Discharge is key to emergency care crisis

The crisis in emergency care has now been acknowledged as a ‘system’ problem, rather than something caused by ‘poorly performing’ acute trusts. I am sure readers of this website have known this all along.

It is important this is recognised, so that the right solutions are considered. Of course, most hospitals could without doubt improve on their internal processes – specialty support to ED, effective daily ward rounds and early in the day discharge, early discharge planning, speedy diagnostic support, effective and knowledgeable management of ‘flow’, and more besides.

But, acute hospitals alone cannot fix this, not for long anyway. The problems run deeper, and the general population now has particular expectations of immediate care. A&E may not offer the best experience, especially when busy, but it does offer rapid assessment by a doctor, immediate diagnosis, and the dispensing of drugs and reassurance without having to make multiple phone calls and search out a late-opening chemist.

The crisis is not, barring a few exceptions, caused by increased attendances at A&E. Overall numbers are similar to last winter, and where they have risen it is largely due to ‘minors’. These add to the workload, but do not tend to materially affect throughput.

Our own analysis suggests the key difficulty is discharge. It isn’t the only pressure, but it is the pre-eminent one. We can accurately predict tomorrow’s performance from today’s discharge numbers. Adequate discharge numbers mean the next day starts with available capacity, and the daily workload and ‘flow’ will nearly always be managed well and smoothly, with obvious benefits to patients.

The discharge process slowed over last winter. Official ‘delayed transfers of care’ did not rise, but the duration of the (laborious) assessment process was longer. And our repeated point prevalence audits showed significant numbers of patients waiting for community health capacity to become available. It seems clear that our community healthcare providers lack sufficient capacity, and on ‘block contract’ arrangements they cannot over perform.

There are no queues in community healthcare, social care, or primary care. When the system reaches gridlock, their queues are situated in our beds, on our wards. The visible queue then forms in ED, or outside as the ambulances start waiting. These queues are what our surgical colleagues might call a ‘false localising’ sign.

One might say these pressures have always been present, but it doesn’t take a huge change to tip a system that always runs ‘hot’, with very high bed occupancy, into crisis.

Solutions? We have a full and detailed action plan, with three broad groups of steps we are taking:

- Internal actions. All those listed above, together with an investment in ‘supervisory ward sisters’. These ward leaders are not ‘in the numbers’ and are therefore free to manage quality, staffing rotas and sickness, and arrange early in the day discharges. We are also implementing electronic white boards (‘Jonah’) so we can track patients and properly manage capacity

- Collaborative work with partner organisations. ‘Trusted’ assessment with community health and social care, to avoid duplication and speed up this arduous process. There are other avenues to explore too – is there an alternative to housing community ‘queues’ in the most expensive part of the service? And then there is primary care, including urgent care/walk-in centres. How could they work differently to offer alternatives to attending the local ED?

- Additional capacity. We have very little of this in our hospitals, but as we are housing significant numbers of patients at any one time who could be better managed at home with support, or in an intermediate care bed, we feel we should purchase these ourselves. We already run some ‘virtual wards’ offering post-discharge support and we will enlarge this capacity significantly. We are also  exploring a link with a specialist in assisted living for those patients unable to manage in their own homes.

A final thought. At a recent international conference I learned that the UK now has fewer in-patient beds per head of population than European countries, North America, and Australia. Have we reached our limit in terms of bed reductions?

Courtesy of Mark Newbold