Chris Roseveare is a Consultant Physician in Acute Medicine at University Hospitals Southamption, and is Editor of Acute Medicine Journal. He tweets at @CRoseveare. Here he discusses a recent report from Sky News: Hundreds Discharged From Hospitals Every Night
It’s 2am on a Sunday in a hospital in the UK, and the duty consultant physician has just been called in. It has been a difficult weekend for the medical team: the Acute Medical Unit (AMU) was already full on Saturday morning following a busy Friday night. Compounding this, the locum agency were unable to fill the SHO vacancy on Saturday and the foundation year 1 called in sick for her night shift. Sunday had started with 15 medical patients waiting to be clerked in the Emergency Department (ED), and the medical team have struggled all day to clear the backlog. Ambulance trolleys are now queued in the corridor in the ED; there are ten patients who have waited more than four hours for a bed in the AMU, two of whom are approaching a twelve hour wait. Beds have been opened – and filled – in the managed care unit as well as the medical ambulatory care area. More than 20 patients have been ‘outlied’ into the surgical division during the course of the weekend, which has necessitated cancellation of a number of elective surgical admissions planned for surgery tomorrow. There no longer seems to be any room for manoeuvre.
In consultation with the on-call executive, the duty manager now has a plan: several patients have been identified across the hospital whose discharge is planned for Monday morning – perhaps if they could be discharged from hospital overnight this could help ease the pressure in the ED….? The medical consultant is on her way into the hospital. This will be a difficult discussion.
A recent report on Sky News suggested that ‘over 300,000 patients’ had been discharged from hospital overnight since 2012, including over 60,000 who were over 75. The report featured a case in which a patient was discharged from an ED in a confused state and was later found wandering a mile away. Earlier this year, the Royal Victoria hospital in Belfast declared a major incident due to capacity pressures; the following day, national radio ran interviews with the carers of patients who had been discharged or transferred to other hospitals overnight during this crisis. Capacity pressures in hospitals across the UK are not unusual, and Sunday nights are often a pressure point; the scenario above is entirely imaginary – but I suspect that many hospital clinicians and managers across the UK will have been faced with similar challenges, and difficult decisions, over the past 12 months.
However this does not tell the whole story. There are many situations where the timing of discharge is driven by clinical, rather than organisational factors. For example, a patient who requires a troponin measurement 10-12 hours after onset of chest pain will require this to be measured after midnight if the pain came on after lunch. There are many patients – including patients aged over 75 – who would far prefer to be discharged after 11pm and spend the rest of the night in their own bed, rather than being kept in until morning. To suggest that overnight discharge is always the result of a precipitous or inappropriate decision, driven by capacity pressures, is incorrect. Many of the 300,000 patients described by Sky News will have been discharged following a planned, safe and senior decision, taken in partnership with the patient and their carers.
Many EDs and AMUs now provide a consultant presence until after 10pm, enabling the balance of risk and patients’ wishes to be carefully evaluated at a senior level. For older or vulnerable people careful attention clearly needs to be paid to suitability for discharge, as well as what support is in place. However it is possible for this to be done, even late at night, facilitating a safe return home and avoiding an unnecessary overnight hospital stay. Such decisions should always be taken on an individual basis, and in discussion with the patient and their carers. Overnight discharges that are not clinically appropriate, or against the wishes of the patient, should never be contemplated.
The high levels of bed occupancy in acute hospitals across the UK means that periodic ‘bed crises’ are inevitable. In order to avoid this, hospitals need to design systems which provide sufficient capacity and flow to maintain occupancy at levels below 90% on a consistent basis; however they also need escalation plans with the ability to predict and respond to such crises during daylight hours. Waking patients to be sent home at 2am should never be considered an acceptable solution to ease emergency pressures.