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SHORT ARTICLE
Abstract
In an ideal system, patients admitted acutely to hospital should have their care provided in an area with the most appropriate ward-based medical, nursing and allied professional staff prole. Frequently this does not happen due to the physical structure and organisation of our hospitals in Scotland. Acute medical admissions may be tted in to the end of many different speciality ward areas while still under the care of a single internal medicine team as medical boarders. A survey of local medical and nursing staff revealed that a majority would not wish their relatives to be cared for in this way. It remains important to provide speciality beds for those patients who require them, but it is also necessary to develop a system that enables more patients to receive optimal care in the correct environment. In this article, we describe the issue, the problems created and some possible solutions. Keywords: acute medical admission, bed management, medical boarding, acute medicine
The organization of the care for patients admitted acutely to hospital with medical problems can have a major impact on their experience of the health service and clinical outcome. The recent introduction of a four-hour quality standard has resulted in major organizational focus on the process of medical receiving, with an emphasis on moving patients off trolleys in good time. This target has had a signicant knock-on effect on many aspects of care and processes throughout our hospitals. Many patients are assessed, treated quickly and discharged directly from assessment areas, but a signicant proportion require admission to a hospital bed, either under the care of an acute (general) physician or under specialty care. This presents challenges relating to the design of a hospital bed prole to best meet the needs of the population, and to the boundaries between general and specialty care. In the ideal world, a patient would be admitted under the care of an appropriate specialty (this includes general medicine) in their own base unit, with a resident core specialty team who have the expertise and systems in place to best look after that individual. The National Health Service (NHS) is constantly under nancial pressure and, as beds cost money, there is an incentive not to have any extra bed capacity in a hospital. Bed management teams have been developed to nd the most appropriate bed for any individual patient, but there are times when the most appropriate bed for an individual is not available and they are admitted as a medical boarder or outlier. By this we mean they are admitted under the care of one specialty (in our hospital usually
DOI: 10.1258/smj.2011.011187
general medicine) to a ward that is not the base unit for that discipline and has no resident staff from their specialty. In a report for the Scottish Government on behalf of their Emergency Access Team, Dr Beckett noted that all mainland NHS Boards in Scotland rely on a policy of boarding patients.1 Indeed the report states Over winter 2008 2009 in some sites up to 60% of all medical patients were boarders, occupying more than 10% of the total bed complement. This amounted to 5290 total boarded bed days. During a three-month period at the Western General Hospital, Edinburgh, the number of medical boarders varied from two to 56 patients. On average there are approximately 14 medical boarders across the year, with many more in winter than summer. These patients are distributed across the whole hospital and are often in as many as eight different wards, including neurosurgery, oncology, respiratory medicine, rheumatology, dermatology, surgery and urology. One might suggest that boarding is an inevitable consequence of the high bed occupancy in many acute hospitals, but it can be argued that it is actually a system design failure in bed proling, and at times specialty support, rather than an inevitable event. The problem is more than just the number of acute medical beds. Many hospitals now are actively managed through bed management teams to make sure that most beds are used efciently and there is no excess bed capacity. However, specialty units are of a xed size. Sometimes they need more beds than they have and sometimes less. If they are not using all of their beds, our systems actively manage patients into these beds as boarders.
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There are a number of problems that arise when caring for these patients. Communication difculties present in a variety of ways:
A major difculty is the management of sick or unstable patients when reviewing others in a distant unit across the hospital. Staff in an outlying ward may not pay as much attention to a patient who is not seen to be one of theirs. There are also challenges to the nursing skill, e.g. a patient with heart failure in an oncology ward, the basic inefciency of a safari ward round and the potential to increase hospital acquired infection through movement of staff and patients. All of the above are likely to contribute to an increased length of stay for these patients. The development of acute receiving units, where patients are kept for short periods of time until either they can be discharged or an appropriate bed can be found for them, has increased exibility of bed use. These areas are, by their very nature, busy and do not provide a calm environment for patients who are likely to stay in hospital for more than 24 hours. A number of methods have been implemented to attempt to decrease the risk to patients associated with boarding:
All of the above have some effect, but take resource, and do not deal with the primary problem. We recently conducted a survey of staff within Western General Hospital and have found that 100% (68) of doctors and nurses questioned, were happy for themselves or a relative to be admitted for medical care at the WGH. However, 74% of doctors would refuse to be a medical boarder themselves and 92% would not accept a relative to be a medical boarder. The nursing staff were generally more accepting, with only 21% refusing to be a medical boarder, and 45% refusing for a relative to be a medical boarder. These gures highlight the feeling among staff that medical boarders receive a poorer quality of care and that they lack the condence in the way the system works. This problem has been around for a long time without a denitive solution in most NHS Boards in Scotland. NHS Boards have been requested to work towards eliminating the boarding of patients as a solution to bed capacity problems. Specically, the boarding of patients from the Admissions Unit and/or Emergency Department should never occur.1 There are a number of possible ways to decrease boarding. These include:
At the end of each round of a receiving unit, consultants are asked to identify patients suitable for boarding and to suggest preferred ward areas for these patients, while acknowledging that this is not best care; Specialists are encouraged to actively take as many appropriate patients as possible into their beds and to lower their threshold for accepting patients (rather than leaving them under general medicine) when there is pressure in the system. There are many heated debates about the appropriateness of this, either within the receiving area or at times relating to general medical boarders in specialty units;
2012 Volume 57 Number 1
The concept of having the single exible, shared area in one place in a hospital has many attractions, protecting specialty units while potentially providing a good environment for patients as well as for medical, nursing and all other staff. Continuing to have the exible bed complement at the end of multiple wards across a hospital cannot be considered to be a reasonable way to care for vulnerable, medically sick patients. It must be hoped that we will soon look at medical boarders as a thing of the past, as their care is undoubtedly
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suboptimal at present. In the meantime the number of medical boarders in any NHS Board should be recorded and reported. This is a measure of both the quality of care provided and cooperation between specialty groups in the care of acutely unwell patients, a core function of any hospital.
Reference
1 Daniel Beckett. Winter Pressures in NHS Scotland 20082009. Report for the Emergency Access Delivery Team, Scottish Government. See www.shiftingthebalance.scot.nhs.uk/downloads/ 1251120568-Winter%20Pressures%20Report%20-%20nal%20-%20 rich%20text%20format.pdf (last checked 13 February 2012)
2012
Volume 57
Number 1