Professor Jonathan Pinkney from the Plymouth University Peninsula Schools of Medicine and Dentistry and lead researcher on the PenCLAHRC funded Avoidable Acute Admissions (AAA) project, talks about the current winter crisis in hospitals.
With our hospitals on high levels of alert and seemingly insurmountable pressures on the rest of the NHS and social care networks, now more than ever before, the question is being asked: “what next for our NHS?”
In recent months, an increasing number of hospitals have been put on level five alerts as pressures from emergency admissions have serious repercussions for bed occupancy and planned (elective) treatments.
The issues faced by our health and social care services are as complex as they are unprecedented but the situation is not wholly hopeless. Whilst there is no ‘magic bullet’ to solve the current crisis or cut future crises off at the pass, there are solutions that have been shown to be effective when properly implemented.
Last year we published the findings of the AAA study, which investigated how hospitals try to avoid unnecessary emergency admissions - the primary cause of non-essential stays in hospital. The study identified a series of innovations that can help to address this pressing problem in different ways.
The research team, led by Plymouth University and including experts from the Universities of Exeter, the West of England and Bristol, investigated how the emergency departments and staff of four major hospitals (Bath, Exeter, Gloucester and Plymouth) responded to emergency care pressures, along with the experiences of their patients.
There is evidence that a significant proportion of acute hospital admissions are avoidable and hospitals across the country have introduced a range of innovative initiatives to try to avoid these unnecessary admissions. Until we carried out our study, there had been no research to investigate how well such measures work in practice and whether they meet the needs of patients.
We found that the likelihood of a decision being made to admit a patient to hospital was not determined solely by the medical diagnosis and perceived risk. It was also influenced by the seniority and experience of the clinical staff making the decisions, the patient’s social circumstances, access to certain investigations, the proximity of the four-hour target and the availability of time to arrange alternatives to hospital admission.
The approaches taken to reducing unnecessary admissions varied considerably across the four hospitals, with different innovations developed to respond specifically to local need. Some of the main innovations included a hospital based acute GP service, ambulatory care units, a range of discharge assessment procedures and teams for elderly patients, the availability of rapid access outpatient clinics and the use of observation areas where patients were not subject to the four hour target - allowing more time to gather vital medical and social information, observe, investigate and make arrangements that could avoid hospital admission.
Early patient assessment by senior staff always played a central role in reducing admissions in all four hospitals but their expertise was deployed in different ways, including in a purely advisory “controller” capacity supporting trainees and other frontline staff. For example, during the current crisis the Royal Devon & Exeter NHS Foundation Trust has put consultants at the point of reception in its Emergency Department, helping to effectively prioritise care and admissions.
Our study found that, on the whole, patients were very happy with their experience of hospital emergency care, although they were aware of the severe pressures on the hospitals and there were certain areas of criticism from carers. For medical and nursing staff of all grades, there were concerns around pressures of work, staff retention and also the use of locum staff.
The fundamental problem is the high demand for hospital treatment, but pressures on staff, recruitment difficulties and reliance on temporary staff also contribute to admissions. In addition, the four-hour rule, which expedites treatment decisions, can result in decisions about care being made in a rush in the final half hour. This may be why some of the ‘off the clock’ innovations we observed were thought to be successful in avoiding admissions.
Hospitals and their staff are under immense pressure to ensure that each and every patient receives the best and most appropriate treatment. The emergency department is a particular pressure point and we were impressed by how each of the four hospitals in the study addressed the issue of avoiding admitting patients to the ward where unnecessary. Whilst there were common themes in how the hospitals approached this issue, the systems and innovations they put in place were informed by local knowledge and need.
The results of our study showed that there is a range of different methods that hospitals can use to safely reduce numbers of potentially avoidable hospital admissions and improve patient care. Some of these approaches are already in use, whereas others could be more widely adopted or scaled up in ways that could contribute to reducing pressures on acute hospitals.