Download the appendices for this paper
We have produced information on the length of stay, emergency bed days and emergency admissions for each PCT in England. This information will show PCTs where their organisation ranked with others in our analysis. The emergency bed days per PCT also show where the additional bed savings we have identified exist.
- Older people and emergency bed use: appendices
- Average emergency length of stay for patients over 65, per annum, England PCTs: appendices
- Needs-weighted emergency bed days per person over 65, per annum, England PCTs: appendices
- Needs-weighted emergency admissions per person over 65, per annum, England PCTs: appendices
More on older people and emergency bed use
- Read Candace Imison's blog: Use of emergency hospital beds: why is there so much variation?
- See the press release for this paper: 2.3 million fewer overnight hospital stays needed if all areas perform as well as top 25%
The only headline measure that matters to me is outcome. Protracted lengths of stay in hospital lead to poor outcomes but so do community based diagnosis-avoidance models of care which lead to repeated critical events managed poorly by an overheated emergency care system.
The solution as far as I am concerned is to rebalance and reconnect medical and functional modelling across the older persons health economy
During a seven months pilot, patients at risk of hospital emergency admission or re-admission were admitted in their homes termed as virtual ward. Admission was based on SPARRA-65 data and personal GP practice/consultant physician’s intelligence.
The virtual ward team comprised of a hospital based consultant physician, two GPs, district nurse and GP practice manager. District nurses paid regular visits to patients. A weekly teleconference was held among virtual ward team to discuss patients. GP practice was enabled to upload virtual ward documentation directly into SCI STORE EPR.
There were twenty one admissions. There were no unscheduled admissions of virtual ward patients into the hospital. There was 25% reduction in emergency admissions, 12% in re-admissions and 12-13% in LOS when compared to the same period in the previous year. Patients felt that they benefited from increased nursing input but not all understood the concept of virtual ward. It was a zero finance pilot. Activity was easily accomodated in current working schedule.
Virtual ward provides a new interface between primary and secondary care for improved patient care due to timely and appropriate intervention, more effective communication, & easier clinical decision making. A reduction in hospital emergency admissions, readmissions and LOS was shown.
Now we are rolling out Lochaber Virtual ward care model to more GP practices in the Fort William area with participation of more hospital based consultants.
Any question to which Cornwall, Norfolk and North East Lincolnshire is the answer cannot be the right one.
The corollary of supply induced demand is to question the use of demand repression in rural, under-resourced areas.
I agree with the doctor who says that we should only cut emergency beds after system reforms have improved out of hospital care sufficient for us to see that demand for emergency care is reducing. At present it is still increasing.
The Royal College of Physicians of Edinburgh (RCPE) endorses the desire to minimise the number of admissions to acute beds that all sectors of society, but especially the elderly, require. The RCPE is keen to state from the outset that no consultant physician wants to admit a patient to hospital unless it is absolutely clinically necessary: pressures on acute beds mean that only patients who are in urgent need of medical care can be admitted.
The latest paper from the King’s Fund suggests that if all primary care trusts could reduce admissions and minimise length of stay to that of the most successful areas then 7000 fewer acute beds would be required in England. They acknowledge that the drivers of variation in performance are complex, including age of patient, level of deprivation and geographical access: areas with well developed integrated service and those with higher levels of an aged population have lower levels of acute hospital bed use. It is suggested that areas with a high number of aged population also have a more developed integrated service.
It is for these very reasons that caution is required in interpreting this report. If acute hospital beds are reduced without a concomitant development of integrated services, patients will be potentially worse off. There is evidence of an inexorable rise in acute hospital admissions especially to acute medical units with increasing weight of expectation of what medical care can provide. We feel in these circumstances that it is vital that the promotion of admissions avoidance, particularly of older people, does not restrict appropriate access to best care at times of medical need.
Boarding of patients is rife within the acute hospital sector and this itself is associated with a range of well-evidenced adverse outcomes for patients, including increased death rates, length of stay, re-admission and the development of medical complications (1) . This problem would be exacerbated with even fewer beds being available and the pressure to achieve the elective workstream would increase with more surgical procedures having to be postponed due to a lack of beds.
The RCPE conducted a survey in May 2012 to obtain a snapshot of senior doctors’ practical ongoing experiences of boarding in Scottish hospitals. Key findings included 80% of respondents reported that boarding is now experienced all year round in Scottish hospitals (with 50% reporting that boarding had taken place during the last week in May); 71% of respondents believe boarding levels in Scotland are high and increasing, at a time when the Scottish Government has been reducing the number of acute beds in Scotland; 99% believe boarding has a very negative or negative effect on the quality of patient care, 95% a very negative or negative effect on the length of patient stay, 68% a very negative or negative effect on death rates and 68% a very negative or negative effect on rates of patient re-admission to hospital (2).
It is vital that the significant investment necessary to provide integrated services must be accurately calculated so that if the King’s Fund report is to be implemented, adequate resource is made available to enable this development prior to closure of acute hospital beds. This would allow proper consideration of the most appropriate use of the resource available to the health sector to deliver the services that are required in disparate localities.
We support shifting care closer to home; however the ambition to reduce reliance on the acute sector must not be pursued to the detriment of quality of patient care (3)
(1) Spivrulis, P.C., Da Silva, J.A., Jacobs, I.G. et al. (2006). The association between hospital overcrowding and mortality amongst patients admitted via Western Australian emergency departments. Med J Aust, 184(5); 208-212.
Community care workers these days can, and are able to, with training, take on skilled tasks that used to be previously performed by nursing staff.
As we keep adding in drugs (and never subtracting ) we are always going to multiply the chance of drug related problems, and thus it seems preventable hopsital admissions,
Silo working and over specialisation in Medicine is just making this situation worse. The NHS must develop a strategy (Physicians, GPs, Pharmacists) for proper medication reviews in older frail patients and have the confidence to stop drugs (and/or respect a patient's own wishes to do so) before they cause the problems.
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