The HSE is embarking on a campaign to reduce A&E trolley waiting times, by managing patient hospital stays more efficiently. Laura Slatteryreports
They are sometimes called "bed blockers" - people who no longer need acute care but whose delayed discharge from hospital exacerbates the problem of emergency department overcrowding. But the Health Service Executive (HSE) is now embarking on a national campaign to improve planning for patient discharges, claiming shorter hospital stays will reduce A&E trolley waiting times more efficiently than providing extra beds.
John O'Brien, the national director of the HSE's Winter Initiative campaign, says measures such as spreading the rate of patient discharges more evenly across the week, ramping up the capability of hospital diagnostics services and not admitting day surgery patients the night before their operation will create thousands of extra bed days every year.
"The big problem is getting the people who don't need to be there home," says O'Brien.
A report on the HSE's first Winter Initiative, which ran from October 2006 to March this year, concluded that a strong, system-wide focus on discharge planning is required to improve use of existing beds. The HSE now plans to extend nationally the local projects that were run in Sligo, Cork, Tallaght and Beaumont.
Last Friday, the organisation invited a British-based expert in discharge planning to give a seminar so that the Irish health system can learn from the best international practices.
Liz Lees, a nurse consultant in acute medicine at the Heartlands Hospital in Birmingham, addressed hospital managers about providing more information to patients, managing hospital capacity and avoiding the consequences of a premature discharge.
"All the building blocks are here, even though at this point they are not as far along as we are in Birmingham," Lees told The Irish Times. "But we have been working on this for five years, and there are still things that we haven't got right."
Often the degree of discharge planning depends on how patients are first admitted, Lees says. If they are elective cases, there are systems in place, but if they come through the doors of the A&E unit, these procedures break down. The great task becomes how to get these patients into a hospital bed - getting them out of it again later becomes more of an afterthought.
The HSE's research has found that 40 per cent of acute hospital patients admitted last winter could have been treated in a non-acute setting. There was no discharge planning in place for 60 per cent of patients, while only 17 per cent were given an estimated discharge date.
A study of procedures at Tallaght hospital shows that without any radical increase in resources, improving discharge planning could free at least 60 beds.
Increasing the capability of diagnostics facilities such as radiology and labs by 25 per cent - so that more patients aren't kept in overnight because they're waiting to have tests or get test results - would result in a 6 per cent increase in total inpatient discharges, the study found.
The HSE also estimates that by not admitting day surgery patients one or two nights before the operation, 140,000 bed days a year could be released across the State.
As well as requiring cultural change, encouraging home pre-op preparations is one of the measures that would involve higher levels of community healthcare, and O'Brien cites nurse-led community intervention schemes in Dublin, Cork and Limerick, the Hospital in the Home initiative and rapid-access clinics for the elderly as part of the solution.
With more than 60 per cent of people in acute hospital beds over the age of 65, more nursing home beds are also critical. The number of cases where a patient's discharge from acute hospital care was delayed due to the unavailability of nursing home beds or family to care for them at home peaked at 448 in July 2005, but there was still an average of about 300 such patients last winter.
The HSE hopes that increasing the number of consultants under the 100-plus recruitment scheme and the longer hours under the new consultants' contract will result in a more even spread of discharges over the course of the week. At present, very few discharges take place on Fridays and Saturdays, meaning there is a glut of patients in hospitals over the weekend - the busiest period for emergency departments.
"We're not saying this can happen overnight," says O'Brien. But he believes that improving the use of existing beds, as well as having the advantage of being cheaper than creating new beds, is also the longer-term answer to overcrowding. A former hospital manager in Limerick, he recalls the introduction of 50 new beds there five years ago eased pressure on services only temporarily. "Within a matter of weeks, the queues were longer than ever."
Lees backs this view. "When we were too busy, we would frequently open extra wards. We don't do that any more. It was the easy way out - to open more beds and not look at who is in your beds."
Giving better information to patients, which "doesn't happen in many situations", O'Brien says, will be a key part of the HSE's strategy.
O'Brien compares admitting patients without giving them an estimate discharge date to checking into a hotel with no check-out date. However, giving patients an estimate of when they will be ready to leave must be sensitively handled, he adds. "Otherwise it can go the other way and patients can think, 'oh, they're trying to kick me out'."