The influence of home care supply on delayed discharges from hospital in England

Background Delayed transfers of care (DTOC) of patients from hospital to alternative care settings are a longstanding problem in England and elsewhere, having negative implications for patient outcomes and costs to health and social care systems. In England, a large proportion of DTOC are attributed to a delay in receiving suitable home care. We estimated the relationship between home care supply and delayed discharges in England from 2011 to 2016. Methods Reduced form fixed effects OLS models of annual DTOC attributed to social care at local authority (LA)-level from 2011 to 2016 were estimated, using both number of days and patients as the dependent variable. A count of home care providers at LA-level was utilised as the measure of home care supply. Demand (e.g. population, health, income) and alternative supply (e.g. care home places, local unemployment) measures were included as controls. Instrumental Variable (IV) methods were used to control for any simultaneity in the relationship between DTOC and home care supply. Models for DTOC attributed to NHS and awaiting a home care package were used to assess the adequacy of the main model. Results We found that home care supply significantly reduced DTOC. Each extra provider per 10 sq. km. in the average local authority decreased DTOC by 14.9% (equivalent to 449 days per year), with a per provider estimate of 1.6% (48 days per year). We estimated cost savings to the public sector over the period of analysis from reduced DTOC due to increased home care provision between £73 m and £274 m (95% CI: £0.24 m to £545.3 m), with a per provider estimate of savings per year of £12,600 (95% CI: £900 to £24,500). Conclusion DTOC are reduced in LAs with better supply of home care, and this reduces costs to the NHS. Further savings could be achieved through improved outcomes of people no longer delayed. Appropriate levels of social care supply are required to ensure efficiency in spending for the public sector overall.

EP.TH.462Elective colorectal procedures: postoperative stay & outcomes

Aim This was a re-audit of (ACPGBI) Association of Coloproctology of Great Britain and Ireland guidelines for the management of colorectal cancers 3 rd Edition 2007. “Surgeons should expect to achieve an overall anastomotic leak rate below 8% for anterior resections and below 4% for other types of resection. Surgeons should expect to achieve operative mortality of less than 7% for elective colorectal cancer surgery.” To ensure that our Anastomotic Leak rates & Mortality rates are below the recommended standards. Method All elective colorectal surgeries from 01/01/2011 to 31/06/2012 from a busy colorectal the firm were included in study. A thorough analysis & review of Discharge Summaries was done including type & number of elective colorectal surgeries, anastomotic Leak rate, 30 day mortality and readmission rate, average(Mean & median) postoperative stay and common postoperative complications were identified. The reasons for delayed discharge identified. Results The anastomotic leak rate was 3.0% (2/65). Thirty-day mortality was 1.53%(1/65). The mean postoperative stay was 9.1days (Median 7 days). Twenty postoperative complications were identified: 6 patients had ileus; 6 patients had minor wound infection; 2 patients had an anastomotic leak; 2 patients had stoma related complications; 2 post-op collections; 1 C-Diff infection & 1 Hospital-acquired Pneumonia. The common reasons for delayed discharges were Social reasons, ileus, reoperations, inability to cope with a stoma and Hospital-Acquired Pneumonia. Conclusions Our anastomotic leak rates (3.0%) & 30-day mortality (1.53%) are well below recommended standards by ACPGBI. Our median postoperative stay was below to National average (7days Vs 8days colonic cancer &10days rectal cancer).

182 Improving Handovers from A Neurosurgical High Dependency Unit to Ward Teams

Introduction A good handover is fundamental in providing continuity of care within a multidisciplinary team, allowing for safe and effective management of patients. Method Handovers between the neurosurgical high dependency unit and the ward team were prospectively evaluated as patients were stepped down over a 6-week period. The handover rate and consequences of poor handovers (missed investigations, referrals, or delayed discharges) were documented. After 6-weeks, handover proforma was introduced and the rates were recalculated. Results In the initial 6-week period, 36 patients were transferred, with only 2(5.6%) appropriately handed-over. Consequently, 9(26%) patients had delayed scans, 5(15%) missed referrals, and 24(71%) delayed discharges. In the 6-week period following the introduction of the proforma, a total of 28 patients were transferred, with 19(67.8%) documented handovers. Consequently, 1(3.5%) patient had a scan delay, 0 missed referrals and only 2(7%) patients had delayed discharges. Conclusions By raising awareness of handovers and introducing a proforma, we improved documented handovers by 62.3% whilst reducing the rate of missed investigations, referrals, and delayed discharges by over 90%. This project highlights how small, simple, and easy to enforce changes can lead to significant improvements in the quality of care provided to patients.

How latent patterns of interprofessional working may lead to delays in discharge from hospital of older people living with frailty – ‘Patient more confused than usual?’

Unnecessarily delayed discharges from hospital of older people living with frailty can have negative consequences for their health and add significant costs to health services. We report on an ethnographic study at two English hospitals and their respective health and social care systems where we followed 37 patient journeys. The study aim was to understand why delays occur. Our findings indicate that working practices in the study hospitals may have inadvertently contributed to delays. While many pieces of patients’ clinical and social information were collected, recorded and accessed in different ways by different professionals, to facilitate a discharge, these pieces needed to be re-found, integrated and re-constructed. A key component of this process was information related to patients’ social, family and functional background. This was often missing, not accessed or perceived to be of low value compared to other more readily available clinical information. Patients’ re-construction was thus often incomplete, or insufficient to reduce the clinical and prognostic uncertainty associated with frailty and to manage risks inherent in older people's discharge. Where this key component was present and integrated into decision-making in multi-disciplinary team working, uncertainty and risk were managed more constructively and sometimes avoided an escalation of care needs.

Long admission waiting list at the Orchard clinic-why?

AimsThe Orchard clinic is one of the three medium secure units in Scotland. This project was completed: To gain an understanding of the causes of the Orchard clinic's long admission waiting list.To use this information to improve current clinical pathways, service development and further research and development.MethodTo study the longitudinal traffic flow through the clinic from January 2017 to December 2019, data were collected for this time retrospectively from electronic minutes of fortnightly bed management meetings at the Orchard clinic.This was cross checked with the Orchard clinic's record of admissions and discharges during this time and approved by the Forensic Research and Audit Group, NHS Lothian.ResultNovember 2018 onwards, a surge of 90% was observed in the admission waiting list.Looking at the trends of traffic flow through the clinic during this time, the following observations were made:1. More admissions than discharges, especially November 2018 onwards.2. New referrals for medium secure care at the Orchard clinic peaked twice during this time.3. Delayed discharges peaked in July 2018 and further in January 2019 running parallel to the surge in admission waiting list thereafter.4. 42% patients on the delayed discharge list belonged to other health boards awaiting local low secure/community placements.ConclusionDelayed discharges were identified as a constant parallel to the long waiting list and hence identified as the main factor contributing to it. Out of area (non-NHS Lothian) admissions were noted to be linked to these delayed discharges.Regular peaks in new referrals was also noted to be contributory.

248 Improving Handovers from A Neurosurgical High Dependency Unit to Ward Teams

Introduction A good handover is fundamental in providing continuity of care within a multidisciplinary team, allowing for safe and effective management of patients. Method Handovers between the neurosurgical high dependency unit and the ward team were prospectively evaluated as patients were stepped down over a 6-week period. The handover rate and consequences of poor handovers (missed investigations, referrals, or delayed discharges) were documented. After 6-weeks, handover proforma was introduced and the rates were recalculated. Results In the initial 6-week period, 36 patients were transferred, with only 2(5.6%) appropriately handed-over. Consequently, 9(26%) patients had delayed scans, 5(15%) missed referrals, and 24(71%) delayed discharges. In the 6-week period following the introduction of the proforma, a total of 28 patients were transferred, with 19(67.8%) documented handovers. Consequently, 1(3.5%) patient had a scan delay, 0 missed referrals and only 2(7%) patients had delayed discharges. Conclusions By raising awareness of handovers and introducing a proforma, we improved documented handovers by 62.3% whilst reducing the rate of missed investigations, referrals, and delayed discharges by over 90%. This project highlights how small, simple, and easy to enforce changes can lead to significant improvements in the quality of care provided to patients.

Delayed Discharge Bridging Two Sputtering Modes from Modulated Pulsed Power Magnetron Sputtering (MPPMS) to Deep Oscillation Magnetron Sputtering (DOMS)

Delayed discharges due to electrical breakdown are observed in modulated pulsed pow er magnetron sputtering (MPPMS) plasma of titanium. The delayed discharge, which is remarkable with decreasing argon gas pressure, transforms the discharge current waveform from a standard modulated pulsed discharge current waveform to a comb-like discharge current waveform consisting of several pulses with high power. In addition, the delay times, consisting of statistical times and formative times in the delayed MPPMS discharges, are experimentally measured with the help of Laue plot analysis. The pressure dependence of delay times observed indicates that the delayed discharge behavior matches the breakdown characteristics well. In the present study, the delayed discharge dynamics of the comb-like discharge current waveform, which can be the origin of deep oscillation magnetron sputtering, are investigated based on measurement of the delay times and the characteristics of discharge current waveforms.

Initiatives for improving delayed discharge from a hospital setting: a scoping review

ObjectiveThe overarching objective of the scoping review was to examine peer reviewed and grey literature for best practices that have been developed, implemented and/or evaluated for delayed discharge involving a hospital setting. Two specific objectives were to review what the delayed discharge initiatives entailed and identify gaps in the literature in order to inform future work.DesignScoping review.MethodsElectronic databases and websites of government and healthcare organisations were searched for eligible articles. Articles were required to include an initiative that focused on delayed discharge, involve a hospital setting and be published between 1 January 2004 and 16 August 2019. Data were extracted using Microsoft Excel. Following extraction, a policy framework by Doern and Phidd was adapted to organise the included initiatives into categories: (1) information sharing; (2) tools and guidelines; (3) practice changes; (4) infrastructure and finance and (5) other.ResultsSixty-six articles were included in this review. The majority of initiatives were categorised as practice change (n=36), followed by information sharing (n=19) and tools and guidelines (n=19). Numerous initiatives incorporated multiple categories. The majority of initiatives were implemented by multidisciplinary teams and resulted in improved outcomes such as reduced length of stay and discharge delays. However, the experiences of patients and families were rarely reported. Included initiatives also lacked important contextual information, which is essential for replicating best practices and scaling up.ConclusionsThis scoping review identified a number of initiatives that have been implemented to target delayed discharges. While the majority of initiatives resulted in positive outcomes, delayed discharges remain an international problem. There are significant gaps and limitations in evidence and thus, future work is warranted to develop solutions that have a sustainable impact.

Collaboration between a tertiary pain centre and community teams during the pandemic

People with chronic pain faced potential treatment disruption during the COVID-19 pandemic in Singapore, as the focus of healthcare shifted. A model of rapid integration of a pain centre with community healthcare teams was implemented to care for vulnerable older patients with chronic pain and multiple comorbidities. Telemedicine and home visits by community nurses were used, with risk-mitigation measures, ensuring comprehensive assessment and treatment compliance. Medications from pain physicians were delivered at home through a hospital pharmacy. A secure national electronic health records system used by all teams ensured seamless access and documentation. Potential emergency department visits, admissions and delayed discharges were thus avoided. Integration of community teams with chronic pain management services can be recommended to ensure pandemic preparedness.

Defining Delayed Discharges of Inpatients and Their Impact in Acute Hospital Care: A Scoping Review

Background: With the ever-increasing demand on acute healthcare, the hospital discharge process and delayed discharges are considered relevant in achieving optimal performance in clinical settings. The purpose of this paper is to review the literature to identify conceptual and operational definitions of delayed discharges, identify causes and effects of delayed discharges, and also to explore the literature for interventions aimed at decreasing the impact (in terms of reducing the number/rate of delays) of delayed discharges in acute healthcare settings. Methods: An extensive literature search yielded a total of 26 248 records. Sixty-four research articles were included in the scoping review after considering inclusion/exclusion criteria and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) search strategy. The following databases were utilized: Cochrane, EBSCO, PubMed, PubMed Central, Medline, and Web of Science. The search was carried out between January 2017 and March 2020 and covered literature ranging from 1990 to 2019. Results were reviewed by authors for duplicates and filtered using the inclusion/ exclusion criteria. Tables were created to classify the chosen articles (n = 64), allowing us to organise findings and results. Results: Conceptual and operational definitions were analysed. In turn, causes and effects of delayed discharges were extracted and represented in diagrammatic format, together with specific interventions used in acute healthcare settings to lessen the effect of delayed discharges. Operational definitions of delayed discharges were found to be more difficult to establish, particularly in the light of the vast number of different scenarios and workplace interventions uncovered in the literature. The main causes of delayed discharges were faulty organisational management, inadequate discharge planning, transfer of care problems, and age. The main effects were bed-blocking, A&E (Accident & Emergency) overcrowding, and financial implications. The main interventions included ‘discharge before noon’ initiative, ‘discharge facilitation tools,’ ‘discharge delay tracking’ mechanisms, and the role of general practitioners and social care staff. Conclusion: This paper fills a gap in the fragmented literature on delayed inpatient discharges by providing a researchbased perspective on conceptual and operational definitions, causes and effects, as well as interventions to minimize their impact. The findings and definitions are intended as points of reference for future research.