Making Best Use of Beds: elective and emergency care

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Making Best Use of Beds elective and emergency
care www.modern.nhs.uk/beds
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Overview of content

• Context and diagnosis
• Background to the work
• A typical picture of flow through beds in the UK
• Solution ideas
• What we found worked and the effect
• Key messages for implementation
• Resources to support work on beds

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Beds a key constraint in the system
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Background to the work

• Beds long seen as a core problem
• Emergency Services Collaborative and Improvement
  Partnership for Hospitals encouraged focus on
  whole flow
• Waiting for a bed the most common cause of
  breaching emergency waiting time target
• Research of best practice across UK
• Package of support to Trusts

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Our starting point

• The availability of beds within a Trust is a
  constant problem
• Lack of beds is usually the result of a temporary
  mismatch between the demand for beds and the time
  at which they are available (capacity)
• The root cause of this problem is the variation
  in patient flows through the Trust

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Bed availability a problem of variation
IN-PATIENT STAY
ADMISSION
DISCHARGE
Variation in patient pathways and processes. E.g.
in Length of Stay
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We always bring our hips in on Tuesday !
IN-PATIENT STAY
ADMISSION
DISCHARGE
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Variation in admissions
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Variation without the weekend effect
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Mr Smiths TURP patients always stay five days
but Mr Jones only keeps them in for three days
IN-PATIENT STAY
ADMISSION
DISCHARGE
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Variation in length of stay
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Were too busy in the morning to think about
discharges. They all get done in the afternoon.
IN-PATIENT STAY
ADMISSION
DISCHARGE
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Total Admissions Discharges
May 2002 - December 2002
120
Admission
Discharges
100
80
60
40
20
0
21/08/2002
01/05/2002
15/05/2002
29/05/2002
12/06/2002
26/06/2002
10/07/2002
24/07/2002
07/08/2002
04/09/2002
18/09/2002
02/10/2002
16/10/2002
30/10/2002
13/11/2002
27/11/2002
11/12/2002
25/12/2002
Discharges vary more than admissions
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Variation within each day
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What drives bed availability in the UK?
Admission Queues
Distress Driven Discharge
Custom Practice
Patient Flow
Discharge
Weekends
Holidays
Managed Flow
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Its chaos now! 15 DTAs in AE no free beds
- we need to get the wards to discharge ASAP
Bed Occupancy
20 free beds this morning but lots of electives
TCI
Just about got them all in by the end of the day
- well done!
I think we have it all under control now - lets
hope next week is better
We need more beds
800
780
760
740
720
Beds Occupied
700
680
660
640
620
600
Mo
Mo
Mo
Mo
Tu
Tu
Tu
Tu
We
We
We
We
Th
Th
Th
Th
Fr 0
Fr 6
Fr
Fr
Sa
Sa
Sa
Sa
Su
Su
Su
Su
0
6
12
18
0
6
12
18
0
6
12
18
0
6
12
18
12
18
0
6
12
18
0
6
12
18
Day/hour Of Week
occupied beds
estimated beds available
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• What can we do about it?
• Solution ideas

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Improvements that worked

• Short term
• Gaining operational control of beds
• Moving discharges earlier in the day
• Longer term
• Using prediction and scheduling tools
• Addressing elective flow variation
• Segmenting flows by length of stay
• Strategic, improvement led, capacity planning

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• What would happen if we implemented
• a few of the recommendations?
• Restricting ourselves to modest changes

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Reducing the in day beds mismatch
Arrivals and discharges by hour Monday only
30
25
20
15
number of arrivals or discharges per hour
10
5
0
Mo 0
Mo 6
Mo 12
Mo 18
24
hour of week
Emer Adm AE
Emer Adm direct
Elec Adm
Disch
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The need for beds during the day
This trust needs about 35 more beds at midday
than it did at midnight
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How moving a few discharges can help
discharges before and after
30
25
20
15
10
5
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
before
after
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Demand and capacity are more balanced
Arrivals and discharges by hour monday only
30
25
20
number of arrivals or discharges per hour
15
10
5
0
Mo 0
Mo 6
Mo 12
Mo 18
Tu 0
hour of week
Emer Adm AE
Emer Adm direct
Elec Adm
Disch
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Less of a daily peak in demand for beds
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Variation in length of stay
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Aiming for average LOS over the week
Length of stay by day of admission
9
8
6.5
6.5
6.5
6.5
6.5
7
6.1
6.2
6
5
Average length of stay (days)
4
3
2
1
0
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Target short stay patients for a big impact
Greatest impact will be seen by concentrating on
shorter LOS - usually simple discharges
250
200
150
Number of patients
100
50
0
0
3
6
9
12
15
18
21
24
27
30
33
36
39
42
45
48
51
54
57
Length of stay (days)
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Daily bed requirement reduced from 78 to 68
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• How to approach implementation
• Key messages

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Key messages for implementation

• 1. Look across the whole system admission to
  discharge, electives and emergencies
• 2. Understand the unique pattern of variation at
  your hospital
• 3. Understand the main sources of variation
  including unnecessary queues / carve out
• 4. Plan for short and long term improvements and
  manageable changes

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Key messages for implementation

• 5. Map and measure your main flows
• 6. Concentrate on the 80 of simple discharges
  first
• 7. Aim for real time data analysis
• Integrate work on beds into existing plans
• Respond appropriately to common and special cause
  variation

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Resources to support work on beds

• All MA materials and UK Department of Health
  Checklists on the website
• www.modern.nhs.uk/beds
• Also toolkits produced by the PFC

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Five innovations to improve length of stay
management and whole system patient flow