HOSPITAL HANDOVER: COULD NEXT-GENERATION VOLUMETRIC MODULAR HELP DEAL WITH CONGESTIVE HOSPITAL FAILURE?

With headlines proclaiming an ambulance service may collapse by August, surges in serious incidents (SIs) caused by ambulance delays, and multiple deaths due to care delays highlighted by the Care Quality Commission, Darwin Group wanted to look at the issue. Could a look towards next-generation volumetric modular help Trusts deal with congestive hospital failure?

With an almost perfect storm of factors combining to place pressure on Health and Social Care Organisations, an increase of 18.15% of non-booked type 1 attendances between March and February 2022 saw over 200,000 additional patients requiring treatment over the period across England. Matched with this is the staggering increase in bed occupancy that has seen 60 out of the 190 NHS organisations in England report over 90% occupancy as a total in their Q4 KH03 returns for 2021/22. Over the same period in 2020/21 only 16 of the NHS organisations reported exceeding 90% occupancy.

Recently a prominent Ambulance Service revealed that its crews and patients spent 34,140 hours waiting outside hospitals in April, compared to just 5,372 the year before. The handover delay arises from the inability to transfer the patients to the care of the trusts, this could be due to insufficient capacity in the A&E department caused by a lack of space or staff, or difficulty admitting patients into a hospital bed. With patient flow presenting the greatest impact can surge facilities be the solution to a whole-system approach?

WHAT IS CONGESTIVE HOSPITAL FAILURE?

Congestive Hospital Failure was a term fashioned to highlight the impact of new patients arriving at Urgent and Emergency Care (UEC) when all beds are full. As beds become full, and patients are not moved on, new patients cannot be accepted from ambulances, or examined. As a result, patients may be diverted elsewhere, and departments miss their 4 hour waiting time targets.

Between February and March 2022 there was a 24.87% increase in the number of patients admitted to ED/A&E as non-booked attendees that exceeded a 4 hour wait time. A total of 507,216 attendees compared to 406,182 the month before. Attendees seen within a 4-hour window increased only 14.12% with 708,354 seen compared to 620,709 previously.

A WHOLE-SYSTEM APPROACH TO HOSPITAL HANDOVER

To look at how volumetric modular construction can help ease congestive hospital failure we first have to look at the patient flow so we can define the two main pinch areas that cause the largest impact. Let’s look first at the inwards route to an Urgent and Emergency Care (UEC) department.

When an ambulance arrives at an ED/A&E department, the national guidance states “all handovers between ambulance and ED/A&E must take place within 15 minutes with none waiting more than 30 minutes”. Whilst it doesn’t necessarily mean that the patient is held in the ambulance, we are seeing more and more reports of ambulances waiting outside of ED/A&E as there is no corridor space to even bring in the patient. Recently over forty patients waited for more than ten hours in the back of ambulances in one month at hospitals for an NHS Trust in the West Midlands.

This lack of inward care becomes a bottleneck where the ambulance is unable to even bring the patient into the UEC as all areas are currently at capacity. As such the ambulance simply becomes a holding area until space becomes available. However, this in turn has an impact as the ambulance is no longer able to respond to calls and so we have seen an increase in the number of Serious Incidents (SIs) being reported resulting from delays in reaching patients. Of 14 SIs reported by just one ambulance service in February and the first half of March 2022, half of them were due to “prolonged waits for an ambulance response.”

So, if this is a pinch point, would an increase in capacity help relieve the pressure on A and E? In simple terms, yes. An increase in capacity would allow the decant from ambulances to the UEC so that patients can be dealt with in a safe and controlled environment. Whilst they may not be able to fully handover to the staff, procedures could be put in place that would see the ambulance return to service with an additional paramedic joining the ambulance for onwards service. Likewise, the Trust could also adopt a similar approach to Leeds Teaching Hospital NHS Trust which accepts ownership of the patients as soon as they enter the hospital site. This has enabled, along with a well-designed process, the sites to have a dedicated hospital ‘ambulance team’ always staffed by two nurses.

However, this fails to negate the outwards patient flow which is another area that is creating a pinch point in the process. Reports state that approximately 14 per cent of the total patients in beds in England are defined as medically fit, highlighting the continued issues with discharging to the community, other NHS services, social care, and mental health settings. On an average day during the week ending 20th February 2022, 11790 patients remained in the hospital despite being medically fit to be discharged.

A NEW LOOK AT ONWARD PATIENT FLOW

Whilst not necessarily new in thinking an area that is gaining momentum within the NHS is the use of step-down accommodation for onward patient flow. Step-Down accommodation offers facilities for continued care in a community based, recovery-focused environment which enables an early discharge from UEC in a safe and supported way. However, a lack of step-down care, community hospital beds and private sector nursing homes and residential care beds exist following the COVID-19 Pandemic.

Typically staffed by a Senior Occupational Therapist, Senior Nurse, Patient Flow Support Worker, Support Worker, and local Community Mental Health and Home Treatment Teams, they allow 24-hour live-in care for a short period to support the move of individuals from inpatient services to the community. Likewise, several trusts have trialed the use of Step-Down beds within Care homes including those providing nursing care, with the results showing a reduction by up to 50% in customers who are eligible for Continuing Health Care (CHC) services within the first month.

The existence of Step-Down Beds may be able to support discharge where for example, there are delays in the completion of assessments, or through patient or family choice. The provision of Step-Down Bed services will help to support people experiencing delays in discharge due to awaiting a community health or social care assessment, ensure robust holistic assessments to be undertaken which achieve the right patient outcome, and provide necessary time to consider the options, so that an appropriate onward package of care and support can be arranged with the family and the patient/customer.

HOW CAN NEXT-GENERATION VOLUMETRIC MODULAR CONSTRUCTION HELP WITH PATIENT FLOW?

With everything considered one of the biggest challenges is time. West Midlands Ambulance Services Nursing Director, Mark Docherty recently stated“Around 17 August is the day I think it will all fail” he said. “I’ve been asked how I can be so specific, but that date is when a third of our resources will be lost to delays, and that will mean we just can’t respond. Mathematically it will be like a Titanic moment.” 

With a timeline ticking like a bomb waiting to go off, should NHS Organisations be looking towards Volumetric Modular buildings as a solution. Firstly, Volumetric Modular has come a long way since it was first introduced to the NHS, the next-generation superstructures offer the same build quality and longevity as a traditional build but with an at-pace build time. During the COVID-19 Pandemic, Darwin Group was able to design and build a 400-bed covid surge hospital in just 20 weeks. 280 next-generation volumetric modules were installed in just 70 days thanks to off-site manufacturing before transport to the site. Could the NHS benefit from regional Step-Down Accommodation built using volumetric modular construction? Is this an area that ICS/ICB should be looking at?

Likewise, a 24-bed acute medical unit (AMU) was delivered to Hereford County Hospital in just 12 weeks. The AMU works closely with the Emergency Department and the Clinical Assessments Unit which means that patients needing medical treatment can now be rapidly assessed and treated in a purpose-built environment close to ED. Acute Medicines Consultant, Dr James Bartlett said “Patients like it because they get seen and get a bed quickly. We can also arrange support for their discharge quickly which means less time in our beds.”

The speed at which these projects can be completed offers a real solution to the hospital handover problem and could be the tool needed to navigate away from this looming ‘Titanic moment’ but only if we start to take the actions required now.