Our recent blog, Can’t See the Ward for the Trees, discussed the recent headlines about declining NHS bed numbers. The headline masks a more complicated reality: everyone working in the NHS knows that acute beds are under more pressure than ever before. Beds may be running at unsustainable levels of occupancy, but this does not mean they are being used effectively.
In this blog, we are focusing on one part of this issue: are acute beds always being used to treat patients in need of acute care? The short answer to this question is “no”. Pressures in social care mean that many patients in acute beds are medically fit for discharge but cannot find a safe place to go outside hospital.
But what about admissions? The data that we routinely analyse for our clients suggests patients are being admitted in significant numbers into acute beds for conditions that may not require acute interventions. This is validated by the opinions of the many clinicians we work alongside.
For example, in one hospital an average of more than 50% of their acute beds had a patient who had been admitted through A&E where they were classified as having a “minor intervention”. That’s not to say the patient did not have other underlying comorbidities and elements of frailty, but it does raise the question of whether there are routine admissions that could be avoided or handled differently post admission.
Figure 1: Total occupied beds, by admission source
Note: on a typical day of c.500 admissions (blue dots), roughly 300 would be individuals who presented with a “minor”.
Of those admitted in this channel, there is a cohort of patients that stayed a significant number of days, but received no procedures. Figure 2 gives an example, based on data from another hospital. It suggests that out of the patients aged 65+ that were admitted via A&E, 25% stayed more than 3 days but had no procedures performed.
Figure 2: Distribution of length of stay (for patients staying no more than 10 days), aged 65+ and by procedure
A cold analysis of the data suggests that there are significant numbers of patients finding their way into acute beds who are not receiving acute interventions – possibly not requiring admission into an acute hospital. This conclusion is backed-up by the opinion of local clinical experts. Our analysis suggests that the decision to admit a patient is a complicated one that is being driven by more than just underlying acute need. A clinician’s over-riding priority will be to be keep a patient safe and often the simplest and quickest way of achieving this in a busy A&E will be to admit a patient into an acute bed.
A campaign is currently running in many hospitals to end PJ paralysis (1), focused on getting patients out of their bed and moving around.
Whilst interrogating the data alone cannot identify the needs of any individual patient, it can shed light on underlying trends which have a material impact on both efficiency and outcomes. When combined with local clinical and operational expertise, this type of data analysis can be hugely insightful in aiding performance improvements.
In our experience, we’ve seen organisations improve their A&E performance by installing senior clinicians front of house to help improve decision making and divert unnecessary admissions. One of these organisations achieved 97% on its A&E target in recent weeks. So, the key is really to prevent people putting on their PJs in the first place. At least not until you get home and back into the bed we all prefer to be in – our own bed.