Sleep outs – nemesis of every clinician

Adhi (V Adhiyaman), geriatrician and Chair of Welsh council of the BGS. Tweets at @adhiyamanv

bedEvery clinician hates having sleep outs. Sleep outs or outliers used to be a rare occurrence in the past and happened only in extremely busy winter months. Now it is a norm due to reduction in bed capacity across England and Wales. In every hospital there are around 15-30 sleep outs at any time (even more if one includes the patients in emergency department waiting for a medical bed).

Most of the sleep outs are direct admission of medical patients to non-medical wards. It is not the clinicians who decide the sleep outs anymore. Bed managers make this decision and frequently hassle the medical registrars to identify sleep outs so that they don’t have to take the ownership of their decisions. Registrars are fed up of doing this as they are always busy with the take or dealing with other medical issues.   

Most of the sleep outs tend to be elderly patients whose problems are thought to be trivial. Sleep outs are dangerous in many aspects including wrong allocation to a firm, low priority on surgical wards, always seen at the end of the ward round, lack of expertise from the nursing staff etc. Literature is limited on medical outliers and few existing ones have shown an increased length of stay, patient dissatisfaction and safety concerns from all professionals.

What is the solution? The commissioners, leaders and managers should acknowledge the need for more medical beds. The fact that we have around 30 outliers at any time means that we need extra capacity with adequate medical and nursing support staff. The argument that we need to lower the number of beds because a third of our patients do not need to be in hospital may sound appropriate in principle, but it is far from reality. The reasons patients stay longer in hospital are beyond our control and examples include lack of beds in care homes and long delays to purchase care in the community.

UK has the fewest number of hospital beds per person than any other country in Europe except for Sweden, who has invested heavily in the community. Hospital services are overstretched, overcrowded and have started to break down. Older people are being blamed for blocking the hospital beds and geriatricians are blamed for being unable to provide a miraculous solution. As geriatricians we should continue to push for managing patients in the right environment and try to make the commissioners listen to provide adequate capacity and invest in schemes to provide more support in the community.

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