Joint memorandum by Dr K Sritharan and
Dr W Lynn, Ealing District Hospital (DD 12)
DELAYED DISCHARGES FROM HOSPITAL
Like many medium-sized District General Hospitals
Ealing has been coping under increasing pressure for many years.
Attendance at A/E and acute admission rates has risen by 2-6 per
cent annually over a period where bed numbers have been reduced.
This is compounded by the effects of our ageing population (average
age of acute medical admissions has risen by 10 years) and increased
dependency of our inpatient caseload. Thus we now have more patients
who are less well requiring a greater amount of nursing, medical,
therapy and social support. Many patients require input from social
services to provide support in the community, residential or nursing
home placements. There is a widely appreciated shortfall in capacity
within the social service sector. London Borough of Ealing, for
example, has suffered approximately a 25 per cent loss of residential/nursing
home placements over the past three years. In the absence of appropriate
placement the default for frail patients who are not safe to go
home is to keep them within an acute hospital setting.
This is obviously a state of affairs that no
one would condone or wish to continue. The problem that faces
us at grass roots level is how to cope on a day to day basis.
The additional patients crammed in to every corner of the hospital
(we have been running with between 30-50 additional unfunded beds
for most of the past three months) further impede our efficiency
and lead to more delays. Patient safety is compromised and all
grades of staff work at an intensity which leaves them quite exhausted.
It is little wonder therefore that we are experiencing great difficulty
in retaining/recruiting staff to work in these areas.
Everyone agrees that things must changethe
question is how?
This report does not pretend to have any of
the answers but is a simple description of the practical day to
day issues facing medical/nursing staff at our hospital and some
of the ways in which we are trying to cope. The views have been
garnered from many staff within the hospital but are our personal
opinions and should not be taken as an official view from the
Trust executive. The Trust management are fully aware of the issues
that we face and have been extremely supportive in trying to facilitate
change in work practices and in bidding for new resources.
Size of the problem
We have performed a number of different audits
examining reasons around delay. A representative one day "snapshot"
of our adult inpatient load identified issues around social delay
and access to diagnostic/therapeutic procedures as the two key
areas leading to delayed discharge (Figures 1 and 2).
The discharge process is complex and inefficiencies,
as well as deficiencies in manpower, funding and resources are
encountered at every level. These all perpetuate the delay that
exists when discharging a patient from hospital.
Figure 3 is a schematic representation of some
of the complex issues surrounding the discharge process. The key
obstacles to discharge are highlighted within figure 3 and discussed
in more detail below:
(i) Once a patient has been referred to the
Intermediate Care Service (ICS) in order to progress further a
social worker (SW) needs to be allocated. It is the responsibility
of the SW to complete the financial assessment (which typically
takes three hours to compile per patient), without which a patient
cannot appeal for funding.
In recent months Ealing Hospital has
seen a decrease in SW numbers from eight to three. This has largely
been due to a well-intended drive to improve quality of care by
employing solely permanent not agency staff. The majority of SWs
at Ealing Hospital originally however, were recruited from agency.
This shortage of public sector staff reflects the poor pay within
Additionally, ICS strictly speaking
are only responsible for patients within Ealing Borough. This
is a cause for concern as follow-up of the status of social patients
who live outside the Borough is time-consuming, communication
is poor and progress is thus slow.
The deficiency in SW numbers places
a strain on a department already pushed beyond its capacity and
produces one of the largest obstacles to discharge.
(ii) Once the decision to place a patient
in a nursing or residential home has been made, a nursing needs
assessment needs to be compiled by the ward staff. A deficiency
of nursing staff and poor follow-up of the status of assessments,
previously co-ordinated by a now disbanded Discharge Liaison Team,
has resulted in patients waiting anecdotally up to three months
before presenting to Panel for funding.
(iii) Patients may present repeatedly to
Panel (which meets twice a month) before funding from either the
social services or health authority pot is approved. This quite
farcical and frustrating masquerade disguises gross under-funding
within the sector.(iv) Once funding has been approved the
wait for a nursing home, residential home or continue in care
bed can be in the order of months. There are approximately 500
nursing home beds in the Ealing Borough all of these are privately
run. There are even fewer residential homes; the majority of these
are again privately run and fall well above the criteria for social
service funding. Moreover, most patients are unwilling to cross
Borough boundaries and the result is that many patients are inappropriately
"hotelled" in acute medical beds.
Additionally, there is an unwritten
rule of one week in which patients need to be returned to the
nursing home or the bed may potentially be forfeited.
With an ageing population the demand
for placement will only ever increase. However, over the last
decade or so we have seen a decline in the number of these beds.
(v) The Core Assessment Team (CATS) play
an invaluable role in facilitating rapid discharge from hospital
(either immediately or within 48 hours from admission) and in
preventing admission through accident and emergency and general
practice. CATS however only operate from the hours of 9am to 4pm,
Monday to Friday. This often results in a patient who is medically
fit for discharge being "hotelled" in acute medical
beds for up to 72 hours if admitted out of hours or over the weekend.
(vi) The rehabilitation service composed
largely of occupational therapy (OT) and physiotherapy (PT) have
access to a 72 bedded rehabilitation centre which is open solely
to residents of Ealing Borough.
The decision of whether a patient's
living environment is safe is the remit of OT. The OT department
is overwhelmed with referrals and it typically takes between three
days and two weeks to complete OT input. Following this there
may be further delays due to obtaining equipment.
(vii) The voluntary sector may be accessed
rapidly through CATS and play an invaluable role in facilitating
rapid discharge from hospital. Although not a block to discharge,
this resource is not co-ordinated and easily saturated.
There are numerous incidences where the wait
for investigations eg endoscopy, feeding tube (PEG) insertion,
ultrasound, Computed Tomography (CT) etc is the sole reason for
Ealing Hospital has recently acquired a new CT scanner
which is able to process patients faster. This has significantly
reduced the wait for CT scans but the CT is still underused because
the rate-limiting step is now the lack of staff time particularly
radiographers and radiologists. This is typical of the way the
NHS had traditionally been funded where a new capital development
often comes without due attention to the revenue funding required
to maximise the potential of the new equipment.
The wait for coronary angiography (see figures
4 and 5) exemplifies a situation where demand for a service far
outstrips supply. Advances in interventional cardiology, supported
by evidence-based medicine, mean that we have patients who cannot
be safely discharged until they have had their coronary anatomy
assessed (by angiography). This is a teaching hospital-based procedure
with an acknowledged lack of capacity throughout the UK. The result
is very frustrating to patients and staff alike with ambulant
self-caring patients waiting for days/weeks while new acutely
ill patients cannot find a bed. This is not only uneconomical
but is poor patient care over which the frontline staff has very
What are we trying to do?
A discharge planning Steering Group
has been established at Ealing Hospital to examine the discharge
process and to discuss potential solutions. Auditing and evaluation
of departmental and inter-departmental organisational structure
and flows in workload is vital in identifying blockages in the
system. This group has already performed some patient pathway
evaluation and is planning further audit work.
Proper incorporation of the discharge
planning process into staff education and induction. We have produced
a step by step guide for particularly the medical teams, to allow
them to get the best out of the current somewhat bewildering system.
This stresses factors such as early but appropriate referral to
ICS/SW/OT/PT. Emphasis needs to be placed on achieving an efficient
and functional post-take ward round. Senior nursing staff presence
at these (although sometimes practically difficult due to the
variability in their timing) will facilitate the process. Standardising
the referral process to therapy services may also help. Early
activation of the discharge process will inevitably reduce delay.
Guidelines must be updated regularly and pressure points in the
pathway subject to audit.
The progress of patients along the
social and rehabilitation conveyer belt needs to be reliably documented
and delays actively pursued. Although Muti-Disciplinary Team (MDT)
meetings (held once a week) act as an invaluable reference point,
currently limited resources have been allocated to this role.
Patients as well as relatives need
to be given adequate and realistic information as to the possible
avenues of discharge open to them. Improved communication, with
patient information leaflets as well as updates on the status
of discharge will identify problem areas earlier on and reduce
any delay introduced by the patient and relatives.
The Trust has facilitated several
workshops including partners from community services, primary
care and the Health authority. This has started a process of us
working towards a shared vision of care for emergency referrals.
A working party has been taking these ideas forward within the
Hospital (called the Pathfinder project) and is now consulting
widely within the Trust. This process is vital for us to try and
offer a better future for our patients and staff. We believe that
Pathfinder will deliver more rapid and effective emergency care
but only if patient throughput in the system is improved preventing
Trust management has been supportive
in preparing bids for additional beds to allow us to deal with
short-term pressures and also to establish coronary angiography
facilities on site. The process for both these bids seems interminable
to clinical staff and definite answers are not yet forthcoming.
This failure of the NHS to react swiftly to problems makes the
front-line staff feeloften mistakenlythat no one
at "higher" levels actually cares.
Staffing of hospitals coupled with
social services and health authority funding is as ever the greatest
hurdle to overcome. Deficiencies occur at all levels as detailed
above; suffice to say that unless there is reliable workforce
planning and active recruitment of staff, as well as adequate
funding for services and provision of rehabilitation facilities,
nursing and residential homes, there will always be delays in
discharging patients from hospital.
There is much that we can do (and are doing)
without additional resources but while the major blocks in social
support and diagnostic services remain we are always likely to
be unable to cope with the extremes of demand around emergency