Miles Witham and Marion McMurdo have shared their concerns about unnecessary ward moves on the Oxford University Press blog.
It’s a Thursday morning in February, and I have just arrived on the ward to start my ward round. Mrs Y, a lady in her 90’s with dementia, was admitted with pneumonia a few days ago. She is on the mend, rehabilitating well, and we planned to get her home tomorrow with some extra home care. Now she is nowhere to be seen.
“She was moved out to the dermatology ward last night” the senior charge nurse tells me apologetically. “No beds again, and we had half a dozen patients in the acute medical unit waiting to come up.”
At the end of the ward round, I make my way across to the dermatology ward. Mrs Y is thoroughly disorientated, wandering around and becoming more and more agitated. She is proving to be challenging to care for; the dermatology nursing team lack the skills to look after frail patients with dementia. Later that day, she falls on the way back from the toilet, giving herself a nasty bang on the head. Her discharge is delayed by several days whilst she recovers from her fall and her confusion.
This story will sound familiar to all too many of us who work in hospitals looking after older, frail people, and it is all too familiar to our patients and their loved ones. Boarding (the practice of moving patients from ward to ward in hospital to make room for other patients) is bad care. As explained in our editorial in Age and Ageing, moving frail, older patients makes them more vulnerable to falls, more likely to become confused and disorientated (delirium), and the need to hand over care to a team that is unfamiliar with the patient and family leads to miscommunication and delays in planning care and discharge.and more agitated. She is proving to be challenging to care for; the dermatology nursing team lack the skills to look after frail patients with dementia. Later that day, she falls on the way back from the toilet, giving herself a nasty bang on the head. Her discharge is delayed by several days whilst she recovers from her fall and her confusion.
Most importantly, older patients do best when they are looked after by specialists in the care of older people, working on a specialist ward with specialist nurses. Moving to a non-specialist ward means that they don’t get the benefit of the best care, which means that they are more likely to become unable to look after themselves, more likely to enter a nursing home, or more likely to die.
Patients don’t want to be boarded, but few are asked if they mind. Families don’t want it, and nor do clinical staff — 90% of doctors in a recent survey would object if their relative was being boarded. So what is the solution? Boarding is a symptom — a symptom of a system of health and social care that is not working as it should. It is not the fault of individuals, and exhorting individuals to improve isn’t going to work. The solution lies with us all: government, hospital management, GP practices, social work departments, and hospital staff. We need enough beds, but we also need new ways of looking after older people that mean they spend less time in hospital.
Hospitals are not always good places for older people, but sometimes a hospital admission is necessary. Boarding is dangerous, inefficient, and is a classic example of the type of bad care discussed by the Francis report. The solution will take all of us working together, but the one thing that each of us can do individually is be a voice for our patients. Boarding is not acceptable, and we should speak up and say so at every opportunity.
Miles Witham is Clinical Reader in Ageing and Health, and Marion McMurdo is Professor of Ageing and Health, at the University of Dundee, Scotland. Their academic work focuses on clinical trials of exercise, nutrition and medications to improve physical function and quality of life in frail older people; they both work as Consultant Geriatricians, looking after older people in a specialist clinical service. They are the authors of the paper ‘Unnecessary ward moves’ in Age and Ageing.
Age and Ageing is an international journal publishing refereed original articles and commissioned reviews on geriatric medicine and gerontology. Its range includes research on ageing and clinical, epidemiological, and psychological aspects of later life.