Theatres can be surprising. As I discovered on a hospital project

Avoiding the avoidable is an excellent goal. But sometimes healthcare, including acute healthcare, is simply unavoidable. Not all the people walking into Emergency Departments are ‘walking wounded’ or ‘worried well’ who can be sent home with instructions to see their General Practitioner in the morning. Some really need hospital care and have to be admitted.

However, avoiding the avoidable doesn’t stop at the hospital bedside. Work still needs to be done to make sure that even within a hospital stay, the care delivered is precisely what the patient needs, and no more. In that context, initiatives that I’ve mentioned before that focus on discharge planning are important: from the moment of admission if not before, work needs to be put in place to discharge the patient as quickly as possible:

• The patient should not have to stay longer in hospital than they need to just because test results are not available
• If necessary, doctors have to review the organisation of their work to ensure that all the necessary paperwork, including prescriptions, are signed and ready in time for a prompt discharge
• Where hospitals have to ensure that a patient is discharged to an environment with adequate care, all the arrangements should be in place beforehand

That’s the surest way of avoiding unnecessary hospital care: get the patient out of hospital and no longer incurring the elevated costs of nursing, medical care, tests or hospital drugs, to say nothing of surgery.

Even while in hospital, we can take action to avoid resource wastage. That’s where good information services come into their own again. Sometimes, they don’t even need to do anything exceptionally clever: they simply have to report in a clear and undeniable way on what’s going on in the hospital.

Often, that kind of reporting does just one of two things, both useful:

• It may confirm what everyone knew, or at least suspected, but couldn’t prove
• It may surprise people who hadn’t anticipated that the problem would exist

Occasionally, the same piece of information may confirm one person’s suspicion and surprise another. That happened to me when I was working, many years ago, on a reporting system for theatres (as we quaintly refer to operating rooms in the UK) in a major acute hospital. Theatres are hugely costly, both in the amount of capital they require – not just for building space but also for equipment – and in their running costs, requiring large numbers of highly-qualified staff in relation to the numbers of patients. It’s no surprise that many cost-containment initiatives in hospitals make a specific point of working on cutting unnecessary theatre costs.

One of the costliest areas in a hospital
so no bad place to look for economies

The project was fun because we set up a live link between our reporting system and the theatre management system. That meant we could see what stage of an operation any one case had reached: arrival in theatre, start of anaesthesia, first cut, last stitch, out to recovery, return to ward.

I appreciate that’s only fun for a geek who’s got too used to working on retrospective reporting systems, as I was: to me, it was exciting to be able to follow individual cases in near real time, as the theatre nurses entered information on their own system.

The real surprise came, though, with one particular report. We hadn’t been second-guessing the users at all, but building reports only as they told us they wanted them, using information they’d asked to collect. One of the reports, however, struck me as singularly dull. It simply showed the number of cases when the patient had been due to have a general, regional or local anaesthetic, plotted against which type of anaesthetic was in fact administered. The report looked something like the fictitious example illustrated (from memory – please forgive any implausibility it contains).

Anaesthetic report: I couldn’t see what was so exciting about it

The Medical Director of the hospital was also the head of anaesthetics. He looked at the report and immediately crowed with delight.

“That’s what I thought!” he proclaimed triumphantly.

I looked again at the report. I couldn’t see anything inspiring in it.

“Look at all those times they asked for a regional or general anaesthetic and ended up using a local! What a waste of an anaesthetist’s time, standing by to administer the anaesthetic, without being required.”

Suddenly the report made sense, as did his reaction. And I made a mental note: don’t imagine you know everything a reporting system should do. Talk to the users, learn what they want, and you may come up with something that will surprise you and delight them. 

Particularly if it highlights an area of waste that can be avoided.

Ageing: a crisis for healthcare. Or an opportunity for integrated care?

It’s obvious, isn’t it? The wealthy nations face a crisis due to their ageing populations. The problem’s particularly acute for healthcare.

It’s so obvious that even I have said it in the past. But it isn’t entirely true. The error needs correcting, if only because ageing isn’t a curse but a measure of unprecedented success. At the beginning of the last century, life expectancy in the US was just over 48 years. Today, it is nearly 79. In Britain over the same period, it has grown from 45 to 81. How’s that a disaster?

After all, it’s not as though the picture is the same everywhere. In Syria, life expectancy is 64.5 years. In Sierra Leone it's just 50 years, little better than the US over a century ago.

Where there have been gains, the extra years include an increasing proportion in good health. That’s according to a study by the British healthcare think tank, the King’s Fund. It suggests the trend is likely to continue, with our ageing population adding further years of healthy life.

More years of healthy life? Why’s that a problem?

Not so much a healthcare crisis as a cause for celebration, surely. 

That being said, the trend does raise new challenges for healthcare. They need to be addressed. That means a change in approach.

As the King’s Fund points out, what we are seeing is an increase in the specific kind of health problem characteristic of old age. There are more long-term conditions such as diabetes, some lasting for life, and more patients suffering from several disease conditions at the same time.

Why is that such a challenge to the health services? Because historically healthcare has been built around specialisation. Hospitals are organised into departments dealing with neurology or rheumatology or cardiology. But today they’re having to deal with patients who may have suffered a stroke exacerbated by a chronic heart problem, who are also struggling with the pain of rheumatoid arthritis.

How does a specialist of just one of these conditions approach such a patient?

These issues also raise the question I’ve been addressing throughout this series: in what setting should a patient be treated?

The King’s Fund tells us:

…we must strive wherever possible to ‘shift the curve’ from high-cost, reactive and bed-based care to care that is preventive, proactive and based closer to people’s homes, focusing as much on wellness as on responding to illness. When asked what they value in terms of wellbeing and quality of life, older people report that health and care services when they become ill or dependent are only part of the story. Many other things matter: the ability to remain at home in clean, warm, affordable accommodation; to remain socially engaged; to continue with activities that give their life meaning; to contribute to their family or community; to feel safe and to maintain independence, choice, control, personal appearance and dignity; to be free from discrimination; and to feel they are not a ‘burden’ to their own families and that they can continue their own role as caregivers.

Admission to hospital may be vital in certain circumstances but, as well as being the most expensive way to deliver care, it corresponds to only a tiny part of the aspirations older people expressed to the King’s Fund team. They propose reform based on nine points:

1. helping people maintain their independence, to live at home in good health, for as long as possible;
2. helping people to live as well as possible with simple or stable long-term conditions if they develop them
3. helping people deal with complex or multiple health problems, including dementia and frailty
4. in cases of real crisis, delivering rapid help close to home
5. when it becomes necessary to provide hospital care, making sure it’s good and delivered humanely
6. planning discharge from hospital on admission or before, ensuring patients leave with sufficient support and avoid the risk of readmission
7. providing good rehabilitation and re-ablement services so patients quickly return to the best possible level of health and independence
8. providing high-quality long-term nursing and residential care for those who need them
9. ensuring that services supporting patient choice and control, with all the care and support required, are available towards the end of life

The tenth point is that all the others require integrated healthcare, bringing together medical, nursing and social care, in hospitals, family practices and community settings. An integrated approach sees a patient as a whole, not as the vehicle of a single medical condition, or even several. It accentuates quality of life and does everything to maximise choice and independence. Such care would certainly be the best imaginable.  What may seem paradoxical, but isn’t, is that is also likely to be the least expensive. That’s because it minimises healthcare demand and shifts as much as it can to less costly settings, in particular away from the acute hospital.

This approach will have benefits far beyond care for elderly patients. As the King’s Fund argues:

The balance of evidence is clear that integration can improve people’s experience and outcomes of care, and deliver greater efficiencies… It is important to recognise that achieving improvements for older people will also positively affect care for the rest of the population. More effective urgent care and post-acute rehabilitation and re-ablement services are important for people of all ages, while reducing inappropriate care and shortening acute lengths of stay for older people could release resources to meet other needs.

Avoiding the avoidable and coordinating care more effectively will deliver better care. Far from costing more, that may free up resources. So the ageing of the population may not be so much a crisis, as an opportunity.

Avoiding the avoidable: the problem of delayed discharges

So far I’ve mostly talked about avoiding the avoidable in hospital expense only at the start, the admission stage, of a hospital stay. But the problem arises at the other end too, when a patient has to stay on because the discharge process is delayed. 

There are two main reasons why this might happen.

OK, so why can’t I just go home?

The more obvious one is that the discharge has not been properly prepared. Tests need to be carried out to confirm that the patient is fit to go home, but the results haven’t been received – or perhaps the tests haven’t even been ordered. Possibly the patient needs to take medications home and the necessary prescription hasn’t been sent through to the hospital pharmacy. Or, even more simply, the discharge needs the approval of a doctor who simply isn’t available, called away to an urgent conference which perhaps, and entirely coincidentally, is taking place next door to a prestigious golf course.

This kind of problem occurs everywhere. Recently I read a 2014 study of two hospitals in Brazil. It found that in one of the hospitals, delayed discharged represented a 23% extra occupancy rate, a figure that climbed to 28% in the other. That means a massive proportion, around a quarter, of the beds in those hospitals were occupied at any one time by people who should already have left.

The other main reason for a delayed discharge is particularly familiar in a nation such as England. Patients can’t leave because there’s nowhere for them to go where they will receive the ongoing care they need. This is particularly acute for older people who may be living alone with no one available to act as carer. They can only be discharged once there is a social worker or community nurse available to help them, or perhaps a bed in a care home.

Delayed discharges generate two problems. First of all, it’s bad for the patients: people generally recover better in their own beds than in hospital and, in any case, simply by staying on patients are exposing themselves to unnecessary risk, if only of infection from other patients around them.

Secondly, the delayed discharge is bad news financially. Acute hospital care is the most expensive care and, even though costs will be lower towards the end of a stay by which time the patient requires less treatment, the mere fact of occupying a bed is expensive. That’s without taking account of the impact on other patients who might have benefited from being admitted to a bed blocked in this way.

A recent study (February 2016) for the NHS in England by a team headed by Lord Carter of Coles, Operational productivity and performance in English NHS acute hospitals: Unwarranted variations, put a figure on the impact of delaying discharges: “the cost of these delays to NHS providers could be around £900m per year.”

That’s close to 2% of the total expenditure on acute care.

How do we fix these problems?

Both require management action, naturally. For instance, my wife worked until two or three years ago in the Discharge Planning team of our local hospital. Here, nurses, social workers and hospital staff worked out of a single suite of offices, preparing the plan to discharge a patient from the moment he or she was admitted. That meant that the agencies involved in post-hospital care had the greatest possible notice that their services would be needed. They could, therefore, assign staff or find suitable accommodation, at least as far resources allowed, in the most favourable possible conditions, rather than in a rush at the end.

Equally, steps can be taken in plenty of time to ensure that all necessary processes are carried out, the appropriate tests or medications ordered, and the paperwork prepared for someone to sign who will be around at the right time.

Computer systems can help, of course. The kind of pathways management software I’ve been talking about in this series can be used by hospital staff as it can by people in primary care. It can issue alerts not just to physicians but to nurses and care assistants: “for this patient to be discharged tomorrow morning, you have to request this test today,” for instance.

When it comes to helping with groups like my wife’s former colleagues, what’s needed is ways to improve collaborative working between different systems. Social work management software needs to interwork with nurse management and general hospital systems. Fortunately, none of that is impossible and over the last few years, great strides have been taken towards making it happen.

What that means is that avoiding the avoidable can now be tackled at both ends of a hospital stay: discharge, with its own specific problems, as well as admission.

Supporting clinical decisions and helping triage

Most of us understand the need to keep healthcare costs low. On the other hand, when we become patients, we’re not keen to see savings made at the price of increased risk. When it comes to avoiding the avoidable in healthcare, we like to think that costs are unavoidable if they ’re incurred ensuring our safety.

The Netherlands have an out-of-hours service patients can call when their GP practice is shut. The aim is to reduce visits to emergency departments in lieu of family practitioners. Nurses take callers through guidelines, asking a series of questions to establish what care the patient needs and with what urgency.

An out-of-hours call centre at work

A 2007 study set out to find out how well the service was performing. The results were disturbing. In 19% of cases, nurses underestimated the urgency of the patient’s condition. The study’s authors conclude that the service was “possibly not safe,” which feels like an understatement.

Denmark’s out-of-hours service gives evidence of the opposite effect: excessive caution by nurses. The Danish service is principally staffed by GPs, but there’s pressure to use nurses as an economy measure. However, a 2013 investigation found that nurses might be too inclined to refer a case for a GP to see instead of taking a decision themselves. The result? On top of the cost of employing the extra nurses needed, the service, far from reducing calls on GP time, might increase them. Costs could rise instead of falling.

What’s the answer? How can we reduce expenditure by having nurses or, even better, non-medical staff, take responsibility for triage, without either increasing risk to patients or incurring higher costs?

The 2007 Dutch study came up with one answer: it found that the more training nurses had received in the use of the call centre guidelines, the less frequently severity was underestimated. Certainly, telephone triage isn’t simply another application of already acquired skills. It’s a legitimate healthcare service in its own right, needing its own knowledge and expertise.

There is, however, another way in to  improve services. That’s the field in which I’m currently spending much of my time: clinical decision support.

What we’re talking about here is software that helps nurses or non-clinical call handlers work their way through guidelines. At the most trivial level, such software can ensure that nothing’s forgotten. A question might be mandatory, so the handler simply can’t move on until it’s asked. That would ensure essential information isn’t missed. Even with optional questions, their mere appearance on a screen would at least prompt the handler to ask them and might trigger a new line of enquiry.

That, however, is far from enough. There has been research (not enough, yet, but what there has been is telling) into the impact of clinical decision software. A revealing article showed that a call handler might be pushed down the wrong line by the software itself. It cites the example of a handler, a nurse, who had begun to explore what the software offered on the subject of nausea, while the caller had moved on to talk about back pain. With one line of questions already under way, the call handler failed to pick up the second symptom, however important it may have been.

Again, on some occasions, the lack of an appropriate response to certain questions led to a distorting effect: the patient was saying that she felt sick each time she ate, but the software hadn’t allowed for that reply, imposing instead quantitative entries – once a day, three times a day, and so on.

That’s what makes the search for effective software design such an interesting challenge. It’s not enough just to list all possible questions, in a fixed order. It’s vital to take all the information concerning any particular patient into account, without deciding too soon that one item has overriding importance or letting the software itself drive the direction of the investigation. In fact, the system has to:

1. take into account all the information about the patient, entered in whatever order. In other words, as in a real, face-to-face medical consultation, the patient should be able to describe all his or her symptoms without making a judgement about which is the most important 
2. suggest questions to the call handler based on all the symptoms, not just one of them 
3. drop irrelevant questions but propose all the others 
4. handle unquantified information, such as “I feel sick each time I eat”

That would be the kind of clinical decision support software that can really make a difference, because it emulates what happens in a medical consultation: the patient describes symptoms as they come to mind, not in an orderly or pre-filtered way. Alongside the kind of comprehensive training we’ve already seen is needed, such support software could bring us closer to the goal we seek: a triage service that delivers a reduction in costs without an increase in risk.

In fact, it would be valuable for far more than triage. It can make a major contribution to managing medical pathways in general. But that’s the subject of my next post.