.000 ADMISSIONS ACCORDING TO TYPE OF SERVICE OF HOSPITAL B1RTHS DEATHS TYPE OF SERVICE ADM 1SS1ONS NUMBER RATE NUMBER RATE TOTAL 225,964 31.346 138.7 7,871 34.8 GENERAL 195, 567 31 .027 158.7 6.694 34.2 NERVOUS AND MENTAL 4.662 ■ - 675 144.8 TUBERCULOS1S 1 .683 1 0.6 283 168.2 OTHER SPECIAL 24,052 318 13.2 219 9.1 large hospital at Oak Ridge In Anderson County have not been- Included. In Anderson County, 676 hospital births were recorded which were not included In the survey. In 1944, 69,799 births were recorded In Tennessee. Using the 31,346 hospital births reported by the hospitals In the sur- vey, 44.9 per cent of the births occurred In them. From the data given on certlflcates, 49.0 per cent of the births occurred In hospitals. Of the births to mothers resi- dent of the cities of 10,000 population and over, 76 per cent occurred In hospitals, while of births from other areas, only 36 per cent occurred In hospitals. There has been an Increase each year In Tennessee In the number of hospital births and proportion of births occurring In hospitals. According to Information given on birth certificates In 1934, only 7,674 or 14.7 per cent of the live births occurred In hospitals while In 1944 over three times as many, 49.0 per cent, occurred In hospitals. Thus, the use of hospitals for delivery has Increased. Further Increase will depend on the provi- sion of hospital beds In rural as well as In urban areas. In the United States In 1944, 75.6 per cent of the births occurred In hospi- tals. In several states the percentages were above 90. In New York State, 95.0 per cent of the births occurred In hospitals. With Increasing hospital facilities and use of hospitals for delivery, It Is expected that the percentage of births In hospitals will approach 100 per cent. The number of deaths reported In the survey of Tennessee hospitals was 7,871 or 34.8 per 1,000 admissions. Of these deaths, 6,694 or 85.0 per cent occurred In general hospitals. There were 675 deaths In nervous and mental hospitals or 8.6 per cent of the deaths In hospitals. The numbers of deaths In tuberculosis hospitals (283) and In other special hospitals (219) were small. For 1944, 28,619 deaths were recorded In Tennessee. Using the 7,871 hospital deaths reported from the hospitals Included In the survey, 27.5 per cent of the deaths were In these hospitals. Of the tuberculos- is deaths In Tennessee In 1944, 1,883, only 283 or 15.0 per cent occurred In tubercu- losis hospitals. Data from death certificates for 1944 revealed that 9,251 deaths or 32.3 per cent of all deaths recorded In Tennessee occur- ed In hospitals. This number, 9,251, Is 1,380 larger than the number of hospital deaths reported In the survey. This differ- ence Is due to deaths In Veterans and Army hospitals, to deaths In a few small hospi- tals and In Oak Ridge Hospital. During the war years two large hospitals, Thayer Gen- eral In Davidson County and Kennedy General In Shelby County, were In operation and deaths would have occurred In them. In the United States In 1944, 45.4 per cent of the deaths occurred In all types of Institutions Including hospitals. As Insti- tutions such as feeble minded and rest homes are probably Included, this figure Is slightly higher than the percentage of deaths In hospitals. In New York State, 55.4 per cent of the deaths were In insti- tutions. It Is believed that 50 per cent of deaths would occur In hospitals if hos- pital beds were provided In all sections of the State. This Is the standard used In 10 TABLE X NUMBER OF BEDS. AVERAGE DAILY CENSUS. AND PERCENTAGE OCCUPANCY ACCORDING TO TYPE ( OF SERVICE AND OWNERSHIP TOTAL NON- PROFIT PROPRIETARY GOVERNMENTAL TYPE OF SERVICE BEOS PERCENT- PERCENT. AGE AGE AVERAGE OCCU- BEDS AVERAGE OCCU- CENSUS PANCY CENSUS PANCY BEDS AVERAGE CENSUS PERCENT- AGE OCCU- PANCY BEDS AVERAGE CENSUS PERCENT AGE OCCU-' PANCY TOTAL 14766* 12335.1 83.5 3872 3007.5 77.7 1509 1004, 1 66.5 9385 8323.5 88.7 GENERAL 60 25* 4501.6 74.7 3325 2566.0 77.2 1066 701.7 65.8 1634 1233.8 75.5 NERVOUS MENTAL AND 6 748 6343.5 94.0 . . 170 118.1 69.5 6578 6225.4 94.6 TUBERCULOSIS 109 1 884.9 81.1 265 237.1 89.5 - - - 826 647.8 78.4 OTHER SPECIAL 902* 605.1 67.1 28 2 20 4.4 72.5 273 184.3 67.5 347 216.4 62.4 * Data regarding patient days for use In calculating average census were i not given for e Ight general hospitals, six proprietary and two non-profit. with 204 beds; i and for six other special proprietary hospitals with 117 beds. planning for hospital care. The occupancy of hospitals has to be considered In hospital planning. In Table X data regarding percentage occupancy of hospitals are given according to type tff service and ownership. The 131 hospitals giving data regard- ing admissions and patient days reported 4,502,307 patient days, or on the average 12,335.1 patients per day. These 131 hospi- tals had 14,766 beds and the percentage occupancy was 83.5. The percentage occupan- cy of general hospitals was 74.7. The per- centages for the non-profit and governmental general hospitals were higher than for the proprietary hospitals. The percentage occu- pancy for the nervous and mental hospitals was 94.0 and for tuberculosis hospitals, 81.1. The other special hospitals had a smaller percentage occupancy (67.1) than the general, tuberculosis and nervous and mental hospitals. Study of the general hospitals by size of hospital showed that the percentage oc- cupancy varied by size (Table XI). For gen- eral hospitals with 100 beds or more, on the average 78.9 per cent of the beds were occupied, while for those with less beds. TABLE XI NUMBER OF BEOS. AVERAGE DAILY CENSUS AND PERCENTAGE OCCUPANCY IN GENERAL HOSPITALS ACCORDING TO SIZE SIZE OF HOSPITAL BEDS AVERAGE PERCENTAGE CENSUS OCCUPANCY TOTAL 6.025 4*501.6 74.7 UNDER 50 BEDS 1.559 1.064.7 68.3 50 - 99 BEDS 525 326.1 62.1 100 BEDS AND OVER 3,941 3.110.8 78.9 66.7 per cent were occupied on the average. This is in accordance with findings In other areas and has been useful In hospital planning. All of the beds in tuberculosis, ner- vous and mental and ftther special hospitals are allotted for specific services. In ad- dition some of the beds In general hospitals are allotted for specific services. TABLE XI I ALLOTMENT OF BEDS TO SPECIFIC SERVICES ACCORDING TO TYPE OF HOSPITAL TYPE OF HOSPITAL SPECIFIC SERVICE TOTAL GENERAL NERVOUS AND MENTAL TUBER- CULOSIS OTHER SPECIAL HOSPITALS • NUMBER 145 101 9 7 28 HOSPITAL BEDS 15,087 6,229 6.748 1 .091 1 .019 GENERAL MEDICAL 469 469 - - GENERAL SURGICAL 662 662 - - OBSTETR1 CAL 690 673 - 17 PEDIATR1C 514 41 5 99 CONTAG1OUS 91 91 - TUBERCULOS1S 1,152 61 1.091 - NERVOUS AND MENTAL 6.810 50 6,748 12 CHRONIC. CONVALESCENT AND REST 254 7 - 247 VENEREAL DISEASE 248 - 248 0 RT HOP ED 1C 213 - 213 EYE. EAR. NOSE AND THROAT 149 - 149 ALCOHOL 1C 34 - 34 UNASSIGNED 3,801 3,801 . . In Table XII the number of beds allot- ted to specific services are given accord- ing to type of hospital. Of the 6,229 general hospital beds, 3,801, or 61.0 per cent, were not allotted for a specific service. The two services with the largest numbers of assigned beds were obstetrical with 673 and general sur- gical with 662 beds. The number of beds as- signed for general medical was 469 and for pediatric 415. The total number of beds for specific services are also shown In Table XII. In addition to 1,091 beds In tuberculosis hos- pitals there were only 61 other beds desig- nated for tuberculosis patients. Fifty beds In general hospitals and 12 In other spec- ial hospitals were allotted to nervous and mental patients which gave a total of 6,810 beds for nervous and mental patients. E. HOSPITAL EXPENSE Eighty hospitals supplied data on the schedules regarding expenses. In general, these were the larger hospitals. For the 80 hospitals reporting expenses, the patient days were 3,816,252. Thus, considering the total number of patient days for hospitals In this survey, expenses were obtained for over 80 per cent. The total expenses and expenses per day according to type of hos- pital are given In Table XIII. The expenses per day varied consider- ably according to the type of hospital. The average cost per day In general hospitals was $6.74. The expenses per day In nervous and mental hospitals was small, $0.77. In tuberculosis hospitals, It was $2.62 per day and In other special, $3.27 per day. It Is realized that the expense Is usually greater In general hospitals which have patients for short periods of time. Expenses are less for patients requiring care over a long period of time. A larger proportion of the governmen- tal and non-profit hospitals supplied data regarding expenses than of the proprietary hospitals. Thirty of the 40 non-profit hos- pitals and 21 of the 24 governmental hospi- tals reported expenses. Only 29 of the 80 proprietary hospitals gave data on expenses. The expenses per day for the 80 hospitals 12 TABLE XI 1 1 PATIENT DAYS AND EXPENSES FOR 80 HOSPITALS REPORTING EXPENSES ACCORDING TO TYPE OF SERVICE OF HOSPITAL TYPE OF NUMBER OF PATIENT EXPENSES SERVICE HOSP ITALS DAYS EXPENSES PER DAY TOTAL 80 3.816,252 $10,494,000 GENERAL 63 1.134.984 7,647,000 $6.74 NERVOUS AND MENTAL 7 2,295.451 1,766,000 0.77 TUBERCULOSIS 4 278.476 730,000 2.62 OTHER SPECIAL 6 107,341 351.000 3.27 according to ownership and type are given in Table XIV. The numbers of hospitals reporting In some of the groups are so small that con- clusions regarding the expenses according to ownership may not be Justified without consideration of the detailed services ren- dered. For the general hospitals, however. It may be noted that the expenses per day were $5.61 for governmental hospitals,, $5.99 for proprietary and $7.68 for non-profit hosp Itals. F. HOSPITAL PERSONNEL Information regarding personnel work- ing In the hospitals was recorded for 143 hospitals. In this section of the report, the personnel employed full-time or part- time and volunteer personnel are given and the full-time personnel studied according to type and size of hospital and function of the personnel. The 143 hospitals reported 9,761 per- sons working In the hospitals (Table XV). Of the 9,761 persons, 8,985 or 92,0 per cent were full-time personnel, 352 or 3.6 per cent were part-time and 424 or 4.3 per cent were volunteer personnel. Two hospitals with 70 beds failed to Information regarding personnel. One general hospital with ten beds was reported to have only part-time personnel. For the remaining 142 hospitals, data regarding TABLE XIV * EXPENSES PER DAY FOR 80 HOSPITALS REPORTING ACCORDING TO OWNERSHIP AND TYPE ' OF SERVICE OF HOSPITAL TOTAL NON- PROFIT PROPRIETARY GOVERNMENTAL TYPE OF SERVICE TOTAL HOS- PITALS HO SP ITALS REPORT!NG NUM- EXPENSES BER PER DAY HOSP1TALS TOTAL REPORTING HOS- NUM- EXPENSES P1TALS BER PER DAY TOTAL HOS- P ITALS HOSP ITALS REPORT!NG NUM- EXPENSES BER PER DAY TOTAL HOS- PITALS HOSP ITALS REPORTING NUM- EXPENSES BER PER DAY TOTAL 145 80 41 30 80 29 24 21 GENERAL 101 63 16.74 34 27 17.68 56 26 $5.99 1 1 10 15.61 NERVOUS MENTAL AND 9 7 0.77 . . . 4 2 8.59 5 5 0.69 TUBERCULOSIS 7 4 2.62 2 1 1 .92 - - - 5 3 2.89 OTHER SPECIAL28 6 3.27 5 2 3.88 20 1 1 .39 3 3 3V23 full-time personnel are given In Table XVI according to type and size of hospital. In general hospitals there were 7,480 full-time personnel serving these hospitals with 6,149 beds or 1.22 persons per bed. The personnel per bed In tuberculosis hos- pitals was 0.35 and for nervous and mental hospitals, 0.10. The small general hospl- 13 TABLE XV NUMBER AND PERCENTAGE OF PERSONNEL. FULL- TIME. PART- TIME AND VOLUNTEER BY TYPE OF SERVICE OF HOSIPTAL TYPE OF SERVICE HOS- PITALS HOSPITALS REPORTING TOTAL PERSONNEL FULL-TIME PERSONNEL NUMBER PER CENT PART-TIME PERSONNEL NUMBER PER CENT VOLUNTEER PERSONNEL NUMBER PER CENT total 145 143 9 .761 8.985 92.0 3 52 3.6 424 4.3 GENERAL 101 99 8.170 7,480 91 .6 289 3.5 401 4.9 NERVOUS AND MENTAL 9 9 698 687 98.4 1 1 1 .6 TUBERCULOS1S 7 7 418 383 91.6 35 8.4 - - OTHER SPECIAL 28 28 475 435 91 .6 17 3.6 23 4.8 tals did not have as much personnel as did the large hospitals. This Is, of course, related to the services rendered. Also, some of the large hospitals had nursing training schools which Increased the per- sonnel employed. The general hospitals with 100 beds and over had a ratio of 1.46 per- sons per patient, and the general hospitals with less than 50 beds had a ratio of 0.71 persons per patient. TABLE XVI NUMBER OF BEDS . FULL- TIME PERSONNEL AND PERSONNEL PER BED ACCORDING TO TYPE OF SERVICE AND SIZE OF HOSPITAL TOTAL UNDER 50 BEDS 50 - 99 BEDS 100 BEDS AND OVER TYPE OF SERVICE BEDS PERSONNEL NUMBER PER BED BEDS PERSONNEL NUMBER PER BED BEDS PERSONNEL NUMBER PER BED BEDS PERSONNEL NUMBER PER BED TOTAL 15007 8985 0.60 2321 1567 0.68 994 787 0.79 11692 6631 0.57 GENERAL 6149 7480 1.22 1683 1197 0.71 525 537 1.02 3941 5746 1.46 NERVOUS AND MENTAL 6748 687 0.10 160 153 0.96 50 24 0.48 6538 510 0.08 TUBERCULOSI S 1091 383 0.35 72 28 0.39 54 33 0.61 965 322 0.33 OTHER SPECIAL 1019 435 0.43 406 189 0.47 365 193 0.53 248 53 0.21 The number of full-time personnel In general hospitals Is given In Table XVII according to their function. Six per cent of the personnel were considered administrative personnel. Nearly two-thirds (64.7) were professional. The TABLE XVI 1 FULL-TIME PERSONNEL IN GENERAL HOSPITALS ACCORDING TO FUNCTION, AND SIZE OF HOSPITAL TOTAL UNDER 50 BEDS 50 - 99 BEDS 100 BEDS AND OVER FUNCTION NUM- PER NUM- PER NUM- PER NUM- PER OF PERSONNEL BER CENT BER CENT BER CENT BER CENT TOTAL 7.480 100 .0 1. 197 99.9 537 100.0 5.746 99 .9 ADMINISTRATIVE 447 6.0 131 10.0 38 7. 1 278 4.8 DIETARY 743 9.9 174 14.5 61 1 1 .4 508 8.8 HOUSEHOLD AND PROPERTY 1.384 18.5 174 14.5 64 1 1 .9 1 . 146 19.9 PROFESSIONAL SERVICES 4.838 64.7 717 59.9 374 69.6 3,747 65.2 OUT-PATIENT SERVICE 68 0.9 1 0.1 - - 67 1 .2 professional personnel Included those em- ployed In medical and surgical service, nursing service, library service, social service, X-ray and radium department, lab- oratories, operating and delivery room, pharmacy, physical and occupational therapy departments, etc. Data regarding type of nursing person- nel were given for only 33 general hospi- tals (Table XVIII). These Included all of the large general hospitals with 100 beds or more and eight of the ten general hospi- tals with 50-99 beds. Such Information was obtained from only ten of the general hos- pitals with less than 50 beds. The schedule used for the small hospitals did not In- clude such detailed Information. These 33 hospitals supplying data re- garding type of nursing personnel had 4,282 professional workers or 0.89 her bed. Of these workers 3,517 or 82 per cent were nursing personnel. There were 748 graduate nurses or 0.15 per bed. The student nurses numbered 1,910 or 0.40 per bed. The remain- ing 859 were practical nurses, attendants, nurses aides, and maids, etc. The nursing personnel per bed was greater for the hos- pitals with 50 or more beds than for the small hospitals due principally to the In- clusion of student nurses. TABLE XVI 1 1 NURSING AND OTHER PROFESSIONAL FULL-TIME PERSONNEL IN 33 GENERAL HOSPITALS WITH NUMBER PER BED ACCORDING TO SIZE OF HOSPITAL TYPE OF TOTAL UNDER 50 BEDS 50 - 99 BEDS 100 BEDS AND OVER PERSONNEL NUMBER PER BED NUMBER PER BED NUMBER PER BED NUMBER PER BED HOSPITALS REPORTING 33 10 8 15 BEDS 4.828 41 2 475 3.941 TOTAL PROFESSIONAL 4. 28 2 0.89 190 0.46 345 0.73 3.747 0.95 NURSING PERSONNEL 3.517 0.73 180 0.44 31 1 0.65 3,026 0.77 GRADUATE 748 0.15 61 0.15 71 0.15 616 0.16 STUDENT 1.910 0.40 - - 126 0.27 1 .784 0.45 P RACTI CAL 174 0.04 74 0.18 59 0.12 41 0.01 ATTENDANT 30 0.01 - - 3 0.01 27 0.01 NURSES AIDE 368 0.08 24 0.06 10 0.02 334 0.08 MAID AND OTHER 28 7 0.06 21 0.05 42 0.09 224 0.06 OTHER PROFESSIONAL 765 0.16 10 0.02 34 0 .07 721 0.18 DISCUSSION Selected data regarding hospital fac- ilities have been presented to show the ex- isting conditions In Tennessee. Although there are deficiencies In some of the data, considerable Information has been obtained to .show the needs and the factors to be considered In planning for hospitals and hospital beds for the population of Tennes- see. Some of the hospitals Included In the survey are small and*the beds cannot be classed as acceptable according to stand- ards. Also, under the federal provision for construction of hospitals, financial aid will be available for only certain hospi- tals, those which are not used for profit. According to the Public Health Service Reg- ulation Issued pursuant to Public Law 725, 79th Congress, known as the Hospital Survey and Construction Act, a non-profit hospital means "any hospital owned and operated by a corporation or association, no part of the net earnings of which Is applied, or may lawfully be applied, to the benefit of any private shareholder or Individual. " A detailed discussion d-f the needs of hospi- tal and health department facilities will be given In the fourth section of this re- port. 15 HOSPITAL AND HEALTH DEPARTMENT FACILITIES AND NEEDS IN TENNESSEE II. SURVEY OF HEALTH DEPARTMENT FACILITIES IN TENNESSEE In the state-wide Inventory of hospi- tal andhealth department facilities, sched- ules of Information regarding public health services wejre completed. In the present re- port selected data from the survey of health departments In operation In December, 1945, have been used to show the type of facili- ties available and the services rendered to the population of Tennessee. A. DISTRIBUTION OF HEALTH FACILITIES Schedules were completed for three city-county health departments(Chattanooga- Hamllton, Memphls-Shelby, and Jackson-Madl- son), for two city health departments (Knoxville and Nashville) and for fifty- one counties with full-time health service. In all, flfty-slx schedules were obtained for study of the facilities and services rendered. The counties In Tennessee with full- time health services are shown In Figure 1. Thirty-four counties had full-time health departments (Including the three city-coun- ty health departments referred to above); two counties (Davidson and Knox) also had city health departments, and twenty coun- ties were Included In seven district health departments. Forty-one counties were with- out full-time health service at the time of this survey In December, 1945. These coun- ties without health service, with a few ex- ceptions, were located In two areas namely, In the upper Cumberland section and In the section of Tennessee cut by the Tennessee River as It flows north. Both of these sec- tions Include sparsely populated areas and many of the poor counties of the state. The estimated 1944 population* of the area of Tennessee with full-time health service was 2,394,873. Based on the estimat- ed population of the state of 3,045,345, * The estimated population for 1944 Is used In this report since data forservlces and personnel were submitted for the year 1944. FIGURE I FULL-TIME COUNTY HEALTH DEPARTMENTS AND DISTRICT HEALTH DEPARTMENTS. 1944 PULL-TIME COUNTY HEALTH DEPARTMENTS POLL-TUB DISTRICT HEALTH DEPARTMENTS AREA WITHOUT PI’LL-TIME HEALTH SERVICE 16 78.6 per cent of the population had full- time health service. Although forty-one counties were without full-time health service at the time of this survey, twenty- one of these had had such service at some time In the past. Shortages of professional personnel during the war and since termina- tion of the war were In part responsible for lack of health services and lack of cover- age of the remaining 650,472 population. In the schedules sent to the health departments, Information was obtained re- garding the central offices and auxiliary offices In these areas. It has been found that in addition to administrative or cen- tral offices In the county seats, offices are needed In other centers of population. Through such auxiliary offices, services are being made available to the population In many Isolated communities. Even within the large cities, decentralization o f health service has- been found advantageous to the program and several additional health of- fices have been established In centers dis- tributed over the cities. In addition to the 56 central offices, there were 93 aux- iliary offices. The locations of the cen- tral offices are shown In Figure 2 by a large black dot and the location of the auxiliary offices by smaller dots. The lo- cations of the auxiliary offices within the cities of Chattanooga, Knoxville, Memphis, and Nashville could not be shown but the numbers of such offices are Indicated by FIGURE.2 LOCATION OF 56 CENTRAL OFFICES AND 93 AUXILIARY OFFICES IN AREAS WITH FULL-TIME LOCAL HEALTH SERVICE. 1944 ) ce. tral offices AUXILIARY OFFICES the group of small dots near the large dot Indicating the central office. There are two central offices shown for the city and county health departments In Davidson and Knox Counties. B. BUILDINGS USED BY HEALTH DEPARTMENTS Health department facilities are hous- ed In many different kinds of buildings. The common practice In the past has often been to assign one or two rooms In the court house for the health department. Such space In the small court houses has not been sat- isfactory for use In an active program ren- dering clinic service for venereal disease, tuberculosis, maternal and child hygiene, etc. The types of buildings In use a't the time of the survey are given In Table I for the 56 central offices and 93 auxiliary of- fices. Twenty-eight health facilities were housed In separate buildings; twenty-two of these were the central offices and six were 17 auxiliary offices. Twelve of the separate buildings were designed for health facili- ties and the remaining sixteen were resi- dences, stores, etc. of a court house or city hall plans were made for the assignment of certain space for the. health department. In Table I, how- ever, the building Is classed according to Its primary purpose. The county court house was used for offices of fourteen health departments. With the exception of one large health department In a court house designed to Include the health department, the quarters In court houses averaged 3.5 rooms and had 877 square feet of floor space. These central offices were consider- ed Inadequate for the programs being con- ducted. Many of the auxiliary offices were found In city halls, schools, hospitals and community centers. The establishment of clinics In community centers has been valu- able In rendering health department service to the population. Also clinics In hospi- tals are being found advantageous. Several of the newer auxiliary centers have been established In hospitals and community cen- ters. Nearly half of the central offices were rented. Sufficient space usually was not available In the court house or other pub- lic buildings. Only eight of the 93 auxil- iary offices were rented. When space for these auxiliary offices was not available In public buildings. It was usually donated. The adequacy of space has been evaluat- ed by the health officers and for 46 or 31 per cent of the facilities the space was considered adequate (Table II). For central offices, only space in separate buildings was considered adequate to carry on the program and only twelve of the central offices In separate buildings were adequate. The eleven county health de- partments and one city health department TABLE 1 TYPES OF BUILDINGS HOUSING HEALTH FACILITIES FOR CENTRAL AND AUXILIARY OFFICES TYPE OF BUILDING TOTAL CEN- TRAL OFFICE AUXIL- IARY OFFICE TOTAL 149 56 93 SEPARATE BUILDING 28 22 6 HEALTH DEPARTMENT 12 10 2 RES 1DENCE 7 4 3 STORE OR BANK 4 4 - HOSPITAL. MEDICAL SCHOOL OR DOCTOR'S OFFICE 3 3 - OTHER BUILDING 2 1 1 IN OTHER BUILDING 121 34 87 COUNTY COURT HOUSE 1 4 14 • CITY HALL OR MUNCIPAL BUILDING 15 2 13 STORE OR BANK 8 3 5 SCHOOL 14 • 14 OF FICE 15 9 6 HOSPITAL. MEDICAL SCHOOL OR DOCTOR'S OFFICE 12 1 1 1 COMMUNITY CENTER 14 - 14 RESIDENCE 6 1 5 OTHER GOVERNMENT BUILDING 11 3 8 OTHER BUILD 1NG 12 1 11 Nearly all of the auxiliary offices and thirty-four of the flfty-slx central offices were housed In buildings designed for purposes other than the health depart- ment. In a few Instances In the construction TABLE I 1 ADEQUACY OF SPACE FOR CENTRAL AND AUXILIARY OFFICES TOTAL CENTRAL OFFI ICES AUXILIARY OFFICES BUILDING ADEQUATE ADEQUATE ADEQUATE TOTAL NUM- PER TOTAL NUM- PER TOTAL NUM- PER BER CENT BER CENT BER CENT TOTAL 149 46 31 56 12 21 93 34 37 SEPARATE BUILDING 28 13 46 22 12 55 6 1 17 IN OTHER BUILDING 121 33 25 34 0 • 87 33 38 with adequate central office buildings for the health department programs as now being conducted are listed below: 1. Coffee County with central office in Manchester of nine rooms, 3,748 square feet of floor space, built for the health department In 1943 by the federal government. 2. Gibson County with central office In Trenton of sixteen rooms, 6,452 square feet of floor space, built for the health department in 1937 by the Commonwealth Fund. 3. Marshall County with central office In Lewlsburg of fifteen rooms, 2,883 square feet of floor space, built for the health department In 1944 by the Federal Works Administration and purchased by the county. 4. Monroe County with central office In Madlsonvllle of seven rooms, 1,574 square feet of floor space, built for the health department In 1941 by the county. 5. Montgomery County with central of- fice In Clarksville of fifteen rooms, 4,790 square feet of floor space, built for the health department In 1943 by the Federal Works Adminis- tration and purchased by the county. 6. Obion County with central office in Union City of nine rooms, 1,728 square feet of floor space, built for the health department In 1940 by the county. 7. Rutherford County with central of- fice In Murfreesboro of twenty-one rooms, 7,833 square feet of floor space, built for the health depart- ment in 1931 by the Commonwealth Fund. 8. Sullivan County with central office In Blountvllle of twelve rooms, 5,100 square feet of floor space, built in 1937 by the Commonwealth Fund. 9. Unicoi County with central office In Erwin of five rooms, 924 square feet of floor space. This Is a re- sidence built In 1927 which Is being used for the health department. 10. Weakley County with central office In Dresden of seven rooms, 1,980 square feet of floor space, built for the health department In 1938 by the county. 11. Williamson County with central of- fice In Franklin of twenty-five rooms, 4,770 square feet of floor space, built for the health depart- ment in 1936 by the county. 12. Nashville City Health Department of 62 rooms, 31,619 square feet of floor space In a separate building originally designed for a hospital in 1913. TABLE 1 If NUMBER OF ROOMS AND FLOOR SPACE IN ADEQUATE AND INADEQUATE CENTRAL AND AUXILIARY OFFICES AVERAGE SQUARE NUMBER OF AVERAGE FEET FLOOR SPACE TYPE OF OFFICE HEALTH TOTAL NUMBER OF PER PER FACILITIES ROOMS ROOMS FAC 1L1TY ROOM total 148* 667 4.5 129 7 288 CENTRAL OFFICE, ADEQUATE 1 1 1 41 12.8 3798 296 CENTRAL OFFICE. INADEQUATE 44 283 6.4 1708 266 AUXILIARY OFFICE. ADEQUATE 34 91 2.7 862 322 AUXIL1 ARY OFF ICE. INADEQUATE 59 152 2.6 775 301 ♦ One large health department facility with 62 rooms and 31, 619 square feet of floor space has been excluded from this table as It was very large and was not typical of health fac- llltles In Tennessee. 19 A higher proportion of the auxiliary offices In other buildings were considered adequate. Eleven of the fourteen offices In community centers, five In schools, three In hospitals and 14 others In various build- ings were adequate for the purposes for which they were being used. The number of rooms and floor space of adequate and Inadequate central and auxil- iary offices has been studied for use In planning for health department facilities (Table III). The adequate central offices of county health departments had 12.8 rooms while the Inadequate had only 6.4 rooms. The average square feet of floor space for adequate health departments, 3,798, was over twice that found In inadequate health departments, 1,708. The auxiliary offices consisted of 2.6 rooms on the average and of 807 square feet of floor space. The adequate and Inad- equate auxiliary offices differed only slightly In size. The numbers of rooms In adequate and inadequate central offices are given In Table IV. Since the adequate and Inadequate auxiliary offices did not differ In size, the combined data are presented. Although office space of less than five rooms was not satisfactory for central offices, two-thirds of the auxiliary of- fices had only one and two rooms and many of these small auxiliary offices were sat- Isfac tory, C. PERSONNEL OF HEALTH DEPARTMENTS For this section of the report the personnel employed In health departments has been' studied. The type of personnel, full-time or part-time, and the distribu- tion of the full-time personnel have been obtained. In Table V the personnel employed either full-time or part-time in the 56 health departments Is given according to type of personnel. T^BLE IV NUMBER OF ROOMS IN ADEQUATE AND 1 i NADEQUATE CENTRAL OFFICES AND AUXILIARY OFFICES NUMBER OF CENTRAL OFFICES AUXILIARY ROOMS ADEQUATE 1NADEOUATE OFFICES TOTAL 12 44 93 1 . . 31 2 - 6 30 3 - 7 15 4 • 8 6 5 1 5 2 6 - 5 4 7 2 4 1 8 - 2 1 9 2 - - 10 - 2 2 11 - 1 - 12 1 ■ ■ 13 - - - ' 14 - - 1 15 2 • • 16 AND OVER* 4 4 ■ ] ♦ Adequate central offices with 16, 21, 25 and 62 rooms; Inadequate central offices with 17, 18, 22 and 31 rooms. TABLE V FULL-TIME AND PART- TIME PERSONNEL EMPLOYED IN HEALTH DEPARTMENTS ACCORDING TO TYPE TYPE OF PERSONNEL TOTAL FULL- TIME PART- TIME TOTAL 782 732 50 MEDICAL 85 56 29 NURSING 271 263 8 SANITARY ENGINEERS ANf SANITARIANS 121 121 DENTISTS 2 2 TECHNICIANS 2 2 LABORATORY 22 21 1 VETERINARIANS 2 1 1 PHARMACIST 1 1 VENEREAL DISEASE INVESTIGATORS 5 5 HEALTH EDUCATORS 5 5 NON-PROFESSIONAL 266 255 1 1 Although usually full-time personnel are employed for health department work, fifty part-time persons were also working In health departments during the period covered In this survey. Twenty-nine of these were medical personnel assisting In clinics and eight were nurses. The total number of 20 20.000 population this would mean five workers. The minimum recommended staff for a health department has been the four-piece unit of health officer, nurse, sanitarian and clerk. The need for public health nur- ses would be at least one per 5,000. Thus the staff for a county of 20,000 population should be seven or 3.5 per 10,000 popula- tion. Ih only two city-county health depart- ments, two city health departments, one county with special program and one other county health department were there suffic- ient public health personnel for conducting the health department program. The types of personnel with rates per 10.000 population are given In Table VII for the state, for the four city areas with large health departments (Knoxville, Nash- ville, Chattanooga-HamlIton and Memphis- Shelby County), and for the other health doctors serving full-time or part-time was 85. There were 271 nurses and 121 sanitary engineers and sanitarians and 39 other pro- fessional personnel working In health de- partments. The non-professional personnel numbered 266. As given In these survey reports,there were 732 full-time workers In health depart- ments. On the basis of the total population of Tennessee, this gave 2.4 workers per 10,000 population. In the areas served,how- ever, there were 3.1 workers per 10,000 population. In Table VI and Figure 3 the numbers of workers per 10,000 population are shown for the county, city and district health departments. In only ten areas (two city, two city- county, five county and one district health department) were there as many as 2.5 work- ers per 10,000 population. For a county of TABLE Vt NUMBER OF FULL- TIME PERSONNEL IN COUNTY, CITY AND DISTRICT HEALTH DEPARTMENTS WITH NUMBER PER 10,000 POPULATION HEALTH DEPARTMENT NUMBER RATE HEALTH DEPARTMENT NUMBER RATE TOTAL 732 3. 1 MONROE 2 0.8 ROANE 3 1.0 COUNTY RUTHERFORD 12 3.5 ANDERSON 6 2.0 SEVIER 3 1.2 BLOUNT 6 1.4 SHELBY.MEMPH1S 208 5.5 BRADLEY 3 1 .0 SULLIVAN 16 2.1 CARROLL 3 1.2 SUMNER 14 4.1 COCKE 2 0 .8 TIPTON 3 1 . 1 DAY 1DSON 24 2.4 WASHINOTON 10 1 .8 FAYETTE 4 1.3 WEAKLEY 5 1 .7 61BSON 15 3.3 WILLIAMSON 9 3.4 GILES 4 1.3 GREENE 4 1 .0 CITY HAMBLEN 4 2. 1 KNOXVILLE 73 6.4 HAMILTON- CHATTANOOGA 70 3.7 NASHVILLE 94 5.4 HARDEMAN 3 1.2 \ HAWK 1 NS 4 1.3 DISTRICT HAYWOOD 6 2. 1 BEDFORD. COFFEE, FRANKLIN HENRY 5 1 .9 GRUNDY. MARSHALL. WARREN 30 2.6 KNOX 11 1 .5 BLEDSOE. RHEA. SEQUATCHIE 5 1.6 LAUDERDALE 5 2.0 CARTER. JOHNSON, UNICOI 8 1.2 L 1 NCOLN 4 1 .4 CROCKETT. DYER 9 1.7 M CM1NN 3 1 .0 HICKMAN. LEWIS 3 1 .4 MAD ISON- JACKSON 10 1 .8 LAKE. OBION 10 2.3 MAURY 4 0.9 MACON. TROUSDALE 5 2.3 MONTGOMERY 10 2.9 ' 21 FIGURE 3 FULL-TIME PERSONNEL IN HEALTH DEPARTMENTS AND DISTRICTS WITH NUMBER PER 10.000 POPULATION J.0 Persons and Over 0.1 - I.I4. Persons Separate City Health Departments Knoxville 6,ii. 1*5 - 2.9 Persons None Nashville departments In the state. The rates for the state are based on the estimated population for the entire state. For the two areas with full-time health service the rates are based on the population In those areas. There were 41 counties without full-time health service. Of the 732 full-time public health workers, 445 or 61 per cent were employed In the four health departments which In- clude the large cities of Tennessee. There were 5.2 workers per 10,000 population In these areas and only 1.9 per 10,000 popula- tion In the remaining counties with full- time health service. The nursing service In the state was limited to less than one pub- lic health nurse per 10,000 population. The number of personnel of each type per 10,000 population was greater for the four areas with large cities than for the other areas. As with hospital beds and other facilities, the cities are better able for financial TABLE VI 1 FULL- TIME PERSONNEL WITH RATES PER 10.000 POPULATION FOR FOUR LARGE HEALTH DEPARTMENTS AND FOR 52 OTHER HEALTH DEPARTMENTS ACCORDING TO TYPE OF PERSONNEL TYPE OF PERSONNEL TOTAL TWO-CITY COUNTY AND TWO CITY HEALTH DEPARTMENTS 52 OTHER HEALTH DEPARTMENTS NUMBER RATE NUMBER RATE NUMBER RATE TOTAL 732 2.4 445 5.2 28 7 1 .9 MED!CAL 56 0.2 23 0.3 33 0.2 NURS1NG 263 0.9 146 1.7 117 0.8 SAN 1 TAT 1 ON 121 0.4 81 1 .0 40 0.3 OTHER PROFESSIONAL 37 0.1 34 0.4 3 * NON-PROFESS 1 ONAL 255 0.8 161 1.9 94 0.6 * Less than 0.05 22 and other reasons to provide services for the population than are the other areas of the state. D. SERVICES RENDERED BY HEALTH DEPARTMENTS The kinds of services rendered by health department personnel are many; some can be measured and others cannot. Through the dally coding and counting of certain activities and through summaries of these activities from monthly tabulations, infor- mation was obtained regarding some of the work carried on In health departments. These services were principally office visits, field visits, Immunizations, and examina- tions. These services were rendered In the following programs; communicable disease control, venereal disease control, tubercu- losis control, maternity service. Infant and preschool hygiene, school hygiene, adult hygiene, morbidity service, crippled children service, general sanitation and protection of food and milk. These services are rendered by the personnel of the local health department. In addition, direct ser- vices In several fields such as In tubercu- losis control through mobile X-ray units. In dental hygiene through examinations and corrections, In Industrial hygiene, In nu- trition, In venereal disease control through treatment centers, are being provided by the State Health Department, Such services are not Included In this report as they are not administered by the local department. The coordinated plan for hospltal and health department facilities Is concerned princi- pally with the physical facilities for the local health departments and hospitals In the cities and counties of the state. For presentation of the services ren- dered (Table VIII) the office and field visits for the year 1944 for the 56 health departments* have been tabulated. Examina- tions, immunizations and visits for treat- ment and advice have been considered office visits. The field visits by sanitary engin- eers and sanitarians, public health nurses and medical officers are also given. ♦ For one health department data for 1945 were used; the services rendered were be- lieved to be practically the same as in 1944. TABLE VI 1 I OFFICE AND FIELD VISITS BY LOCAL HEALTH DEPARTMENT PERSONNEL ACCORDING TO TYPE OF SERVICE. 1944 SERVICE TOTAL OFFICE FIELD TOTAL 1 1.351.479 897.962 453.517 VENEREAL D1SEASE 447.088 414,316 32.772 TUBERCULOSIS 119,442 81.286 38.156 1MMUN1ZAT 1ONS 228.390 228.390 „ SANITATION 171.538 171.538 OTHER 385.021 173.970 211.051 For the year, the total number of vis- its obtained from these summaries was 1,351,479. Based on the estimated popula- tion Of 2, 394,873 for the area with full- time health service this would give 0.56 visits per capita. Nearly two-thirds of the visits were office visits (807,962) and the remaining were field visits (453,517). The year for which data were obtained was a war year and emphasis was placed on certain services by the health department personnel. One of these services was vener- eal disease control and one-third of the visits were for discovery of or treatment of syphilis, gonorrhea and other venereal diseases. Services In this field have chang- ed greatly In the last few years due to the rapid treatment of syphilis and use of pen- icillin In treatment of gonorrhea. At pre- sent, treatments for syphilis are being given in medical centers and thus the office visits In health departments have been re- duced. According to this tabulation, 119,442 or nine per cent of the visits by health department personnel were for tuberculosis control. At present through mobile and transportable units with use of small films, this service Is being extended and many thousands of X-ray examinations are being made through surveys In Industries, commun- ities and high schools. There were 228,390 persons Immunized In 1944. Immunizations refer to those per- sons who received the appropriate agent for active Immunization. Actually the number of office visits for such Immunizations prob- ably exceeded the number of persons Immun- 23 Ized. Immunizations have been divided ac- cording to type as follows: Smallpox 54, 2U0 Typhoid Fever 115, 111 Diphtheria 40,622 Whooping Cough 13,898 Other and Unspecified 4,469 The field visits for sanitation were divided according to type of program as follows: Environmental Sanitation 100,120 Food Sanitation 48 , 284 Milk Sanitation 23,134 In Environmental sanitation were Included visits to private premises In the Interest of construction of privies, septic tanks and water supplies; to swimming pools; to schools; to public water supplies and to sewage plants. The visits Included under other ser- vices were those for maternal and child hygiene, school hygiene, communicable di- sease control, crippled children service, examination of food handlers, etc. There were 385,021 visits In which such services were rendered. In addition to the tabulated office and field visits, services In recording of vital statistics and morbidity statistics were rendered routinely. The laboratory specimens handled through the health depart- ments were 568, 686. There were £,190 lec- tures reported with attendance of 168,699. These activities of the local health departments require administrative office space, clinic and laboratory space, confer- ence and demonstration rooms, space for re- cord files, space for dental and X-ray equipment, etc. In the central office and auxiliary clinic space In other buildings. E. EXPENDITURES BY HEALTH DEPARTMENTS The budgeted expenditures for the last fiscal year (July 1, 1944 - July 1, 1945) were given by the 56 health departments. Thus, the money available for local health service can be studied according to source of funds. In addition to the health work administered by local health departments, services are also rendered by the State Health Department personnel. In Table IX the amount of budgeted expenditures and per capita expenditures are given for the state and for the two areas with full-time health service. The total budgeted expenditures for the 56 local full-time health departments was $1,938,742 for the fiscal year. Based on the estimated population of Tennessee this was 64 cents per capita. Nineteen cents per capita from federal funds, four cents per capita from state funds, 40 cents per TABLE 1X budgeted EXPENDITURES BY HEALTH DEPARTMENTS WITH PER CAPITA EXPENDITURES FOR FOUR LARGE HEALTH DEPARTMENTS AND FOR 52 OTHER HEALTH DEPARTMENTS ACCORDING TO SOURCE OF FUNDS SOURCE FUNDS OF TOTAL EXP END 1TURES PER CAP 1 TA TWO Cl TV-COUNTY AND TWO CITY HEALTH DEPARTMENTS PER EXPENDITURES CAPITA 52 OTHER HEALTH DEPARTMENTS P ER EXPENDITURES CAPITA TOTAL $1 .938.742 $0.64 $1.095.944 $1.28 $842,798 $0.55 FEDERAL 578.315 0. 19 272.125 0.32 306.190 0.20 STATE 130.706 0.04 12,430 0.01 118.276 0.08 LOCAL 1,204 . 329 0.40 809.589 0.94 394.740 0.26 OTHER 25.39 2 0.01 1.800 * 23.592 0.02 * Less than 0.005 cents 24 capita from local funds and one cent per capita from other funds were spent for xull- tlme local health services. This amount of budgeted expendlturen per capita from all sources Is much below the minimum recommend- ed of $2,50 per capita for full-time health service. The two large city-county health de- partments, Memphls-Shelby and Chattanooga- Hamllton, and two city health departments, Knoxville and Nashville, were able to make greater provisions for health facilities than were the rural areas of the state. The per capita budgeted expenditures for these four areas was $1.28 while for the 52 other health departments It was $0.55. The expenditures of federal money with- in the state during this war year were gov- erned In part by special problems such as venereal disease control and location of military facilities. The year for which data were obtained was one In which health facilities were limited within the state. Sufficient med- ical and nursing personnel were not avail- able for carrying on health departments. Several departments were closed due to lack of personnel. Of the 41 counties without full-time local health service at the time of this survey, 21 had made financial pro- vision for health service at some time In the past. DISCUSSION Selected data regarding health depart- ments, the buildings now In use, the person- nel, services rendered and expenditures by health departments have been presented to show the size and nature of the program at present. Such data will be useful In plan- ning for the extension of the program to the entire population of the state and for the Integration of community services through construction of health department and hospital facilities. Planning for con- struction. of health department centers Is Included In Public Law 725., 79th Congress, known as the Hospital Survey and Construc- tion Act. According to the allowance under that law for public health centers, the number should not exceed one per 30,000 state population. For Tennessee this would be approximately 100. The planning for space for these health department services In hospitals and In separate buildings Is an Important part of the hospital plan. Discussion of the need In this field will be given In the fourth section of this re- port. 25 HOSPITAL AND HEALTH DEPARTMENT FACILITIES AND NEEDS IN TENNESSEE III. RELATED RESOURCES Many factors need to be considered In planning for hospital and health department facilities. Some of these factors which can be studied are population distribution, density of population, income, birth and death rates, use of hospitals, and availa- bility of medical, dental and nursing per- sonnel. Selected data for Tennessee and for the counties of the state are presented for use In the development of the hospital and health department program. A. POPULATION The distribution of the population, the growth and expected growth of the pop- ulation of the state and within the state, and the age distribution are all factors that need careful consideration In planning of facilities. The population of Tennessee according to the federal census on April 1, 1940 was 2,915,841. in the ten years from 1930 to 1940, an 11.4 per cent Increase was noted or an average Increase of 1.1 per cent per year. This percentage increase was only slightly less than that from 1920 to 1930 (Table I). census, there has been considerable move- ment of population. New Industries were es- tablished and many persons moved about, living for short periods of time In differ- ent sections of the country. Estimates of population by any method will be Inaccurate. It Is believed that In general the arithme- tic method provides population estimates which can be used and Interpreted with con- sideration of other known factors regarding the population. For the cities and counties of Tennessee It has been assumed that the annual Increase from April 1, 1930 to April 1, 1940 would continue beyond 1940. For the seven counties In which the population de- creased between 1930 and 1940, the 1940 census figures have been used. These fig- ures for the counties have been added to give the estimated population for the state for each year. The estimated population for Tennessee for 1944, the year for which data were obtained for this study, was 3,045,345. The estimated populations through 1950 would be as follows: 1944 3,045,345 1945 3,075,815 1946 3, 106,289 1947 3,136,755 1948 3, 167, 230 1949 3,197,704 1950 3, 228, 176 Such a growth of the population of Tennessee seems logical based on previous growth, and birth and death rates. The only unknown factors which could prevent such growth would be emigration of population from the state. Although during the war years, Tennessee lost over 200,000 persons to the armed forces, It Is believed that the majority of the military personnel have returned to the state. Even during the war years It did not seem advisable to exclude these persons from the population base as they were selected for service on the basis of good health. For birth, death, hospital bed and other rates, the estimated popula- tions as described above have been used. TABLE 1 POPULATION. INCREASE OF POPULATION AND PERCENTAGE INCREASE ACCORDING TO CENSUS. 1900-1940. TENNESSEE YEAR POPULATION INCREASE NUMBER PER CENT 1900 2.020.616 1910 2.184,789 164.173 8. 1 1920 2,337.885 153.096 7.0 1930 2,616.556 278.67 1 11.9 1940 2.915.841 299.285 11.4 Since the federal census Is taken only every ten years, estimates need to be made for populations In the Intercensal years. During the past few years since the 1940 26 The Department of Commerce Issued a report giving the estimated civilian popu- lation of the United States by counties on November 1,1943. These estimates were based on the registration for War Ration Book Four. This estimate for Tennessee was 2,818,226 which Indicated a loss of popula- tion from 1940 of 97,615. Using data for registrations for war ration books, statis- tics of military Inductions and separations, and statistics of births and deaths, the Department of Commerce released an estimate of civilian population for states for July 1, 1945. The estimated civilian population of Tennessee was 2,832,480 and the loss to the armed forces, 258,668. With the return of the majority of the military personnel It Is believed that the estimated popula- tion of Tennessee for 1946 would probably be similar to the figure obtained by using the arithmetic method, namely 3, 106, 289. The estimates of population for Tennessee without exclusion of military personnel seem preferable In the calculation of rates and analysis of data. The state Is divided Into 95 counties which vary In population from 4,117 to 380,251. There were 11 counties with less than 10,000 estimated population In 1944 and four with over 100,000 population. In the four counties with large populations are located the cities of over 100,000 pop- ulation, Chattanooga, Knoxville, Memphis and Nashville. There are eight smaller cities with populations from 10,000 to 30,000. These 12 cities with 10,000 popula- tion and over are given below with the counties In which they are located. City County City County Bristol Sullivan Jackson Madison Chattanooga. ..Hamilton Johnson City. .Washington Clarksville.Montgomery Kingsport Sullivan Cleveland Bradley Knoxville Knox Columbia Maury Memphis Shelby Dyersburg Dyer Nashville. Davidson The increase In 'population between 1930 and 1940 occurred In both urban and rural areas. The 12 cities listed above had an 11,3 per cent Increase In the ten years while the remainder of the population of Tennessee Increased 11.5 per cent. Only seven counties showed a decrease In popula- tion between 1930 and 1940. According to the last census, of the total population for Tennessee of 2,915,841 on April 1, 1940, 2, 395, 586 (82.2 per cent) were native white, 11,320 (0.4 per cent) were foreign born white, 508,736 (17.4 per cent) were negro and 199 were of other races. The colored population was distribu- ted unevenly over the state, in 1940, 56.3 per cent of the colored population of the state was concentrated In West Tennessee, with 30.5 per cent In Shelby County. In two counties In this section,. Fayette and Hay- FIGURE 1 PERCENTAGE OF POPULATION COLORED BY COUNTIES OF TENNESSEE. 1940 15.0 Pep cent and Over 5.0-9.9 P»r C«nt 10.0-14*9 P»r cent Less Than 5*0 o*at 27 TABLE 1 I POPULATION DISTRIBUTION BY BROAD AGE GROUPS ACCORDING TO CENSUS . 1900 - 19 40 YEAR TOTAL POPULATION POPULATION UNDER 15 NUMBER PER CENT POPULATION 15-44 NUMBER PER CENT POPULATION 45 - 64 NUMBER PER CENT POPULATION 65 AND OVER NUMBER PER CENT 1900 2.020.616 786.466 38.9 918.001 45.4 249,451 12.3 66 .698 3.3 1910 2.184.789 808.281 37.0 1.008.599 46.2 284.306 13.0 83,603 3.8 >920 2.337.885 844,338 36. 1 1 .0 57.610 45.2 334.654 14.3 101.283 4.3 1930 2.616.556 869.830 33.2 1.216,238 46.5 411.278 15.7 119.210 4.6 1940 2,915.841 856.003 29.4 1.405,712 48.2 482.348 16.5 171.778 5.9 wood, the colored population exceeded the white population. In Middle Tennessee the proportion of the population that was color- ed was less than that In West Tennessee. The percentages of the population which were colored are shown In Figure 1 by coun- ties. in 40 counties the colored population was less than 5.0 per cent of the total pop- ulation. In 25 others, the colored popula- tion was 5.0-9.9 per cent of the total and In 32 counties It was ten per cent or more of the population. The age distribution of the population needs to be considered In planning for hos- pitals. Rates of hospitalization Increase with advancing age and thus a population with a large proportion of persons In the older age groups would have a greater need for hospital beds for Illness than would a population with a small proportion of the population In the older age groups. The age distribution of the population of Tennessee has been changing. In 1900 38.9 per cent of the population was under 15 years of age while In 1940 only 29.4 per cent of the population was under 15 years. The percentage of the population 65 years and over has Increased from 3.3 In 1900 to 5.9 In 1940. The distribution of the popu- lation of Tennessee In four broad age groups Is given In Table II. The age distribution of the population of the counties of the state showed consid- erable variation. In many of the counties of East Tennessee the percentages of the population under 15 years of age were re- latively high. Counties with high percent- age of the population under 15 years were those that have a young population and high birth rate. These percentages are shown In Figure 2. While the percentages of the pop- ulation under 15 years of age were In gen- FIGURE 2 PERCENTAGE OF POPULATION UNDER 15 YEARS OF AGE BY COUNTIES OF TENNESSEE. 1940 J6.0 Per cent and Over 30-52.9 Per cent 53*0-55*9 P®r Less Than ?0.0 Par cent 28 FIGURE 3 PERCENTAGE OF POPULATION 65 YEARS AND OVER BY COUNTIES OF TENNESSEE. 1940 7.0 For cont and Over 5.0 - 5*9 Per cent 6.0 - 6.9 Per cent Loss Than 5.0 Per cent eral relatively high for counties In East Tennessee, the percentages of the population 65 years and over were relatively high in many counties In Middle and West Tennessee (Figure 3). The density of population varied wide- ly In the counties of Tennessee from 17.0 persons per square mile In Van Buren County to 511.1 persons per square mile In David- son County. With the exception of two coun- ties In Middle Tennessee and three counties In West Tennessee, the more densely popula- ted counties were found In East Tennessee. In East Tennessee there were 14 counties with 70.0 and over persons per square mile. The number of persons per square mile Is shown for the counties of Tennessee in Figure 4. B. FINANCIAL RESOURCES The financial resources of counties and of individuals are Important factors to be considered In planning for construction of hospitals and hospitalization of sick Individuals. For Information regarding the financial resources of counties, the Tax Aggregate Report of Tennessee for 1945-194$ prepared under direction of the State Board of Equalization, was used. The total amount FIGURE 4 DENSITY OF POPULATION BY COUNTIES OF TENNESSEE. 1944 70 Persons and More per Square Mile 30-U9.9 Person* per Square Mile 50-69.9 Persons per Square Mila Less Than JO Persons per Square Kile 29 Of'money available through county taxes was obtained by multiplying the t.ax'rate of each county by the assessed valuation. These county taxes are given In Table III to the nearest dollar. These figures In- clude only county taxes; there are In addi- tion city taxes which have not been used In this report. The county tax was divided by the estimated population for 1944 and thus the per capita tax was obtained. From the Report of Tennessee Department of Insurance and Banking the deposits of Individuals, partnerships, and corporations were obtain- ed. The deposits by counties were divided by the estimated population for 1945. These deposits per person are given In Table III. The average per capita county tax was $9.65. 'The range of these taxes was great from a low $2.89 per person In Pickett County to $17.28 in Morgan County. The county taxes per person are shown In Figure 5. The counties with taxes per person of $10.00 and over are scattered over the state with many of them In East Tennessee. The-sparsely populated areas on the Cumber- land Plateau and the section of the state near the Tennessee River as It flows north have low taxes. The county taxes as given In Table III will be considered In the pro- vision of local resources for hospital and health facilities. Counties with small populations and limited resources such as Van Buren County with only $13,411 In county taxes, Pickett County with $18,684, Moore with $£6,114, Sequatchie with $£8,7£8, and Union with $29,410 will have to combine their resources with neighboring counties In order to finance satisfactory hospitals and health facilities. The bank, deposits are useful In the analysis of the financial situation. From data published in Report of Tennessee De- partment of Insurance and Banking the de- posits per person In Tennessee were found to be $416 per person In 1945. There was con- siderable variation In these bank deposits per person by counties (Figure 6). The deposits per person for the four large city- counties, Davidson, Hamilton, Knox, and Shelby, exceeded $600 per person. Eighteen others had deposits of $350 or more per person, namely Bradley, Greene, Hamblen, and Washington In East Tennessee; Bedford, Coffee, Lewis, Marshall, Montgomery, Moore, Rutherford, Smith, Trousdale, Warren, and Wilson In Middle Tennessee; and Gibson, Madison, and Obion In West Tennessee. There were 30 counties In which the bank deposits were less than $200 per person. Counties with bank deposits of $350 or more per capita Include those best able to finance facilities while the group of counties with deposits of less than $200 per capita In- clude counties least able to finance hospi- tal and health facilities. FIGURE 5 COUNTY TAX PER PERSON. BY COUNTY. TENNESSEE (TAX AGGREGATE REPORT FOR 1945 - 1946) I 110.00 and Over Per Person ♦ 5.00-17.149 Per Person ♦7.50-19.99 Per Person Leas Than I5*00 Per Person 30 COUNTY TAXES* . TAXES PER PERSON AND BANK DEPOSITS2 PER PERSON BY COUNTIES OF TENNESSEE COUNTY COUNTY TOTAL TAXES P ER PERSON BANK DEPOSITS PER PERSON COUNTY COUNTY ' TOTAL FAXES PER PERSON BANK DEPOSITS PER PERSON STATE 129 .399 . 671 1 9.65 $ 416 LAKE Lauderdale 1 1 1,104 249.858 9.62 10.03 266 303 ANDERSON 274.782 9.35 219 LAWRENCE 247.943 8.39 27 3 BEDFORD 167,670 6.98 366 LEWIS 41.728 6 .84 355 BENTON 62.838 5. 11 237 LINCOLN 224,249 8.02 290 BLEDSOE 57.295 6.45 129 LOUDON 182.429 8.81 343 BLOUNT 704,280 15.95 319 MACON 56.929 3.71 171 BRADLEY 327.758 10.61 382 MCMINN 331.400 10.51 321 CAMPBELL 329,408 9.99 271 MCNA1RY 229.977 11.14 21 1 CANNON 69.700 6.78 202 MADISON 525,256 9.48 420 CARROLL 213,399 8.21 325 MARION 183.825 9.28 170 CARTER 453. 103 12.04 136 MARSHALL 232,590 14.34 454 CHEATHAM 85.019 8.24 164 MAURY 300.68 2 6.98 326 CHESTER 82.782 7.30 309 MEIGS 44,656 6.86 136 CLAIBORNE 182.612 7.36 156 MONROE 214.438 8.41 165 CLAY 57.572 5.02 91 MONTGOMERY 294. 156 8.55 379 COCKE 225.035 8.98 171 MOORE 26.114 6.34 368 COFFEE 97.948 4.93 407 MORGAN 275.454 17.28 1 10 CROCKETT 1 17,589 6.79 336 OBION 36 3.29 5 11.43 36 5 CUMBERLAND 113,322 6.53 204 OVERTON 73.085 3.80 134 DAY 1DSON 3 .323.085 12.22 688 PERRY 61.782 8.02 161 DECATUR 53.800 5.21 196 P 1 CKETT 18.684 2.89 243 DEKALB 54.100 3.67 225 POLK 243.040 15.71 310 D1CK SON 165.893 8.20 273 P UTNAM 181.166 6.63 310 DYER 408.454 11.22 309 RHEA 243.594 13,99 213 FAYETTE 246.828 7.98 101 ROANE 373.369 12.78 323 FENTRESS 81.515 5.21 104 ROBERTSON 341.432 11.61 279 FRANKLIN 211.683 8.54 300 RUTHERFORD 366.670 10.73 350 GIBSON 432,939 9.66 475 SCOTT 263.004 15.68 225 GILES 294.172 9.88 306 SEOUATCHIE 28.728 5.26 151 GRA1NGER 84.698 5.63 87 SEVIER 126.429 5. 16 287 GREENE 414.812 10.06 371 SHELBY 3,067.421 8.07 703 GRUNDY 58.434 4.74 132 SMITH 133.936 8. 15 356 HAMBLEN 212.680 10.93 457 STEWART 59,528 4.36 143 HAMILTON 2 .554.391 13.49 636 SULL1 VAN 827.751 10.79 335 HANCOCK 40.093 3.37 55 SUMNER 285.57 3 8.29 278 HARDEMAN 261.657 10.82 259 TIPTON 281.355 9.95 288 HARDIN 106.90 5 5.78 162 TROUSDALE 59,642 9.44 520 HAWK INS 214,026 7.04 252 UNICOI 164.147 11,13 146 HAYWOOD 166.880 5.88 190 UNION 29,410 3.26 • HENDERSON 152.620 7.68 278 VAN BUREN 13.411 3.09 82 HENRY 302.746 1 1.70 332 WARREN 1 16.575 5.90 47 5 HICKMAN 114.393 7.42 224 WASHINGTON 487.475 9.01 416 HOUSTON 46.583 6.85 131 WAYNE 59.176 4.14 168 HUMP HREYS 92,034 7.31 205 WEAKLEY 282.610 9.55 325 JACKSON 92.963 5.91 187 WHITE 81.281 5.03 344 JEFFERSON 234.196 12.38 236 WILLIAMSON 284.997 10.87 29 5 JOHNSON 61 .035 4.58 135 WILSON 206.245 7.98 361 KNOX 2 .396.345 12.74 663 1. Taxes from 2. Deposits o Popnlation Banking. Tax Aggregate f Individuals, of Tennessee. Report for 1945-1946, State Board of Equali tation. Partnerships, and Corporations on Dec. 31, 1945 divided by Estimated Data for Deposits from Report of Tennessee Department of Insurance and 31 FIGURE 6 AVERAGE BANK DEPOSITS PER PERSON BY COUNTIES OF TENNESSEE. 1945 (BANK DEPOSITS FROM REPORT OF TENNESSEE DEPARTMENT»OF INSURANCE AND BANKING) $350 and Over Par Paraon ♦200 - |27l* Par Paraoi 1275 - I5U9 Par Person Last Than |200 Per Paraoi Although some of the counties with relatively large bank deposits have high county taxes, this relation was not observed for all counties. Thus both bank deposits and county taxes will be useful In consider- ing the ability of counties and Individuals to pay for hospitalization and health work. C. VITAL STATISTICS DATA Vital Statistics data are necessary for understanding health problems and for hospital planning. For sound Interpretation of these data and for *use In planning, the factors which Influence registration need to be understood. The Tennessee Vital Statistics Law re- quires the attending physician, midwife, or other person attending a birth to file a birth certificate with the local registrar. The undertaker, or person burying a body, Is responsible for filing a death certifi- cate. The local registrar, appointed by the State Health Department, sends the cer- tificates to the State Health Department for filing. In counties with full-time health service, the health officer is also the registrar and the health department personnel assists In securing registration of all births and deaths In the area. Registration of deaths Is known to be Incomplete In many of the poorer and less densely populated counties such as on the Cumberland Plateau and In the section cut by the Tennessee River as It flows north. These are areas without health departments, with few hospital beds, and with few doc- tors. If doctors are not In attendance at birth and death, certificates may not be filed and even If death certificates are filed usually the causes of death will not be known. Without accurate data regarding deaths, the size and nature of health prob- lems In these areas can not be known. With the addition of full-time health service in any area, more certificates of births and deaths are filed and registration becomes more complete. During the war years, 1943 and 1944, vital statistics data were affected by the war. Registration of births Improved with the Institution of a cooperative program with the Office of Price Administration. Birth certificates were required for the receipt of food ration books for Infants. This Improvement In registration of births affects the birth rates and also infant and maternal death rates which are based on the live births. Consideration of these factors regarding registration Is Important In In- terpreting the birth and death rates which are presented In this section. The birth rate for Tennessee Increased during the war years due to an Improvement in current registration and to an actual Increase in births. The birth rate of 23.8 per 1,000 population In 1943 was the high- est on record for Tennessee for the period 32 FIGURE 7 AVERAGE ANNUAL BIRTH RATES PER 1.000 POPULATION BY COUNTIES OF TENNESSEE FOR FIVE-YEAR PERIOD 1940-1944. RESIDENT DATA 25.0 and Per 1,000 Population 19.0-20.9 Per 1,000 Population 21.0-22.9 Per 1,000 Population Less Than 1Q.0 Per 1,000 Population for which data are available; that Is from 1917. The provisional figure for 1946 Indi- cates that a new record will be established; for 1946, 76, 171 birth certificates have been filed and the provisional birth rate was 24.5per 1,000 population. For the five- year period, 1940-1944, for which data have been assembled for this study, the: average annual number of births was 64,817 and the birth rate was 21.7. The average annual numbers of births are given by counties In Table IV and the birth rates are shown In Figure 7. Resident data are given for the state and for the counties. High birth rates were noted In many counties In East Tennessee. As seen In Fig- ure 2, counties with high percentages of the population under 15 years of age were also found In that section. This section of the state has a young, rapidly growing pop- ulation. Probably registration was Incom- plete in several of the counties with rela- tively low birth rates. From the study* of hospital beds need- ed In relation to births and deaths It was estimated that four beds at 75 per cent occupancy were needed for each 100 births for an average length of stay of mothers at time of delivery of 11 days. From the data regarding births by counties the number of beds needed for obstetrics can be estimated. The death rate for Tennessee has shown a slight decline In the war years. The average number of deaths per year for the five years, 1940-1944, was 28,828 which gave a death rate of 9.7 per 1,000 popula- tion. The number of deaths and death rates by counties according to residence of the deceased are given In Table IV and the rates are shown In Figure 8. The low death rates such as those of 2.7 per 1,000 population In Fentress County, 3.2 per 1,000 population In Pickett County, etc. Indicate lack of registration. Medical and health facilities are lacking; many deaths are not attended by physicians and certificates are not filed. Death rates of less than 8.0 per 1,000 population are usu- ally due to poor registration. Only In the counties with adequate facllltles are deaths properly certified by physicians and re- corded with the State Health Department. According to the Michigan Study refer- red to above, for the country as a whole the public uses about 250 days of general hospital care for each death and correlated sickness In a general hospital giving a bed-death ratio of 0.7. If 50 per cent of all deaths occur in general hospitals and the death rate Is 10.0 per 1,000 population, using a bed-death ratio of 0.7 and 75 per cent occupancy, 4.7 hospital beds would be needed per 1,000 population. From the data regarding deaths by counties and consider- ing incompleteness of registration the nura- * “Hospital Resources and Needs,” Report of the Michigan Hospital Survey, W. K. Kellogg Found- ation, Battle Creek, Michigan, 1946. 33 TABLE IV AVERAGE ANNUAL NUMBER OF BIRTHS AND DEATHS WITH RATES PER 1 . 000 POPULATION BY COUNTIES OF TENNESSEE FOR THE FIVE-YEAR PERIOD. 1940- 1944. RESIDENT DATA B1RTHS DEATHS B1RTHS DEATHS COUNTY AVERAGE ANNUAL AVERAGE ANNUAL COUNTY AVERAGE ANNUAL AVERAGE ANNUAL NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE STATE 63 .047.0 21.1 27,965.0 9.4 LAKE 289.0 25.3 101.6 8.9 LAUDERDALE 588.2 23.8 248.6 10.1 ANDERSON 655.4 23.4 187.4 6.7 LAWRENCE 682.0 23.4 217.8 7.5 BEDFORD 471.4 20.0 245.4 10.4 LEWI S 1 17.0 19.6 47.2 7.9 BENTON 232.0 19.1 113.2 9.3 LINCOLN 553.8 20.1 267.8 9.7 BLEDSOE 231 T4 26.8 71 .6 8.3 LOUDON 493.4 24.3 165.8 8.2 BLOUNT 1 .260.6 29.5 320.6 7.5 MACON 268.2 17.7 125.2 8.3 BRADLEY 741 .0 24.9 262.6 8.8 MCMINN 701.6 22.5 246.8 7.9 CAMP BELL 869.0 27. I 242.2 7.5 MCNAIRY 420.2 20.5 167.4 8.1 CANNON 222.0 22.0 81.2 8.0 MAD 1 SON 1.063.4 19.4 587.2 10.7 CARROLL 488.4 18.8 261.0 10.0 MARI ON 514.2 26.4 184.6 9.5 CARTER 919.8 25.2 260.6 7. 1 MARSHALL 328.4 20.4 187.2 11.6 CHEATHAM 179.8 17.7 77.4 7.6 MAURY 845.2 20.2 457.0 10.9 CHESTER 197.8 17.6 92.2 8.2 ME IGS 155.4 24. 1 41.6 6.4 CL A 1 BORNE 565.4 22.9 162.6 6.6 MONROE 670.2 26.9 211.8 8.5 CLAY 209.6 18.7 56.6 5. 1 MONTGOMERY 641.4 18 .9 381.8 11.3 COCKE 585.2 23.8 226.2 9.2 MOORE 73.8 18.0 37.0 9.0 COFFEE 471.6 24.3 221.4 11.4 MORGAN 324.4 20.8 72.0 4.6 CROCKETT 370.2 21.4 138.2 8.0 OBION 523.2 16.7 325.6 10.4 CUMBERLAND 399.0 24. 1 100.2 6.1 OVERTON 38 5.2 20.2 89.6 4.7 DAVIDSON 5 . 1 28.2 19.4 2,901.4 10,9 P ERRY 155.8 20.4 61.6 8.1 DECATUR 202.2 19.6 80.2 7,8 P1CKETT 117.8 18.6 20.2 3.2 DEKALB 270.2 18.4 129.0 8.8 POLK 331.6 21.4 101.8 6.6 D1CK SON 404.0 20.2 156.4 7.8 PUTNAM 540.0 20.1 187.6 7.0 DYER 725.6 20.3 327.6 9.2 RHEA 432.0 25.5 147.8 8.7 FAYETTE 748.6 24.4 280.0 9.1 ROANE 726.0 25.4 248.4 8.7 FENTRESS 348.8 23,3 41.2 2.7 ROBERTSON 504.4 17.3 275,0 9.4 FRANKL1N 48 5.0 19.9 194.6 8.0 RUTHERFORD 710.0 20.9 369.2 10.9 6 1 BSON 906.4 20.2 436.6 9.7 SCOTT 367.6 22.4 83.6 5.1 GILES 532.0 18.0 272.0 9.2 SEQUATCHIE 143.2 27.2 41 .6 7.9 GRAINGER 295.6 20. 1 134.4 9.1 SEVIER 582.2 24.3 203.0 8.5 GREENE 835.0 20.7 374.4 9.3 SHELBY 7,293.0 19.7 4.193.6 11.3 GRUNDY 338.8 28.3 91 .4 7.6 SMI TH 276.6 17.0 139.6 8.6 HAMBLEN 458 .0 24.0 21 1.0 11.1 STEWART 243.2 17.9 1 13.6 8.3 HAMILTON 4 .038.6 21.8 2,060.4 11.1 SULL1 VAN 1,869.2 25.6 524.8 7.2 HANCOCK 223.6 19.3 47.8 4. 1 * SUMNER 621 .8 18.5 304.0 9.0 HARDEMAN 460.8 19.3 207.8 8.7 TIPTON 694.2 24.7 250.8 8.9 HARDIN 349.4 19.2 135.2 7.4 TROUSDALE 125.0 20.1 60.2 9.7 H AWK 1 N S 638.4 21 .6 209.2 7.1 UNICOI 354.8 24. 5 103.4 7,2 HAYWOOD 596.8 21.3 269.0 9.6 UN 1 ON 141.2 15.6 65.0 7.2 HENDERSON 352.2 18.0 147.6 7.5 VAN BUREN 86.8 20.6 28.8 6.8 HENRY 434.4 16.8 270.6 10.5 WARREN 398.6 20.2 204.8 10.4 H1CKMAN 303.8 20,0 121.8 8.0 WASHINGTON 1,113.8 21,0 453.0 8.6 HOUSTON 1 38.2 20.8 64.6 9.7 WAYNE 289.4 20.7 100.0 7.2 HUMPHREYS 238.8 19.1 1 20.8 9.7 WEAKLEY 423.8 14.3 302.0 10.2 JACKSON 319.4 20.7 85.8 5.6 WHI TE 363.8 22.6 155.0 9.6 JE FFERSON 448.4 23.9 176.2 9.4 WILL 1AMSON 512.2 19.9 252.4 9.8 JOHNSON 300.2 22.8 109.4 8.3 WILSON 455.0 17.8 271.2 10.6 KNOX 3 .944.8 21.5 1 .762.4 9.6 FIGURE 8 AVERAGE ANNUAL DEATH RATES PER 1,000 POPULATION BY COUNTIES OF TENNESSEE FOR FIVE-YEAR PERIOD. 1940-1944, RESIDENT DATA 10.0 and Over Per 1,000 Population 3.0-8.9 Per 1,000 Population 9.0-9.9 Per 1,000 Peculation Less Than 8.0 Per 1,000 Population ber of beds needed for general hospitals can be estimated. Infant and maternal death rates and tuberculosis death rates are shown for the Counties of Tennessee for the five-year peflod, 1940-1044, in Figures 9, 10, and 11. The Incompleteness of registration of deaths is evident on each one of these charts with low rates In the Upper Cumber- land region. Careful comparisons with the state rates and with rates In nearby count- ies, however, will be of value In under- standing the problems. For the state, aver- age annual rates for the five-year period were as follows: 49.1 Infant deaths per 1.000 live births, 3.4 maternal deaths per 1.000 live births, and 70.3 tuberculosis deaths per 100,000 population. FIGURE 9 AVERAGE ANNUAL INFANT DEATHS PER 1,000 LIVE BIRTHS BY COUNTIES OF TENNESSEE FOR FIVE-YEAR PERIOD 1940-1944, RESIDENT DATA Per 1,000 Live nlrths S*>.0 and Over Per 1,000 Live Births U5.0i5t.9 °er 1,000 Live Births Leas .0 ner 1,000 Ll”e Births D. BIRTHS AND DEATHS IN HOSPITALS Data regarding the place of birth and death given on the certificates Include the name of the hospital If birth or death otcurred In a hospital. The numbers and percentages of the births and deaths occur- Ing In hospitals can thus be obtained from analysis of data from the birth and death certificates filed In the State Health De- partment. 35 FIGURE 10 AVERAGE ANNUAL MATERNAL DEATHS PER 1.000 LIVE BIRTHS BY COUNTIES OF TENNESSEE FOR FIVE-YEAR PERIOD 1940-1944. RESIDENT DATA ij.,5 and Over Per 1,000 Live Births 2.5-5.I4 Per 1,000 Live Births 3.5Per 1,000 Live Births Less Than 2.5 Per 1,000 Live Births The number of births* occurring In hospitals In Tennessee has shown a rapid Increase In recent years. In 1934, the first year for which these data are available, * Birth used in this report refers to lire birth. only 7,674 births were known to have occur- red in hospitals while In 1945, 36,084 or 4.7 times as many occurred In hospitals. The percentage of births occurring in hos- pitals has Increased from 14.7 In 1934 to 54.2 In 1945. The numbers and percentages FIGURE 11 AVERAGE ANNUAL TUBERCULOSIS DEATH RATES PER 100.000 POPULATION BY COUNTIES OF TENNESSEE FOR FIVE-YEAR PERIOD 1940-1944. RESIDENT DATA SO.O and Over °er 100,000 Population 65.0-79.9 Per 100,000 Population 5O.O-6I4..9 Per 100,000 Population Less 'Tlian 50.0 Per 100,000 Population of births occurring In hospitals by year are given In Table V. For study of the use of hospitals for delivery of mothers In urban and rural areas of Tennessee, the data for the twelve cities of over 10,000 population termed the urban area and for the rest of Tennessee, the rural area, have been obtained. The percentage of births In hospItals to mothers who were residents of the urban area has Increased from 49.7 In 1934 to 79.2 in 1946. The increase for mothers of the rural area was from 2.9 per cent in 1934 to 42.5 per cent In 1945. These Increases In the percentages of births In hospitals are seen In Figure 12. It Is evident that in both TABLE V NUMBER AND PERCENTAGE OF BIRTHS OCCURRING IN HOSPI TALS IN TENNESSEE. 1934- 1945 HOSPITAL B1RTHS YEAR B1RTHS NUMBER PER CENT 1934 52.351 7.674 14.7 1935 53,234 8.428 15.8 1936 50,514 9.536 18,9 1937 51.936 10.638 20.5 1938 53.667 12.348 23.0 1939 53.473 13,708 25.6 1940 55.669 16.662 29.9 1941 60.482 20,830 34.4 1942 66.367 26.223 39.5 1943 71 .766 31.356 43.7 1944 69 .799 34.200 49.0 1945 66.6 20 36.084 54.2 FIGURE 12 PERCENTAGE OF BIRTHS IN HOSPITALS ACCORDING TO RESIDENCE OF MOTHER IN URBAN AND RURAL AREAS OF TENNESSEE. 1934-1945 urban and rural areas hospital deliveries are Increasing. Further Increases will de- pend on the provision of hospital beds. For the approximately 30,000 births now occur- Ing In homes, 1,200 hospital beds for ob- stetrics only would be required for hospi- talization of these mothers at the time of delivery. The percentage of births In hospitals has been obtained to show the use of hospi- tals by mothers resident of the counties of Tennessee (Figure 13). The variation In the percentage was great, from 2.5 for Lewis County to 84.2 for Davidson County. Uome mothers living In counties without hospitals had hospital deliveries by going to hospi- tals outside the county. Usually In such counties either a doctor or a midwife at- tended the delivery In the home. Data are available for study of deaths In hospitals In 1944 and in 1937. In 1944, 9,251 deaths occurred In the hospitals of FIGURE 13 PERCENTAGE OF BIRTHS IN HOSPITALS. BY COUNTIES OF TENNESSEE 1944. RESIDENT DATA i*0 P»r Cent and Over 20-39.9 Per Cent Less Than 20 Per Cent 37 Tennessee. Based on the total deaths of 28,619 in 1944, 32.3 per cent of the deaths were deaths In hospitals. Of these deaths, 7,793 occurred In general hospitals, 780 In nervous and mental hospitals, 288 In tuber- culosis hospitals and 390 In veterans hos- pitals. The hospitals of Tennessee are used by residents of neighboring states, especially the hospitals In Memphis by persons from Arkansas and Mississippi. Of the 9,251 hos- pital deaths, 1,169 were of non-residents. There were 322 deaths of residents of Tenn- essee which occurred In hospitals outside of Tennessee. Considering only deaths of resi- dents of Tennessee, 8,4Q4 occurred In hos- pitals. Based on total deaths of residents of Tennessee 30.4 per cent occurred In hos- pitals. Although the number of deaths In hos- pitals has Increased, this Increase was not as great as for births In hospitals. Bata regarding deaths of residents of Tennessee are available for 1937. In that year 6,882 of the deaths of residents of Tennessee oc- curred In hospitals or 23.5 per cent. The Increase In deaths In hospitals has been greater for residents of the rural areas than for the urban areas of Tennessee from 1937 to 1944 (Table VI). The percehtage of deaths In hospitals in the urban area Is approaching 50 per cent. TABLE VI NUMBER AND PERCENTAGE OF DEATHS OF RESIDENTS OF TENNESSEE IN HOSPITALS FOR URBAN AND RURAL AREAS. 1937 AND 1944 1 937- 1944 AREA TOTAL HOSP1TAL DEATHS TOtAL HOSPITAL DEATHS DEATHS NUMBER PER CENT DEATHS NUMBER PER CENT TOTAL 29.330 6.882 23.5 27.652 8.404 30.4 URBAN 9,928 4.1 89 42.2 9,532 4,290 45.0 RURAL 19.402 2,693 13.9 18,120 4.114 22.7 These hospital deaths for Tennessee refer to all types of hospitals and the ex- pectancy of 50 per cent Is for general hos- pitals, For 1944, 7,066 or 84.1 p-er cent of the hospital deaths of residents of Tennes- see were In general hospitals. In the urban area In 1944, 3,595 or 37.7 per cent of the total deaths occurred In general hospitals. The percentage of deaths In the rural area In general hospitals was 19.2. Thus there FIGURE 14 PERCENTAGE OF RESIDENT DEATHS OCCURRING IN HOSPITALS. BY COUNTIES OF TENNESSEE. 1944 25.0 Per Cent and Over 20.0-2U.9 Per Cent 15.0-19.9 Per Cent Loss Than 15.0 Per Cent 38 can be considerable Increase In hospital deaths of residents of the rural area If general hospital beds are available for use of residents of the rural area. The percentage of deaths In hospitals has been obtained to show the use of hospi- tals by residents of the counties of Tenn- essee (Figure 14). Only In the large city- counties of Davidson, Hamilton, Knox and Shelby and In Anderson County which has a new hospital for workers at Oak Ridge were the percentages over 40. In Shelby County nearly 50 per cent (49.7) of the deaths of residents were In hospitals. In several counties the percentages of deaths In hos- pitals were small Indicating that hospital care was probably not available for the sick persons In those areas. Deaths In hospitals have been studied according to cause of death (Table VII). There was considerable variation In the percentages of the deaths In hospitals for the specific causes. The percentages for some diseases such as tuberculosis, 31.1, pneumonia, 30.9, and diphtheria, 46.8 were too low and indicate that hospital facili- ties are needed for care of the sick and prevention of some of the deaths. TABLE VI 1 NUMBER AND PERCENTAGE OF DEATHS IN HOSPITALS BY CAUSE FOR TENNESSEE. 1944 TOTAL DEATHS IN HOSPITALS TOTAL DEATHS IN HOSPITALS CAUSE OF DEATH DEATHS NUMBER PER CENT CAUSE OF DEATH DEATHS NUMBER PER CENT ALL CAUSES 28.619 9,251 32.3 OTHER RESPIRATORY DISEASES 297 109 36.7 TYPHOID AND PARA- DIARRHEA AND ENTER- 1 1 63.6 TYPHOID FEVER 7 ITIS. UNDER 2 YRS. 396 177 44.7 MENINGOCOCCUS DIARRHEA AND ENTER- 86 69 80.2 MENINGITIS ITIS. 2 YRS. AND WHOOPING COUGH 63 12 19.0 OVER 89 29 32.6 DIPHTHERIA 47 22 46.8 APP END 1C1T1S 178 155 87.1 TUBERCULOSIS. ALL HERNIA. INTESTINAL FORMS 1 .883 586 31.1 OBSTRUCTION 270 209 77.4 DYSENTERY 65 25 38.5 OTHER DISEASES OF THE 348 255 73.3 DIGESTIVE SYSTEM 734 378 51 .5 SYPHILIS. ALL FORMS 662 78 1 1 .8 NEPHRITIS 1 .827 421 23.0 INFLUENZA 69 13 18.8 OTHER DISEASES OF THE MEASLES GENITO-URINARY POLIOMYELITIS 18 10 55.6 SYSTEM 393 255 64.9 OTHER INFECTIOUS AND DISEASES OF PREGNANCY. PARASITIC DISEASES 1 53 83 54.2 CHILDBIRTH AND 2.651 817 30.8 PUERPER1UM CONGENITAL MALFORMA- 191 134 70.2 CANCER. ALL FORMS ACUTE RHEUMATIC 44 18 40.9 TIONS AND DISEASES FEVER PECULIAR TO THE DIABETES mellitus 380 179 47.1 FIRST YEAR OF L1FE 1 .641 944 57.5 PELLAGRA 83 12 14. 5 SENILITY 348 68 19.5 CEREBRAL HEMORRHAGE. SUICIDE 200 52 26.0 EMBOLISM. ETC. 2.741 619 22.6 HOMICIDE 31 1 1 33 42.8 OTHER DISEASES OF 442 228 51 .6 MOTOR VEHICLE THE NERVOUS SYSTEM ACCIDENTS 477 250 52.4 DISEASES OF THE 6.122 1,237 20.2 OTHER ACCIDENTAL HEART DEATHS 1 .399 528 37.7 DISEASES OF THE 370 147 39.7 ALL OTHER DEFINED ARTERIES CAUSES 588 282 48.0 OTHER DISEASES OF THE 34 30.9 ILL-DEFINED AND ClRCULATORY SYSTEM 110 UNKNOWN CAUSES 1 .297 171 13,2 PNEUMONIA 1 .635 505 30.9 39 E. ATTENDANCE AT BIRTH BY MIDWIVES TABLE Vf 1 \ NUMBER AND PERCENTAGE OF BIRTHS ATTENDED BY MIDWIVES IN TENNESSEE, 1933 - 1945 ATTENDED BY YEAR BIRTHS MIDWIVES . NUMBER • PER CENT 1933 50.039 7.376 14.7 1934 52,351 7.168 13.7 1935 53.234 6.976 13; 1 1936 50.514 6.641 13.1 1937 51 .936 6.312 12.2 1938 53,667 6.013 11.2 1939 53.473 5.548 10.4 1940 55,669 6.029 10.8 1941 60.482 6.165 10.2 1942 66.367 6,326 9.5 1943 71.766 6.217 8.7 1944 69.799 5.577 8.0 1945 66.620 5.039 7.6 In recent years there has been an In- crease In the use of hospitals for delivery. At the same time there has been a decrease In births attended by midwives. Although 5,039 births were attended by midwives In 1945, It Is expected that this number will decrease If the trend of recent years con- tinues. In Table VIII the numbers and per- centages of births attended by midwives by years from 1933 to 1945 are given. In 1933, 7,376 or 14.7 per cent of the births were attended by midwives while In 1945, 5,039 or 7.6 per cent were attended by midwives. The attendance at birth by midwives has almost been discontinued In the urban area for in 1944 only 359 or 2.0 per cent of these births were attended by midwives. TABLE 1 X NUMBER AND PERCENTAGE OF BIRTHS ATTENDED BY MIDWIVES FOR URBAN AND RURAL AREAS. BY COLOR, RESIDENT DATA. 1944 TOTAL WHITE COLORED ATTENDED BY ATTENDED BY ATTENDED BY AREA TOTAL MlDWIVES TOTAL MlDWIVES TOTAL MlDW1VES B1RTHS NUMBER PER CENT BIRTHS NUMBER PER CENT B1RTHS NUMBER PER CENT URBAN AREA 18,085 3 59 2.0 13.288 96 0.7 4,795 *62 5.5 RURAL AREA 49,015 5. 185 10.6 43.069 2.838 6.6 5.936 2,342 39.5 In rural areas, however, 5,185 or 10.6 per cent of the births were attended by mid- wives (Table IX). The percentage of colored births In the rural area attended by ifild- wlves (39.5) was high. There were two areas In the state where relatively large proportions of the births were attended by midwives (Figure 15). One of these sections was In West Tennessee In the counties with large., pro- portions of the population colored. For Fayette County, the percentage was 65.2 for 1944 and for Haywood, 51.8 for 1944. In this area with a large Negro population there are Negro midwives attending births. The other section Included several mountain- ous counties on the Cumberland Plateau. For Fentress County the percentage was 36.3 In 1944. In this area there are white mid- wives attending births. F. MEDICAL. DENTAL AND NURSING PERSONNEL In considering provision of hospital and health department facilities, personnel available at present and needed In the fu- ture for a satisfactory program Is Import- ant. In this section of the report data re- garding medical, dental and nursing person- nel In Tennessee are presented. For the. Study of Child Health Services of the American Academy of Pediatrics, data* were assembled for physicians and dentists In private practice In Tennessee. An effort was made to obtain Information regarding all physicians and dentists In private practice in Tennessee In the late spring and summer of 1946. Physicians and * Preliminary statistical data to be published by American Academy of Pediatrics, quoted with permission of Chairman for Tennessee. 40 FIGURE 15 PERCENTAGE OF BIRTHS ATTENDED BY MIDWIVES. BY COUNTIES OF TENNESSEE. 1944 >.0 P-"Ce-'t 10-19.9 Per Cent Tbs.- 10 P*r Cent dentists engaged solely In institutional, Industrial or public health work: and In university teaching were excluded. With these exclusions there were found to be only 1,626 physicians and 809 dentists In pri- vate practice In Tennessee. The numbers of physicians and dentists In private practice with rates per 10,000 population are given by counties In Table X and the rates are shown In Figures 16 and 17. On the basis of the population of Tennessee, there were 5.2 physicians In private practice per 10,000 population or one for 1910 people. Over half of these physicians were located In the four large city-counties, Davidson, Hamilton, Knox and Shelby. For these metropolitan counties there were 8.5 physicians per 10,000 popu- lation. In the rest of the state there were only 732 physicians or 3.6 per 10,000 pop- ulation. In many of the rural poorer coun- ties the medical service available was lim- ited with only one or two doctors for 10,000 people. There were.,809 dentists In private practice or 2.6 per 10,000 population. In the large city-counties there were 455 den- tists or 4.3 per 10,000 population while In FIGURE 16 PHYSICIANS IN PRIVATE PRACTICE PER 10,000 POPULATION BY COUNTY. STUDY OF CHILD HEALTH SERVICES. TENNESSEE. 1946 I.1: . ■ ■ 10,000 . . . : 5 Cii U.O - 7.k per 10,000 population Less than if.C per 10,000 population 41 1 At5L t PHYSICIANS AND DENTISTS IN PRIVATE PRACTICE WITH RATES PER 10 .000 POPULATION BY COUNTY. STUDY OF CHILD HEALTH SERVICES*. TENNESSEE. 1946 PHYSICIANS DENT1STS PHYSICIANS DENTISTS COUNTY NUM. NUM- COUNTY NUM- NUM- BER RATE BER RATE BER RATE BER RATE TOTAL 1 .626 5.2 809 2.6 LAKE 5 4.3 4 3.4 LAUDERDALE 10 4.0 5 2.0 ANDERSON 14 4.6 10 3.3 LAWRENCE 9 3.0 3 1.0 BEDFORD 12 4.9 6 2. 5 LEWIS 2 3.2 1 1 .6 BENTON 3 2.4 3 2.4 LINCOLN 13 4.6 4 1.4 BLEDSOE 2 2.2 2 2.2 LOUDON 6 2.8 3 1.4 BLOUNT 22 4.8 9 2.0 MACON 2 1.3 2 1,3 BRADLEY 13 4.1 4 1.2 MCMINN 15 4.7 9 2.8 CAMP BELL 19 5.6 4 1.2 MCNA 1RY 6 2.9 2 1 .0 CANNON 3 2.9 1 1 .0 MADISON 31 5.5 17 3.0 CARROLL 1 1 4.2 5 1.9 MAR 1 ON 3 1.5 4 2.0 CARTER 10 2.6 5 1.3 MARSHALL 5 3.1 2 1 .2 CHEATHAM 3 2.9 0 • MAURY 20 4.5 13 2.9 CHESTER 2 1.7 1 0.9 ME I 6S 2 3.0 0 - CLA1 BORNE 7 2.8 3 1.2 MONROE 10 3.B 4 1.5 CLAY 2 1.7 0 ■ MONTGOMERY IB 5.2 10 2,9 COCKE 8 3.1 3 1.2 MOORE 1 2.4 0 - COFFEE 8 3.9 6 3.0 MORGAN 5 3. 1 0 - CROCKETT 6 3. 5 2 1.2 OBION 16 5.0 12 3.7 CUMBERLAND 6 3.3 1 0.5 OVERTON 5 2.8 2 1.0 D A V1DSON 240 8.6 122 4.4 PERRY 1 1.3 0 • DECATUR 4 3.9 1 1 .0 PICKETT 1 1.5 0 ■ DEKALB 4 2.7 1 0.7 POLK 5 3.2 0 - DICKSON 4 2.0 4 2.0 PUTNAM 7 2.5 5 1 .8 DYER 20 5.4 8 2,2 RHEA 5 2.8 5 2.8 FAYETTE 6 1.9 2 0.6 ROANE 10 3.3 7 2.3 FENTRESS 4 2.5 1 0.6 ROBERTSON 11 3.7 3 1.0 FRANK L I N 5 2.0 5 2.0 RUTHERFORD 18 5.2 9 2.6 G1BSON 18 4.0 10 2.2 SCOTT 4 2.3 3 1 .7 GILES 12 4.0 4 1.3 SEOUATCHIE 0 - 0 - GRAINGER 3 2.0 0 - SEVIER 8 3.2 2 0.8 GREENE 11 2.6 7 1 .7 SHELBY 352 9.0 201 5.1 GRUNDY 2 1.6 1 0.8 SMITH 5 3.0 1 0.6 HAMBLEN 8 4.0 6 3,0 STEWART 3 2.2 1 0.7 HAMILTON 153 7.9 64 3,3 SULLIVAN 34 4.2 24 3.0 HANCOCK 2 1.6 1 0.6 SUMNER 15 4.3 6 1.7 HARDEMAN 8 3.3 3 1 .2 TIPTON 11 3.9 2 0.7 HARD 1N 4 2. 1 1 0.5 TROUSDALE 4 6.2 1 1.6 HAWK 1 NS 11 3.5 3 1.0 UNICOI 3 2.0 2 1.3 HAYWOOD 10 3.5 4 1.4 UN 1 ON 1 1. 1 0 • HENDERSON 4 2.0 2 1.0 VAN BUREN 1 2.2 0 - HENRY 14 5.4 9 3.5 WARREN 4 2.0 5 2.5 H1CKMAN 5 3,2 1 0.6 WASH 1NGTON 27 4.9 15 2.7 HOUSTON 1 1 .4 1 1.4 WAYNE 5 3.4 1 0.7 HUMP HREYS 3 2.4 1 0.8 WEAKLEY 1 2 4.0 7 2.4 JACKSON 4 2.5 0 ■ WHITE 6 3.7 3 1 .8 JEFFERSON 8 4.2 3 1.6 WILLIAMSON 7 2.6 5 1 .9 JOHNSON 2 1.5 3 2.2 WILSON 10 3.8 3 1 . 1 KNOX 149 7.7 68 3.5 COUNTY UNKNOWN 2 0 - * Preliminary statistical data to be publi shed by American Academy of Pediatrics, quoted with per- mission of Chairman for Tennessee. 42 FIGURE 17 DENTISTS IN PRIVATE PRACTICE PER 10.000 POPULATION BY COUNTY. STUDY; OF CHILD HEALTH SERVICES. TENNESSEE. 1946 .0 and over -er 10,000 population r.5 - 2.9 per 10,000 population 0.1 - l.k per 10,000 population None the rest of the state there were only 354 or 1.7 per 10,000 population. Thirteen coun- ties were without a dentist. To obtain data regarding nurses, the Directory of Registered Nurses of Tennessee of the Committee on Nursing Education and Nursing Practice for 1945-1940 was used. There were 5,234 nurses listed In the dir- ectory. Of these, 1,643 gave addresses In other states. Many of these nurses living in other states (463) were not in active nursing, 446 had governmental positions and 294 were engaged In Institutional nursing. The number of registered nurses with Tennessee addresses was 3,591 and of these, 548 were not In active nursing. The type of nursing of the 3,043 nurses believed to be active In nursing at present In Tennessee Is given In Table XI. More nurses were working In Institu- tions, which Include the hospitals, than In any other type of nursing. There were 794 nurses In private duty. Based on the popu- lation of Tennessee, the number of private duty nurses was 2.6 per 10,000 population. Nearly all of these registered nurses in TABLE XI REGISTERED NURSES WITH TENNESSEE ADDRESSES ACCORDING TO TYPE OF NURSING WITH RATES PER 10 .000 POPULATION FOR FOUR LARGE CITY-COUNTIES AND THE REST OF THE STATE FOUR LARGE REST OF TYPE OF TOTAL CITY -COUNTIES STATE NURSING NUMBER RATE NUMBER RATE NUMBER RATE TOTAL 3,043 10.0 2,153 20.9 890 4.4 INSTITUTIONAL 904 3.0 655 6.4 249 1.2 PRIVATE DUTY 794 2.6 677 6.6 117 0.6 OFFICE NURSING 170 0.6 119 1.2 51 0.3 GOVERNMENT 314 1.0 193 1.9 121 0.6 MISCELLANEOUS 111 0.4 85 0.8 26 0. 1 INDUSTRIAL 195 0.6 97 0.9 98 0.5 PUBLIC HEALTH 310 1.0 209 2.0 101 0.5 UNKNOWN 245 0.8 118 1 . 1 127 0.6 43 private duty (85 per cent) were living In the four large city-counties. Only 117 pri- vate duty nurses were living In the remain- ing area of Tennessee or approximately one per 17,000 people. Of the 3,043 registered nurses, 2,153 or 71 per cent were living In the four large city-counties. The rate per 10,000 population was 20.9. Only 890 or 4.4 per 10,000 population were rendering service to the rest of the population of Tennessee. For use In planning for extension of hospital facilities the number of nurses now working In hospitals and rendering pri- vate duty has been obtained. In Table XII the number of these nurses and also the number of nurses In public health and In- dustrial nursing are given by counties. Nurses who did not report type of nursing are believed to be In active practice and are Included In group of nurses In hospi- tals, private duty, etc. The numbers of nurses In public health work, 310, and In Industrial nursing, 195, were small. The public health nurses were working In the health departments as given In Section II. The addresses of a few were In counties without health departments at the time of this survey. These nurses tem- porarily probably were not in active public health nursing at that time. The distribu- tion of the 195 Industrial nurses Is given below: Anderson 14 Blount 11 Carter 4 Coffee 1 Cumberland 1 Davidson 23 Dyer 2 Franklin 1 Gibson 8 Hamilton 19 Hawkins 1 Johnson 1 Knox 24 Lawrence 1 Loudon 3 Madison 5 Marlon i Marshall 4 Maury 1 Obion 1 Polk 1 Roane 6 Robertson 2 Shelby 31 Sullivan 21 Sumner 1 Tipton 1 Washington 4 Weakley 1 Wilson 1 Although nearly half, 97, were found In the large city-counties, 98 were working In other areas with industrial plants. An- derson, Blount and Sullivan were three other counties with large Industries where many Industrial nurses were employed. FIGURE 18 REGISTERED NURSES PER 10,000 POPULATION BY COUNTIES OF TENNESSEE FROM 1945-1946 DIRECTORY 10.0 and Orer Per 10,000 Population 2.0-5.9 Per 10,000 Population 6.0-9.9 Per 10,000 Population Less Than 2»0 Per 10,000 Population The number of registered nurses per 10,000 population Is given by counties In Figure 18. The concentration of nurses In the large city-counties and other counties with cities or Industrial plants is evident from this figure. There were 14 counties without a registered nurse and ten other counties with less than one nurse per 10,000 popula- tion. 44 TABLE XI I REGISTERED NURSES* WITH TENNESSEE ADDRESSES ACCORDING TO TYPE OF NURSING WITH RATES PER 10 .000 POPULATION BY COUNTIES OF TENNESSEE HOSPITAL.PRI- PUB.HEALTH HOSP1TAL .PRI- PUR.HEALTH COUNTY TOTAL VATE DUTY OF- AND INDUS. COUNTY TOTAL VATE DUTY OF- AND INDUS. FICE NURSING NURSING FICE NURSING NURSING NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE NUMBER RATE TOTAL 3,043 10.0 2. 538 8.3 505 1.7 LAKE 4 3.5 2 1.7 2 1.7 LAUDERDALE 4 1.6 2 0.8 2 0.8 ANDERSON 87 29.6 69 23.5 18 6. 1 LAWRENCE 9 3.0 8 2.7 1 0.3 BEDFORD 8 3.3 5 2.1 3 1.2 LEW 1 S - - - - - - BENTON 1 0.8 1 0.8 - - LINCOLN 8 2.9 7 2. 5 1 0.4 BLEDSOE 3 3.4 1 1.1 2 2.3 LOUDON 14 6.8 11 5.3 3 1.4 BLOUNT 47 10.6 35 7.9 12 2.7 MACON 3 2.0 1 0.7 2 1.3 BRADLEY 10 3.2 7 2.3 3 1.0 MCMINN 19 6.0 17 5.4 2 0.6 CAMPBELL 10 3.0 9 2.7 1 0.3 MCNAIRY - - - - - - CANNON 2 1.9 2 1 .9 - MADISON 50 9.0 41 7.4 9 1.6 CARROLL 4 1.5 4 1.5 - MARION 4 2.0 3 1.5 1 0.5 CARTER 17 4.5 12 3.2 5 1.3 MARSHALL 1 1 6.8 6 3,7 5 3. 1 CHEATHAM 1 1 .0 - - 1 1.0 MAURY 31 7.2 28 6.5 3 0.7 CHESTER - - - - ■ ME 1 GS 2 3. 1 2 3. 1 - - CLAIBORNE 5 2.0 5 2.0 - MONROE 2 0.8 2 0.8 - • CLAY 1 0.9 1 0.9 - MONTGOMERY 19 5. 5 17 4.9 2 0.6 COCKE 2 0.8 1 0.4 1 0.4 MOORE - - - - ■ ■ COFFEE 2 1.0 1 0.5 1 0.5 MORGAN 2 1.3 2 1.3 - ■ CROCKETT 3 1.7 2 1.2 1 0.6 OBION 12 3.8 10 3. 1 2 0.6 CUMBERLAND 6 3.5 5 2.9 1 0.6 OVERTON - ■ - ■ - DAVIDSON 646 23.8 556 20.4 90 3.3 PERRY 1 1.3 1 1.3 - DECATUR 4 3.9 4 3,9 - - P 1 CKETT - - - • - DEKALB - - - - - - POLK 4 2.6 3 1 .9 1 0.6 DICKSON 4 2.0 4 2.0 - - PUTNAM 8 2.9 8 2.9 - DYER 1 1 3.0 9 2.5 2 0.5 RHEA 6 3.4 5 2.9 1 0.6 FAYETTE 1 0.3 1 0.3 - - ROANE 31 10.6 25 8.6 6 2.1 FENTRESS 1 0.6 1 0.6 - - ROBERTSON 11 3.7 8 2.7 3 1 .0 FRANKLIN 9 3.6 7 2.8 2 0.8 RUTHERFORD 35 10.2 28 8.2 7 2.0 G1BSON 42 9.4 24 5.4 18 4.0 SCOTT - - - ■ - - GILES 4 1.3 4 1.3 - SEQUATCHIE 2 3.7 2 3.7 - - GRAINGER . - - - - SEVIER 6 2.5 3 1.2 3 1 .2 GREENE 30 7.3 29 7.0 1 0.2 SHELBY 897 23.6 786 20.7 111 2.9 GRUNDY 4 3.2 4 3.2 - SMITH 1 0.6 1 0.6 - • HAMBLEN 16 8.2 1 5 7.7 1 0.5 STEWART ■ • - • - • HAMILTON 252 1 3.3 204 10.8 48 2.5 SULLI VAN 69 9 .0 38 5.0 31 4.0 HANCOCK - - - - - SUMNER 8 2.3 O 0.9 5 1.5 HARDEMAN 2 0.8 2 0.8 - TIPTON 7 2.5 4 1 .4 3 1 1 HARDIN 5 2.7 5 2.7 • TROUSDALE 2 3.2 1 1.6 1 1 .6 HAWK INS 5 1.6 3 1.0 2 0.7 UN 1 CO 1 9 6.1 8 5.4 1 0.7 HAYWOOD 8 2.8 7 2.5 1 0.4 UNION - - - - - - HENDERSON 2 1 .0 2 1 .0 • VAN BUREN - - - • - - HENRY 8 3. 1 6 2.3 2 0.8 WARREN 3 1.5 2 1 .0 1 0.5 H1CKMAN 1 0.6 - - 1 0.6 WASH 1NGTON 83 15.3 73 13.5 10 1.8 HOUSTON 1 1.5 1 1 .5 - WAYNE 2 1.4 2 1.4 • - HUMPHREYS 3 2.4 2 1 .6 1 0.8 WEAKLEY 7 2.4 4 1.4 3 1.0 JACKSON - - - - • WH 1 TE 1 0.6 1 0.6 - - JEFFERSON 8 4.2 8 4.2 - WILLIAMSON 12 4.6 7 2.7 5 1 .9 JOHNSON 6 4.5 4 3.0 2 1.5 WILSON 4 1.5 3 1.2 1 0.4 KNOX 358 19.0 301 16.0 57 3.0 * Registered Nurses September 1945-1946, Coaaittee on Nursing Education and Nursing Practice. DlSCUSSI ON In this section of the report, data have been presented which show a growing state with an 11.4 per cent Increase In the population In the ten-year period from 1930 to 1940. In East Tennessee a relatively high proportion of the population was young and the birth rates were high. There were sparsely populated areas as well as densely populated large city-counties. Data regard- ing county taxes and effective buying In- come revealed that there were wide varla- tlrns In financial resources from very poor counties to relatively wealthy ones. Some counties might be unable to finance hospl- tals and health facilities while others would be able to provide such facilities. The Increase In births In hospitals Indi- cated that In both urban and rural areas mothers were rapidly becoming accustomed to the use of hospitals for delivery and added facilities would be required. A rapid change has been noted from attendance at birth by midwives to attendance at birth by doctors In hospitals. The distribution of doctors, dentists and nurses Indicated that In con- junction with planning of hospitals and health facilities plans needed to be made for securing the services of these groups for the population of rural areas. 46 AND HEALTH DEPARTMENT FACILITIES AND NEEDS IN TENNESSEE IV. HOSPITAL AND HEALTH DEPARTMENT NEEDS IN TENNESSEE In the preceding three sections of this report, the existing conditions In re- gard to hospitals, health departments, physicians, dentists, nurses, etc. have been Planning for health and hospital services necessitates considera- tion of all these services and their rela- tion to each other for the development of a program for Tennessee. The provisions and regulations of the Hospital Survey and Con- struction Act (Public Law 725, 79th Con- gress) and the needs In Tennessee will be discussed In this section. The different types of areas Involved are recognized In the regulations with three types considered; namely, (1) the base area, (2) the Intermediate area and (3) the rural area. The definitions of these areas taken from the regulations for the Hospital Survey and Construction Act are as follows: 1. A base area Is an area with a teach- ing hospital of a medical school or an area with at least 100,000 popu- lation and one general hospital with complement of 200 or more beds for general use. 2. An Intermediate area has a popula- tion of 25,000 or more, and, on completion of the hospItal construc- tion program, would have at least one general hospital of 100 beds suitable for a district hospital In a coordinated hospital system. 3. The rural area Is the remaining area, no part of which Is Included In a base or Intermediate area. In addition to the subdivision of the state Into base. Intermediate and rural areas. It Is necessary to divide the state Into regions, with each region containing a base area, several Intermediate and rural areas. Tennessee can be divided logically Into four regions with the counties contain- Ing the large cities of Chattanooga, Knox- ville, Memphis and Nashville being the base areas of the four regions. This regional division Is planned In view of an Integrat- ed hospital system In which diagnostic and treatment facilities are available to all. In such a system, specialists would be loaned for consultative services from the larger teaching hospitals to the smaller Intermediate or rural area hospitals. Also In such a system patients requiring spec- ialized observation and treatment would be transferred from the smaller to the larger hospitals In which all types of services would be provided. On this regional basis, the extension of medical knowledge and re- sources to smaller hospitals and to areas without resources could be carried out. A. GENERAL HOSPITALS As shown In the first section of this report, from the survey of hospitals there were 101 general hospitals with 6,229 beds at the time of the survey. The maximum state allowance for general hospital beds for Tennessee on the basis of the regula- tions was 4.5 per 1,000 population. On the basis of November 1,1943 population, 12,682 beds In general hospitals would be permis- sible. To obtain this number, 6,453 addi- tional general hospital beds would need to be constructed. The existing general hospitals were unevenly distributed over the state. In 42 counties, there were no general hospitals, In 16 others there was less than one gener- al hospital bed per 1,000 population and In 21 others there were less than two beds per 1,000 population. Thus, at least 79 count- ies are In great need of general hospital beds. Standards were established for the base areas, 4.5 beds per 1,000 population; for the Intermediate areas, 4.0 beds per 47 1,000 population; and for the rural areas, £.5 beds per 1,000 population. The differ- ence In the number of beds according to the standard for the rural area, 2.5 per 1,000 and the number needed for the population, 4.5 per 1,000, would be provided In hospi- tals In the Intermediate or base areas. A similar provision for beds In base areas for the population of Intermediate areas would be made. Methods of estimating needs, and plan- ing for hospital beds considering births and. deaths have been given in the Report of Michigan Hospital Survey*, Hospital Re- sources and Needs, which was a pilot study made by the Commission on Hospital Care. From th