October 2017  

Modern acute hospitals are designed for patients who have acute medical needs, and have therefore focussed their attention on supporting these needs. An increasing issue for these hospitals are patients having to stay in hospital beds for longer than is clinically required.  These non-acute patients run the risk of acquiring hospital-born infections, and may decondition due to lack of appropriate physiotherapy for example. In addition, they prevent other patients from being treated, leading to increases in waiting lists. When clinically appropriate, it is far better for patients to be treated closer to home, as their care can be tuned more closely to their needs.  So what are the best ways to maximise the number of patients who can be treated in this way, and therefore minimise the number who remain in hospital unnecessarily?

We have recently been working to look at what organisations are doing to help impact Delayed Transfers of Care (DTOC). A DTOC occurs when a patient is ready to leave hospital, but is unable to do so, and is therefore still occupying a bed19. DTOCs are multi-factorial so no single intervention will provide overall success.  This makes a coordinated approach across multiple areas the most likely to achieve reductions.

Broadly speaking it is possible to think about initiatives aiming to discharge patients sooner, initiatives aiming to avoid admissions (and hence potential DTOCs) altogether, and initiatives aimed at improving hospital flow of patients to ensure patients do not need to stay longer than medically required for their needs. This paper focusses on these areas, as well as touching upon the New Models of Care Vanguards which are trialling many new mechanisms across multiple areas of interest.  This paper therefore does not focus on reducing delays that occur within the hospital, (such as waits for diagnostics), although some of these interventions would affect them.

If you have an interest in this field, what is included below is a simple starting point for research. It is not an exhaustive list, some of these examples will overlap with others, and the field continuously evolves. Please check, research and decide whether the benefits you are seeking can be achieved through these mechanisms.

Discharging Patients Sooner:

                                How does it work?                                         Examples to investigate:



Whilst the primary mechanism for reducing DTOCs remains looking at ways to discharge sooner, or to avoid the reasons why a discharge cannot safely occur; avoiding unnecessary admissions can also reduce DTOCs. Elderly patients can often experience reduced mobility as a result of staying in a hospital bed. If the original admission could have been safely avoided, it reduces the risk of the patient deconditioning and would thus avoid some of the causes of DTOCs. The following initiatives are all focussed on avoiding these original admissions.

Avoiding admissions (and therefore potential DTOCs)

                              How does it work?                                                      Examples to investigate:


 DTOCs can also be reduced through effective use of clinical specialists and more effective and timely decision making within the hospital.

Initiatives to improve hospital flow (reduce unexpected DTOCs)

                                  How does it work?                                               Examples to investigate:


The final area to explore are the New Models of Care Vanguards happening across the country. This needs a paper to itself, however as a starting point the integrated primary and acute care systems (PACS model) looks to improve clinical decision making which would help DTOC rates.

New Models of Care Vanguards

                                 How does it work?                                                    Examples to investigate:


There is a wealth of material and examples available to support the reduction of delayed transfers of care. It is a developing field with many examples being published on a regular basis. For example, the use of leading edge technologies for patient flow optimisation (e.g. at Johns Hopkins Hospital) should have a significant impact on DTOCs, through optimising patient flow decision making21 .

As with any intervention, form should follow function, which in turn should come from a thorough understanding of the issues. Having a clear and data-driven understanding of the causes for DTOCs in any particular location allows for cross-system buy-in for the potential interventions required. Interventions should always be tuned to suit the local situation. DTOCs do not help patients who are waiting to leave the hospital. They may not be receiving care specifically tuned to their needs (as they are in the wrong clinical setting) which may have an impact on its quality. Extended stays in hospital can have a deconditioning effect on patients which results in increased rehabilitation/ reablement requirements, or patients who could have gone home needing residential/ nursing homes.

These patients could also be nearing their end of life. One example I encountered was of a patient who stayed in hospital 12 days longer than was necessary due to the difficulty in arranging in-home support. Subsequently 10 days after they were discharged they passed away. Over half of their last 22 days of life were in a hospital when they should have been at home with family.

Clearly DTOCs need to be reduced, it represents the right thing to do for the patient, it allows the Acute Hospitals to focus on the sicker patients, and by streaming patients to the right setting at the right time it helps to optimise the running costs of the health and social care system.

The ideas and interventions covered in this paper will not meet every local need. This paper will hopefully provide a stimulus to thinking and further investigation about what more local areas can do, and what fresh approaches they might consider.

Note 1: http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/making-best-use-of-the-better-care-fund-kingsfund-jan14.pdf
Note 2: NHS Providers Right place, Right Time, Better Transfers of Care,
Note 3:
Note 4:
Note 5: http://www.yhscn.nhs.uk/media/PDFs/cancer/CYP%20Docs/Nov%202015/1400%20chemo%20at%20home.pdf
Note 6: CGA at the ED: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4246995/, CGA meta study: http://dx.doi.org/10.1136/bmj.d6553
Note 7:

Note 8: http://www.midlandheart.org.uk/our-news/news/other-news/commission-calls-for-new-approach-to-health-and-wellbeing/
Note 9: https://www.bromford.co.uk/news-hub/blog/2015/june/partnership-working-with-st-giles-hospice/
Note 10: http://www.transformingsystems.co.uk/products-services/shrewd-resilience/, http://tinyurl.com/yd3bsvur
Note 11: http://directory.ageuklambeth.org.uk/
Note 12: http://tinyurl.com/yag2mjuc
Note 13: http://tinyurl.com/yccrtfks
Note 14: http://www.elht.nhs.uk/news/Refer-to-Pharmacy.htm
Note 15: http://www.londonscn.nhs.uk/wp-content/uploads/2016/09/DToC-Report-1st-April-2016.pdf
Note 16: https://londonadass.org.uk/wp-content/uploads/2015/11/DToC-Simple-Guide-Final.pdf
Note 17: https://www.england.nhs.uk/ourwork/new-care-models/vanguards/care-models/primary-acute-sites/
Note 18: http://tinyurl.com/yb69fudr
Note 19: Page 6, https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2015/10/mnth-Sitreps-def-dtoc-v1.09.pdf 
Note 20: https://www.kingsfund.org.uk/sites/default/files/media/Falls%20Rapid%20Response%20team.pdf
Note 21: https://www.youtube.com/watch?v=kBqKjlPGE6I, https://www.youtube.com/watch?v=f8byiZD7p5A

 This email address is being protected from spambots. You need JavaScript enabled to view it. BSc (Hons), PhD, MBA, DipM, MRSC, ACIM, CChem is a Consulting Manager at GE Healthcare Partners.


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