Improving Patient Flow by Chris Isles

Dave Pedley gave an excellent talk two Wednesdays ago on Tackling Crowding in Emergency Departments, triggered no doubt by the number of times recently we have been running at 100% bed occupancy with patients sitting in chairs in the Emergency Department because there were no free cubicles.

The nightmare scenario for us all as the clock ticks inexorably towards December 2017 is that the same thing happens when our fabulous new hospital opens and the TV cameras, newspapers and journalists begin to salivate at the prospect that something goes wrong (there will be no story to report if the transition to the new hospital goes smoothly and there are no corridor patients).

The chances that something could go wrong are actually quite high and the problem is almost entirely medical by which I mean the large number of frail older people living precariously in the community who fall, become immobile, incontinent or delirious and require at least some form of assessment but often admission to hospital.

The omens are not good.  Dumfries and Galloway has the second highest proportion of people in Scotland who are aged 75+ and living alone.  Our Health Intelligence Unit have shown that despite numerous initiatives and new ways of doing things the Medical Unit would be sailing perilously close to 100% bed occupancy if we moved into the new hospital today. (See me previous blog on the new hospital here)

During his talk Dr Pedley showed a powerful 5 minute video by Musgrove Park Hospital in Somerset entitled Tackling Exit Block ie their hospital’s inability to move patients through ED because of numerous interrelated system failures.  (https://youtube/WX1YwKIkWzA).  Musgrove Park ‘s Top Ten Reasons Why People Cant Leave Hospital were as follows:

  1. Discharge delayed so patient can have lunch
  2. Carer/relative can’t pick them up till after work
  3. Nurses too busy looking after other patients to arrange discharge
  4. Waiting for transport or refusing to leave without free transport
  5. Waiting for pharmacy
  6. Waiting for ward round
  7. Waiting for blood or scan results
  8. Waiting for discharge letters
  9. Packages of care planned for late afternoon/early evening
  10. Patient doesn’t want to go to the assigned bed in community hospital

During discussion a number of solutions to our own recurrent difficulties with patient flow were proposed.  These included tackling all of the above in addition to attempting to educate the public about when and when not to attend ED.  My own view is that this might be as fruitless as King Canute sitting in his throne on the beach and attempting to stop the incoming tide on the grounds that any patient who comes up to ED and is prepared to wait up to 4 hours and possibly more to see a doctor or a nurse must feel they have a very good reason to be there (one often quoted reason being that they could not get an appointment to see their GP).

There were some illuminating moments.  We asked Patsy Pattie whether Dynamic Daily Discharge was still as effective as it had been when it was first rolled out.  She replied that some wards needed support on embedding the process.  Dr Pedley praised staff for their firefighting skills on those occasions when patients were unable to access cubicles in ED which prompted Philip Jones, our chairman, to say that a corporate rather than firefighting response was needed.  Many heads nodded in agreement.

A corporate response might mean fixing lots of little things in order to make patients flow through the system more speedily.  Dynamic Daily Discharge could then become an established part of ward routine rather than an optional extra; the paperwork in the medical assessment area might need to be simplified to allow nurses to move patients into the body of the ward more quickly; a nurse on each ward might be designated to carry the ward phone rather than allow it to ring endlessly in the hope that someone else will pick it up; clinical teams would actively consider how patients might get home;  consider community detox for alcohol withdrawal; patients earmarked for discharge might move to the dayroom unless physically unable to do so; hospital taxis might take people home if relatives or patient transport cannot do so; patients could be issued with a prescription to take to their local pharmacy if new medications are required or go home with immediate discharge letter to follow if not.

To these solutions I would add fully funded Ambulatory Emergency Care and Comprehensive Geriatric Assessment services together with more and better social care and a commitment to fill the hospital with more staff on public holidays (of which there will be four within one month of the new hospital opening).

The Chief Executive of Musgrove Hospital finished her contribution to the Exit Block video by saying ‘we need every single member of staff to understand their responsibility in ensuring patients flow through our hospital so that we can discharge them home as quickly and as safely as possible’.  Who could disagree?

Professor Chris Isles is Sub-dean for Medical Education and is a Locum Acute Physician.

2 thoughts on “Improving Patient Flow by Chris Isles

  1. Thanks for this thought provoking blog around systems and flow and the improvement work centred on daily dynamic discharge. I am curious about entry into “the system” and where we are with anticipatory care planning in D&G. Do we have any data or measures in this area?

  2. I agree with much in Musgrove Park’s video and Chris Isles discussion.

    However I think the top ten list now needs to include ‘relatives challenging decision to discharge and acting to delay or prevent this’. This response varies from those with genuine concerns which can usually be mitigated by lengthy discussion and safeguards such as carecall to those who actively obstruct discharge home by for example undermining the confidence of the elderly person by repeatedly telling them they cannot cope, using threats of complaint and on occasion absconding with the person’s keys to prevent home access! In this situation we need to be empowered to instruct relatives, carers and on occasion patients that they ‘have to cope’ and have this clearly supported by the complaints process at all levels.

    Secondly discharges are not the only determinant of hospital bed occupancy. Focussing on admissions is at least as important. This week’s BMJ for example has confirmed what should have been obvious – that if patients are seen by their usual GP they are less likely to be referred for hospital admission! If patients, particularly those approaching end of life, are already being cared for in a residential or nursing home and particularly a community hospital do they really justify transfer back to a district general hospital when their health deteriorates. Far too often this is due to a lack of realistic advance care planning or ignoring the agreed plan!

    So I believe the problem is soluble but not just by everyone in DGHs working towards the earliest discharge. The solution needs to include all those in General Practice, residential & nursing homes and community hospitals using acute DGH beds only for those justifying such care as well as for all families who are able to help support their elderly relatives doing so when medically fit for discharge even if this is personally inconvenient. This exhortation is not to those who already do all of these things but to the minority who don’t.

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