Monday, January 10, 2011

How to combat 'bed blocking' in hospitals | Ian Philp

The longer elderly people are kept on acute hospital wards, the more danger they are in of suffering complicationsGoing into hospital can be a frightening experience for anyone; for older people it can be harrowing. In my most recent medical role, I looked after a group of older people who experienced delayed discharge from an acute hospital ward. Fifteen patients were affected ? one of them was delayed for more than a year. Out of the 15, three died.One of these was a man who was finally about to return home, but acquired a chest infection the day before he was due to be discharged. In spite of treatment this progressed to pneumonia, which led to heart failure and kidney failure.At the end, he asked me if he was going to die. I told him he was severely ill and that this was likely, but that I could give him some treatment to reduce his distressing breathlessness. He died four hours later. I remain upset and angry about how we let down this man who lived out the last weeks of his life, with great dignity, on our ward, rather than enjoying more time in his own home.This man's story isn't unique. Infections that can be acquired in hospitals include chest infections and the intestinal disease clostridium difficile, which causes severe diarrhoea. And the longer an older person remains in hospital, the higher the risk of such adverse events. Long admissions often result in a loss of confidence to cope at home again, atrophy of social support networks and an increased likelihood of moving into permanent institutional care, often under pressure to clear a hospital bed.Between 2000 and 2004, we in England came up with a number of measures to tackle this problem. A range of intermediate care services were introduced to help avoid admission to hospital and support early discharge. The investments were channelled through councils and the health service working in partnership to meet local needs. As a result, delayed discharges from hospitals dropped by 70%, releasing more than a million acute hospital beds.If plans to complete the investment in these services by 2006 had been pursued, delayed discharge in England, with all its human costs, could have been eliminated. But policy attention switched to other priorities and intermediate care services drifted.We are now dealing with the re-emergence of this problem. In a recent survey of doctors working in UK hospitals, 50% said the problem known as "bed-blocking" was worse now than a year ago.I firmly believe it is possible to redesign our health and care system to provide the right services in the right place for older people. In particular, we should incorporate four principles into the redesign of services for older people who currently need emergency hospital care.First, unless emergency services identify a life-threatening condition, if an older person has a fall, goes off their legs or becomes confused, it is better to provide care and support in their own home, with expert assessment of their needs there, rather than admit them to hospital for assessment. Some will be subsequently admitted if a serious underlying illness is identified.Second, frail older people in hospital do better under the care of old age specialists, with better decision-making, more positive experience of care and shorter lengths of stay. Hospitals need to develop systems to identify frail patients, with early transfer to the care of old age specialists.Third, any delay to transfer from acute hospital care is is likely to lead to worse outcomes for older people. In-hospital assessments should be reduced to a minimum. Once acute hospital care is no longer required for medical reasons ? typically after three to five days ? transfer to post-acute care in the community should take place within 24 hours, with assessment of ongoing needs undertaken in the community setting.Fourth, older people take up to six weeks to recover from illness requiring hospital admission. During this period they need additional support, expert assessment of their ongoing needs and an approach which encourages re-ablement, rather than simply meeting their current care needs.Are these changes achievable? Councils and the health service will undoubtedly point to pending budget cuts. But to see how things can be done, we just need to look east. Hong Kong, whose health service is built on a British model, suffered the same problems of delayed hospital discharge as England in the early 2000s. The Hong Kong administration adopted, and fully implemented, the English intermediate care plan, and have eliminated delayed discharge from their hospital systems. Why can't we return to the model that used to work so well for us in the past?Older peopleNHSHealthHealth policyIan © Guardian News & Media Limited 2011 | Use of this content is subject to our Terms & Conditions | More FeedsClayton Brose Allan Kriss Clinton Vanostrand Lance Politte Marylou Craney

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