By Dr Richard Newland, chief executive, CHS Healthcare
At a recent gathering of academics, NHS managers and strategists, a phrase that was repeated in many sessions was the “stranded patient”.
The concept is simple: define the proportion of beds in a hospital occupied by patients who have been there for seven days or more. Although some patients will have a severe illness or trauma that necessitates a hospital stay of more than seven days, many others will be in hospital for an excess of seven days because of unnecessary waits (typically an assessment, referral or availability of community based services). In other words, they are stranded in hospital because they are ‘waiting for something to happen’ rather than any medical need.
Like all good metrics, the stranded patient has a clear utility value. Applying it on a ward level, teams should identify any patient who is in hospital for more than seven days and consider:
- Why does this patient need to remain in hospital?
- What is being done and by whom to get this patient home?
- What could have been done during the first few days of admission that may have prevented this patient from becoming stranded?
Answering and addressing these questions can be a useful tool in more actively understanding and improving patient flow. Reports from individual hospitals show teams are achieving six to ten per cent reductions hospital stays of more than seven days.
On a strategic level, hospital managers can calculate what percentage of patients are staying more than seven days as a proportion of overall patients. Although this will inevitably capture some patients who need to be in hospital for more than seven days, it is argued that this indicator (stranded patient as a proportion of all admissions) is a more meaningful reflection of patient flow than the ubiquitous DTOC.
Delayed transfers of care, measured from the point when a patient is fit for discharge but remains in hospital, produce a high number of cases where delays are caused by problems with services in the community the patient needs. This interface between acute and community care is enormously significant. But we need to acknowledge, measure, understand and improve problems with patient flow which occur within hospitals also. As one chief executive puts it: to look at DTOC alone is to only observe the tip of a very complicated hospital discharge iceberg.
CHS Healthcare has worked in hospital discharge for 20 years and today, we are commissioned to provide services in more than 25 hospitals from Cumbria to the south coast of England. Our experience chimes with many of the principles discussed with the stranded patient metric and improving patient flow. For example, we have seen how effective daily board rounds can be where there is a specific focus upon hospital discharge. The practice of each patient having an Expected Discharge Date (EDD) and Clinical Criteria for Discharge (CFD) are also effective tools for ensuing there is the process and mindset to actively plan for discharge from the moment a patient is admitted.
From experience we know, for example, that if a family needs to find and choose a care home before leaving hospital, this is a process which should be started at the earliest possible stage, in conjunction with medical treatment and care. From experience, we also know that services providing care and support at home are under great pressure in some areas; work to arrange home care packages, particularly if needs are high, should take place at the earliest possible stage. In other words, actively addressing two of the questions asked in the stranded patient metric and working always with the principles of right care, right place at the forefront of care planning.