What was the problem?
The Queen Elizabeth Hospital traditionally managed the winter surge in demand for beds by opening an additional ward. But significant medical and nursing staff shortages made this difficult in 2017/18.
What was the solution?
The trust launched a hospital to home unit in November 2017. It initially provided an extra 16 beds, subsequently increased to 29 during the peak winter months. Medically well patients unable to be discharged home were transferred to the unit, where a multidisciplinary team overcame whatever barrier prevented them leaving hospital. As the unit only accepted patients medically fit for discharge, it did not need an allocated doctor and required fewer nurses than a standard ward. It made more use of allied health professionals, particularly prescribing pharmacists, physiotherapists and occupational therapists. The unit introduced a new non-qualified clinical role – ward-based rehabilitation assistants, combining the competencies of healthcare assistants and therapy assistants. Therapists trained them to support patients with personal care tasks using the principles of rehabilitation. They also followed treatment plans prescribed by qualified therapists.
What were the challenges?
about acute patients’ safety as they would not be routinely reviewed by a
doctor and would have fewer nurses to monitor their condition. To overcome
this, patients needing any medical intervention were transferred to an acute
- Scepticism that there would be sufficient numbers of suitable patients, as acuity always rose during winter. The number of beds was restricted to 16 for the first eight weeks. Then it became clear this was not an issue and beds were increased.
What were the results?
Between late November 2017 and early April 2018, 436 patients were transferred to the unit, which maintained a 99.9% occupancy rate; 344 were discharged and 71 were readmitted within 30 days; 63 were escalated back to the acute base ward.
A main objective was to facilitate discharges for patients with complex rehabilitation and/or social needs commonly associated with long hospital stays. The data for patient length of stay (LOS) indicates this was achieved.
Another important objective was to safely introduce a new staffing model backed by an effective escalation process. The time patients spent in hospital before transferring to the unit did not affect their likelihood of requiring escalation, but patients with longer acute ward stays required escalation more quickly.
Many patients and relatives complimented the unit on the care and compassion that staff showed, its emphasis on enablement and rehabilitation and its problem-solving culture. Newcastle Gateshead Clinical Commissioning Group praised the unit’s culture of effective teamworking, enablement and treating patients with dignity and respect.
The unit received a small number of complaints. A significant number of challenging conversations with patients and relatives took place: the commonest themes were a perception that discharge was planned too quickly and a sense of entitlement to more social care though criteria were not met.
What were the learning points?
the diverse barriers preventing people from leaving hospital requires a
often think a patient is awaiting assessment by another profession when no
referral has been sent – a problem amplified every time a task is ‘handed over’
thorough therapy assessment and treatment plan can reduce or eliminate the need
for home care services in the community.
rehabilitation assistant role should be Band 3 rather than Band 4.
rehabilitation is resource intensive.
large team of rehabilitation assistants is needed because helping somebody to
help themselves takes longer than doing it for them.
costs of a large team are offset by savings from not requiring medical cover.
often found a patient becoming medically unwell due to a change in their
functional status well before any change was apparent in their clinical
threshold for patients requiring escalation to base wards was probably set too
low, and some patients could have been managed on the unit safely.
unit would have been more effective with extended hours for therapists (early
and late shifts like traditional nursing rotas) across seven days.
The trust decided to operate the unit all year round, with 16 beds in summer increasing as winter approaches. It has added an outreach service to support the base ward teams with discharge planning for complex patients.