Abstract
Introduction:
Large numbers of geriatric inpatients within acute settings are deemed medically safe for discharge (MSFD) but stranded within the hospital due to a lack of community services and social care packages, leading to increasing length of patient stay and reduced hospital flow. These patients do not require inpatient care and would otherwise be discharged to their home or residential care. This project aimed to identify these patients and rationalise their medical input to mirror a community setting (without routine daily medical reviews).
Methods:
MSFD patient were identified by the multi-disciplinary team (MDT). Patients identified received standard nursing and therapy input, alongside daily MDT discussion at a board round to progress discharge planning. If the MDT expressed concern about a MSFD patient, they would receive a medical review. A sticker placed in the notes identified patients deemed MSFD.
Results:
A 3-week trial on a 19-bedded geriatric ward showed 46% of bed days were occupied by MSFD patients. On average, 8 MSFD patients did not require daily review. 0.6 unplanned reviews/day were needed due to MDT concern, saving an average of 7.4 patient reviews/day, equating to 3.3 hours/day doctor time saved.
Conclusions:
Doctor time saved allowed redistribution of staff to busier wards with more unwell patients, with no detriment to patient care noted. The trust formalised a SOP and the MSFD pathway was introduced across the geriatric medicine department. A MSFD ward has now been opened, to cohort patients awaiting discharge to community pathways. This ward should require minimal doctor input to allow continued redistribution of medical staff across the hospital, as well as facilitating patient flow by admitting patients who reside on the acute frailty unit who require increased community care.
Comments
Thank you, excellent work. How was nursing care changed in terms of patient observations/NEWS2 frequency?
Hello,
We agreed that it would be at consultant/ward discretion: most patients had observations once a day, with extra sets of observations if the nurses or any other healthcare professional had clinical concerns.
Thanks for your comments!
This is really interesting, thank you!
We also run a ward for people who are medically fit, but find these patients are quite frail and can deteriorate unexpectedly, which is sometimes difficult to manage with low doctor numbers.
We do still do at least daily nursing obs but have been considering doing functional obs too as in frailty the first sign of illness is often functional change. A team from Edinburgh has developed a tool for this using electronic notes. Their poster is on page 1 (I think!)
You're right, those who are frail can become poorly. We found that a daily ward round often didn't change this happening and we were sometimes over-investigating with bloods etc that wouldn't have happened if a patient had been discharged home at the point of being MSFD. If patients were to get poorly in hours, they would still see a doctor and get a medical review and if this happened out of hours, the on-call team could still be called just like any other hospital patient. It's a balancing act for sure!
Will go look for the Edinburgh team's poster, thanks for the tip of!
And thank you for your comments.
MSFD wards.
Creating a MSFD ward has challenges, what level of doctor do you have to staff this ward? I would imagine it's not suitable for a doctor in training as would have low educational level activities and poor senior supervision. I would imaging the work on a MSFD ward to be under stimulating and admin (discharge summary) heavy.
MOFD wards
Thanks for reviewing this. If these patients can be monitored like this and virtual ward rounds take place/ MDTs but remain on the wards which specialise in frailty great- what I have found with MOFD wards is that they are not always staffed with people who have the skills to recognise patients with frailty who are unwell. The advantage of patients staying on the wards where they are known is that the staff recognise when they deteriorate. The staff for these MOFD wards I have found often come from multi- speciality backgrounds. it would be great if you could re audit whether there is a change in LOS/ bed occupancy/ number of patients becoming unwell once you change to MOFD wards.