Day to day demands on nurses have changed fundamentally over the past decade – and not for the better. A decade ago, each ward received one consultant visit per day – and one decision regarding patient discharge. Bed management information was updated just once in any 24 hour period. Now, following the Safer Patient Flow Bundle Red2Green approach, patient status can change hourly and nurses are constantly fielding questions from family members, operational teams, consultants, physios and front line staff trying to move patients through the system.
Nurses spend up to 15 minutes every hour responding to questions about potential bed availability rather than delivering patient care. Add in the need to prepare beds and clean bed areas – a role often undertaken by senior nursing staff – and upwards of 50% of nursing time is spent on non-caring tasks. With the rise in outliers – the inevitable by-product of deadline driven bed allocation – and no wonder morale is falling.
Nurses should not be bed management gatekeepers. Rebecca Boyes, Teletracking Operational Lead, Control Centre, Mid and South Essex University Hospitals Group, outlines the transformation in nursing that is being delivered by Trusts that have embraced a centralised bed management model underpinned by real-time patient flow visibility and supported by the use of dedicated domestic and portering staff.
Given the huge pressure on NHS resources, the shift towards a far more dynamic model, with multiple consultant visits and decisions regarding patient discharge occurring throughout the day, makes sense. This approach can improve patient flow and unblock the ED front door; it certainly enables patients to avoid unnecessary time in hospital. So far, so good. However, this strategy has created a huge burden on ward nurses who have become responsible for the majority of patient flow activity.
Being asked repeatedly whether a patient is ready to be discharged; whether the family is ready to collect that patient; and whether the required tests have been completed to enable the discharge is time consuming and frustrating. These questions take nurses away from the patient – affecting not only the speed with which they can respond to patient needs but also meaning they often miss important conversations between patients and consultants.
Furthermore, with so many demands on their time, tasks such as bed cleaning and declaring a bed available will inevitably slide down the priority list. A bed may lie empty but uncleaned and undeclared for some time, unless spotted by someone undertaking a physical bed audit at some point during the day. The laudable goals of dynamic patient review are being undermined by a fundamental flaw in the process: it places additional – and non-clinical – demands on nurses which result in further delays in bed turnaround, creating more calls and more stress. In addition to undermining the pledges of Time for Care, it doesn’t work: the front door is still blocked. Morale amongst both ED and ward nurses will continue to fall unless this model is radically overhauled.
Optimising Bed Management
The huge frustration is that there is inherent availability within the system. While proven best practice shows that idle bed time between a patient being discharged and a new patient being admitted should be as little as one hour and 45 minutes, the average time within the NHS is six to eight hours. Reducing idle bed time would transform the speed with which patients can be moved through the system, improving outcomes and releasing pressure on ED. But how can this be done without creating even more pressure for nurses?
The Safer Patient Flow Bundle without doubt creates opportunities to improve bed management. But this can only be achieved if Trusts remove the bulk of the responsibility from nurses by adopting a centralised model of patient management, supported by complete visibility of patient flow.
The use of IT systems and tracking technologies, for example, to follow a patient’s flow from admission to discharge, provides a complete and immediate view of bed capacity. A dedicated Control Centre can then use this real-time information, in conjunction with known bed demand from both elective surgery and ED, to optimise bed management. Automating the process in this way means no more calls, no more questions – the Control Centre receives automatic notification that the bed is empty.
Time for Care
With no need to constantly field questions about which patients have been discharged, this complete and real-time patient visibility frees up significant nursing time. Furthermore, the centralised approach provides a platform for an optimised bed management model that removes the burden of bed cleaning from nursing staff. Dedicated teams to support the readying of beds are dispatched immediately an empty bed notification arrives in the Control Centre and as soon as the bed is prepared, the portering team can be alerted to collect and transfer the next patient to the ward. In addition to drastically reducing idle bed time, there is no longer any need for nurses to spend time cleaning or preparing bed areas. Nurses regain valuable time for care. Morale improves – as does patient flow.
With confidence in the accuracy and timeliness of bed availability information, the Control Centre can also look for further improvements in bed utilisation and patient flow. For example, rather than reserving beds for elective surgery patients – an approach that can result in a bed left empty for several hours – with full visibility of patient flow and demand, the adoption of dynamic allocation will further minimise idle bed time.
The Control Centre can also leverage patient specific requirements to drive better bed allocation and reduce outliers, delivering further benefits to nursing staff currently frustrated by the need to care for patients with needs that fall outside their skillsets.
Given the pressures facing nurses it is no wonder that morale continues to fall; that there are currently 41,000 nurse vacancies in the NHS in England and applications to study nursing have fallen by a third since 2016. Nurses want to nurse, to look after patients and deliver a great quality of care. Repeatedly fielding bed availability questions from managers and operational teams was never in the job description.
Dynamic, rather than daily, patient review is without doubt the right approach: a patient ready to go home, should be discharged – that is a better patient experience. But expecting this process to work without changing the bed management model was a mistake – and one that has placed the burden firmly on ward nurses. By rethinking the concept of idle bed time and adopting an efficient and centrally managed approach, a 600-700 bed hospital could not just move away from the constant questioning of nurses in a bid to identify an available bed but actually create 60 beds of additional capacity.
Critically, nurses regain hours of time currently spent on non-caring activity; one Trust estimates it has gained 250 nursing hours per month just from the adoption of dedicated cleaning teams. Add in the time now not spent fielding calls – often challenging calls – regarding bed availability and the implication for day to day nursing experience is very significant. Nurses can get back to nursing – and not before time.