By Matthew Cooke
Most hospitals do not know how many patients they are going to discharge the next day. The highly professional staff of a hospital may be over obsessed with accuracy and individuals. The Apollo Syndrome* abounds, where they demonstrate a fixation on showing how a firm figure cannot be achieved and that they know of individual cases where the prediction was wrong. Despite knowing that most people having a certain operation will stay in for 5 days, they will not label an individual patient because they know some go home earlier and some may develop complications and stay longer. Rather than developing a mathematical model, we end up with no suggested discharge date for anyone. It comes as a surprise to everyone on the day of discharge. This also means that preparations have not been made and so they cannot achieve the hotel’s midday checkout.
Today’s elective admissions (our hotel bookings) should be under our control. We book them and so we can use them to balance the equation. Most elective cases are surgical and surgeons like the ability to select their own lists.
One major operation may occupy one bed for 10 days whereas ten small operations may each occupy a bed for two days. By balancing the lists, the bed requirements can be manipulated.
But what actually decides the mix of the list? Clinical priorities will override all. A case needing urgent care will jump the queue, but it may also be that the consultant is away and so his junior does smaller cases or consultants have heard of the advantages of standardisation and want to do ten similar cases in one day. Each surgeon makes this decision as an individual. If all twenty surgeons choose to do a big case, we only need twenty beds tomorrow: if they all do small cases, we may need 200 and it is random choice. But no, it may be school holidays and the bosses are mostly away, so that is why hospitals are so crowded in the holiday week.
The system is perhaps partially rescued by its adaptive nature. If admissions are not possible then people may be sent home earlier; more may be managed as out-patients; less may be added to the waiting list, but, as soon as beds become available, a pool of unmet need floods through the doors. But there is also maladaptive behaviour – a doctor may keep a patient in hospital to block the bed until he next needs one; patients may be sent home before they are ready to make an extra bed. A simple formula is in reality a complexly interacting system of negative and positive feedback.
So the irony of all this is that the emergency is actually more predictable than the electives. The random event of the emergency seems to provide the stability in the NHS ‘hotel’ system!
*A management term describing a phenomenon where teams of highly capable individuals collectively perform badly
‘Hospitals should be able to organise their beds just like a hotel. A simple system to ensure a bed is available for the next guest. A simple formula should allow calculation of the bed state for the rest of the day. Beds available at present – today’s discharges + today’s elective admissions + today’s emergencies = beds at the end of the day. As long as that figure for the end of the day is positive, then we have no problems.
But it is not always that easy...’
Matthew Cooke FRCS (Ed), FFAEM is Professor of Emergency Care and Director of the Warwick Clinical Systems Improvement Group at Warwick Medical School. This group teaches and researches on systems thinking to improve the quality and safety of care. Matthew was adviser in emergency medicine to the Department of Health until 2007, and has also advised overseas governments on the organisation of emergency care. He is an Emergency Medicine Consultant at the Heart of England NHS Foundation Trust.
Professor Matthew Cooke FRCS (Ed), FFAEM
Warwick Medical School