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 profile. Frequently this does not happen due to the physical structure and organisation of our hospitals in Scotland. Acute medical admissions may be fitted 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.
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 significant 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 significant 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 profile 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 financial 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 find 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 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 profiling, 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 efficiently and there is no excess ‘bed capacity’. However, specialty units are of a fixed 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.
There are a number of problems that arise when caring for these patients. Communication difficulties present in a variety of ways:
Timing of a ward visit by the medical team is unpredictable (depending on number and distribution of patients across the hospital); The key nurse in any unit, who knows the patient might be away at the time of the medical team visit which may be brief if there is only one patient; Meeting physiotherapy, occupational therapy and social work staff is difficult; Notes may be difficult to locate in a new area, take longer to be returned for discharge letter dictation or become lost; There are challenges finding results of investigations and communicating these to patients and staff; There are difficulties communicating with relatives; When patients are moved between wards the responsible medical team may change with a variety of knock on effects; There is the constant risk that some patients become ‘lost’ and are not reviewed by the medical team as they are not on their list of boarders.
A major difficulty 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 inefficiency 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 flexibility 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:
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; Junior doctors within any ward area are asked to manage the basic care for these patients, including investigations and immediate discharge letters; Specialty units are expected to make beds available each day for their projected acute admission work, by discharging or boarding out less sick patients to make room for the more acute admissions; In our own hospital, we have allocated one junior member of staff and one consultant at any one time responsible for all general medical boarders and have planned time for this.
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 figures highlight the feeling among staff that medical boarders receive a poorer quality of care and that they lack the confidence in the way the system works.
This problem has been around for a long time without a definitive 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. Specifically, the boarding of patients from the Admissions Unit and/or Emergency Department should never occur’.
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There are a number of possible ways to decrease boarding. These include:
A change of bed profile for the hospital with a larger general area that is shared by all groups so that any specialty group only has patients in two areas of the hospital – their base unit and the generic shared unit; A re-distribution of general or specialty staff and their teams to provide general and specialty care in any unit; A decision that all patients in any (medical) unit are under the care of one of the consultants in that unit (irrespective of the diagnosis or consultants specialty) with the proviso that consultations from other specialists are readily available. In this scenario the allocation of patients from the receiving area to different units would need careful consideration and a system to move patients into more appropriate areas also developed.
The concept of having the single flexible, 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 flexible 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 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.