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Finding a better way to manage emergency admissions

Reorganising the medical admission arrangements at Stobhill Hospital, Glasgow

Why was the initiative launched?
What was done?
Is it working?
Tips for success
To find out more contact

Why was the initiative launched?

Acute medical services at Stobhill Hospital, like many other hospitals, are under increasing pressure because of the steady rise in the numbers of medical emergencies. Many factors, such as lack of home support, conspire to limit the numbers of patients who can be sent home without admission. In 1993, Stobhill Hospital had 229 beds for acute medical services in a mix of medical and specialist units on two sites in Glasgow.

Admissions were managed through three medical units taking emergencies every third day. The system was starting to creak under the pressure. Problems included disruption for patients every third night on take, delays transferring elderly patients within the hospital, lack of specialised facilities for post MI patients, and anxiety about maintaining adequate nursing cover within falling budgets. Something had to be done.

What was done?

A multidisciplinary team was charged with developing a new system. They knew that research suggested that existing resources were likely be used inefficiently, and that reorganisation should bring improvements. To help them develop ideas on which to base a new system they visited three other hospitals that were broadly like Stobhill. They were keen to learn from the experience of others.


Stobhill team
Hamish McLaren clinical director
Myra McMurdo discharge planning co-ordinator
Winnie Miller operations manager
Christine Robb ward manager
Lesley Summerhill director of nursing

Stobhill Hospital: new system for medical beds - August 1993
Number Ward Beds
1 Acute medical receiving 26
3 General medical 56
1 Coronary care unit 6
2 Cardiology 40
1 Respiratory disease 24
8 Total 152

The team promoted extensive local debate about possible alternatives. What was the best way forward? What resources were available? How could they find a better way?

The target was not to achieve a specific financial saving but to improve the service provided. An important factor in the discussions was the willingness of managers to allocate additional resources if needed to ease the implementation of a new system.

As a new system was being developed it was clear that fewer beds would be needed. Over time improved organisation allowed a gradual reduction until there were about a third fewer. Staff supported this process because the beds were kept until the case for them not being needed was proved. The new system includes eight wards all on one site with a focus for admissions on an acute medical receiving ward.

All medical emergencies except those admitted to the coronary care unit are now admitted to the acute medical receiving ward for investigation and assessment. To spread the load across the senior medical team one consultant takes charge of the ward for each 24-hour period. All patients are reviewed at least daily and referred or discharged as appropriate to ensure that space is available for new admissions. The rota commitment has been planned to avoid disruption to other activities like outpatient clinics.

Three features of the new system are important.

First, the appointment of a patient management team charged with handling the administrative aspects of the patient's hospital stay. They ensure that patients are speeded through the system and discharged home as early as possible.

Second, arrangements for specialty transfers were improved : consultants from cardiology, respiratory medicine and elderly care now visit the receiving ward daily to ensure the timely transfer of patients.

Third, a fast track service for laboratory investigations was introduced to ensure that time waiting for results is kept to a minimum.

A contingency plan was devised in 1996 to deal with winter pressures. This designated and trained staff so that an additional ward could be opened at short notice.

The team's effort to involve everyone in developing and refining the new system paid dividends when it came to implementation. It was a natural progression from the discussion. Specific training initiatives were not needed. People simply took on the new way of doing things.

Is it working?

Despite the significant reduction in the number of beds, the hospital has been able to handle the continuing increase in medical emergencies without any serious problems (Table). Specific advantages of the new system are:

Stobhill hospital: changes in medical bed use 1992-1996
  1992 1994 1996
Medical discharges 7,904 9,630 10,000
Average stay (days) 7.1 4.8 4.5
Emergencies (%) 77 87 93
Total staffed beds 223 167 161

An unexpected bonus has been the effect on staff morale. Stobhill is an old hospital whose continued existence has been under threat. The successful introduction of the new system, and the interest of clinicians and managers from other hospitals, has made staff aware that they are working in a successful and innovative organisation. A local survey has also shown that 91% of nurses (n=26) and 93% of medical staff (n=11) perceived the new systems being better than the old, a view shared by 52% of patients (n=22),

The hospital has relied on the system to help them cope with winter pressures. Periods of exceptionally high demand last only for a few days and the contingency plan put in place at the hospital has proved its value. The additional ward has been used for 14 days in 1995/96 and 10 days in 1996/97 enabling the hospital to avoid cancelling any elective surgical procedures.

However, as with all changes there are disadvantages to be tackled:

&f Continuity of medical and nursing care is reduced - but good communications can overcome any problems.
&f Because of the rapid turnover administrative procedures such as handling of discharge letters and follow-up appointments have to be efficient.
&f Patients who are not discharged from the receiving ward move at least once during their stay.
&f Ward rounds in the receiving ward have to take precedence because of the need to free beds.

There is local satisfaction that the system introduced in 1993 has served the hospital well for six years. But with the continuing rise in the level of medical emergencies there is no place for complacency. As with any new system introduced to respond to a problem its time will come! The team is acutely aware of the need to watch the situation with care and act if the system starts to crumble.

Tips for success

√ Involve all clinicians from the outset in planning new systems: ensure members of the senior management team are involved.
√ Reorganisation will involve a change in working practices for many: help all clinicians to accept this fact.
√ Cooperation of other departments may be important: such as a fast track for investigations to ensure that patients can be assessed promptly.
√ Show that resources are not needed before they are taken away.
√ Links with other similar organisations can allow innovations developed elsewhere to be adapted for local purposes.
√ Some extra resources might be necessary to create new posts or resources to facilitate a new system.
√ Look for innovations, such as new roles or posts to help ensure success - e.g. the patient management team used at Stobhill.

To find out more contact

Hamish McLaren
Clinical Director
Stobhill NHS Trust
Balornock Road
Glasgow G21 3UW

Telephone 0141 201 3309
Fax 0141 201 3888

The following material is available: Detailed report of the initiative together with supporting papers.

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