We are seeing unacceptable waits at NH Emergency Departments, which in turn are driving a severe deterioration of the service provided by Ambulance Trusts. Some patients are dying before they get through the front door of the hospital.
An analysis by CAREFUL, a company that makes medical handover software, suggests there is more that acute trusts can do to manage the problem. Ambulance queues hide the fact that the bottleneck is not at the front door of the hospital. It is the back door, which is blocked because of insufficient community and social-care provision.
In a typical acute trust, 50 per cent of all beds are taken up by patients who are fit for discharge. An increase in social-care provision won’t come online in the weeks before the winter crisis is upon us. Acute trusts have only half their bed capacity available, so they need to ensure efficient discharge planning to reduce unnecessary overnight stays and discharge earlier in the day.
Freeing up hospital beds
I am a former senior A&E doctor in the NHS and senior medical director of hospital groups in both the UK and China. The need for good discharge planning is well recognised by trusts. They know that to free up beds they must ‘sweat the asset’ before the longer-term solutions from the Integrated Care Boards come into play. Our evidence suggests that, despite investment in large EMR systems, hospitals still don’t have the digital tools to manage discharge.
Managers find it difficult to know what is happening and spend hours walking the floors to understand the status of individual patients. Even in digitally advanced hospitals, critical tasks are regularly lost or forgotten, creating avoidable delays.
Trusts need to concentrate on the median hour of discharge (the point in the day when 50% of all discharges happen) as a key measure. They need to focus on managing the outstanding tasks for each patient in order to bring this forward.
Changing the median hour of discharge
Our analysis suggests that for an average trust, bringing forward the median hour of discharge by just a few hours — from say 5pm to midday — could release 30–40 beds in the middle of the day. That would create better flows through the emergency department, and in turn create a noticeable improvement in ambulance turnround.
In 2019 (the last year for which figures are available) NHS hospitals wasted £250m a year through delays to discharge. Research published by CAREFUL shows nearly 35% of all doctors and nurses use spreadsheets or word documents to record patient status and tasks. These are critical to understanding patient flow and discharge. Vital information is obscured by these informal systems.
CAREFUL launched its platform this year to make handover safe and save lives. It is designed to make patient status and tasks visible, to speed up decision-making and prevent hold ups. Visibility is critical to discharge planning.
A new approach to handover
The CAREFUL platform can be up and running to replace manual handover sheets in a matter of days. The system works on mobile, tablet or desktop presenting critical information for each patient, along with task lists assigned to individuals, clarifying who needs to do what, and when. As staff change shift and patients move through the hospital, tasks and status information move with them. As a result, staff and managers always know what is happening for each patient and, crucially, who is responsible.
CAREFUL uses privacy-by-design principles and is regulatorily compliant in the UK, Europe and the US. As a cloud-based application, it is fully encrypted and protected. It is also fully interoperable using industry standard messaging – so that it can integrate with healthcare systems.
To address the ambulance crisis, we need to support staff in acute trusts with the right digital tools to drive earlier discharge.
This article first appeared in Emergency Services Times August 2022.