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From response to recovery in elective care: lessons learned for Patient Flow

At the time of writing (May 2020), it's been estimated that there are 37,500 empty hospital beds across the NHS and 2,000 critical care beds, in addition to the substantial Nightingale bed capacity. The lack of reliance upon Nightingale capacity is a success marker of the service reconfiguration undertaken as the NHS has proactively repurposed and, in places, completely transformed to meet the demands of COVID-19. It also reflects a ‘flattening of the curve’ from the original modelling.

A rare drop off in non-elective demand has also afforded Trusts the headspace to consider how they can do things differently. We know that elective activity needs to return in a safe and coordinated way, and this includes the planned flow of patients in, through and out of the hospital.

This blog is the latest in our series of ‘response to recovery’ viewpoints focused on elective care. They are intended to provide NHS leaders with some key considerations to help inform their return to delivering elective care.

Plan for non-COVID surges

While the drop in the number of Emergency Department (ED) attendances is helping (estimates show up to a 60% drop-off), the data also suggest there has been a significant reduction in chest pain, strokes and appendicitis across the general population. But experience tells us is this is highly unlikely. Social distancing and self-isolation may have contributed to fewer road accidents and alcohol related injuries, but beyond that it’s more likely that patients who would otherwise have attended are suffering at home. When they eventually do present, their condition may be more complex and their length of stay prolonged.

Data also indicates that COVID-19 will continue to be a predominant presenting condition, even if the number of COVID-19 admissions is reducing.

So Trusts not only need to recover their services, wards and pathways, but ensure sufficiently robust planning to meet a potential surge in the numbers and acuity of elective and non-elective patients. This must be carefully coordinated within a climate of increased demand and complexity.

Don’t expect to return to traditional ward configurations

Simply reopening the same wards is likely to be insufficient to meet demand if there is a surge in elective and non-elective numbers. Ward configuration should be modelled, risk assessed and simulated in the same way as demand for beds.

For example, the need for radiology, pharmacy, clinical and nursing workforces will likely be higher and more complex. A second workforce consideration will be will the reallocation of consultants currently deployed within wards and emergency departments (ED). Finally, surgical bed capacity needs to be considered – designated ‘cold’ sites would be the optimum set up to meet a surge in demand but are not a viable longer-term solution, given they have their own workforce pressures.

We cannot yet be sure of further waves of COVID-19, so careful and deliberate modelling to help Trusts adapt quickly to changes in demand, and adjust ward configuration and workforce accordingly, will be crucial.

Pockets of transformation to be embedded longer term

COVID-19 has forced a transformation of ED pathways. For example, we are now seeing Trusts achieve 100% against the 4-hour target for the first time. Consultant triage, ward-take, rapid imaging, revised ED and Acute Medical Unit (AMU) processes and workforce redeployment have assisted greatly.

Trusts now need to consider a) whether it is appropriate for such processes and workforce models to be maintained, b) the risks and mitigations to doing so, and c) what a phased transition would look like, given the need for recovery alongside continuing COVID-19 treatment.

We have seen heroic efforts from the entire healthcare system, working collectively to safely transfer medically fit patients to their most appropriate place of care and freeing up acute beds to address frontline challenges. Trusts, community providers, local authorities and care and nursing organisations have collaboratively eroded existing barriers which typically manifest as bottlenecks at the heart of the Delayed Transfers of Care (DTOC) challenge. Although the financial implications of this are not yet fully understood, transitioning back to the pre-COVID status quo cannot be the answer.

The recent surge in reported COVID-19 deaths within care homes does of course need consideration. Discharging patient en masse back to care homes would be dangerous, but retaining them within the acute wards would surely overburden the system. Therefore, the future use of care homes during COVID-19 and beyond needs to be very carefully designed. COVID-19 positive and negative separation seems the most obvious answer, but this could only be effective by ensuring the appropriate workforce and equipment to safely treat patients in each setting.

The scale of recent changes acheved by the NHS is a direct result of dynamic and decisive operational and clinical leadership to meet the demands of COVID-19. Imposing similarly tight grip and control leadership for the future management of ED performance, referral to treatment (RTT), cancer and DTOCs should be explored.

The NHS has typically been a slow adopter of control centre approaches and technologies, however now may be the optimum time to consider how real time data and information can best support decision making, aligning workforce capabilities and managing inpatient flow, from ED to length of stay, to discharges and DTOC.


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