Hospital discharge and flow

The key out of hospital cell responsibilities are to ensure appropriate capacity in the system and to support hospital discharge and flow.

The following has been in focus since the last update:-

Discharge, capacity & flow

Our Place-based systems have worked very hard over the last few months to ensure patients have a safe discharge and that patient flow is maintained during the pandemic. It has been a really challenging task, with hospitals almost overwhelmed in the last couple of months, high acuity levels of patients being discharged and staff struggling to have time to manage the discharge process.

The cell has supported Place based and sub-system leads to come together to share progress, challenges and lessons learned and there are many consistent themes about what has worked well.

The myth that discharge delays are all about a lack of physical capacity in the communities seems to have been busted (although CCGs and Councils had commissioned surge capacity, as they usually do for Winter).  What has been clear is that capacity to actually manage the process is a much greater problem, along with some of the processes themselves.

In January, we were required to agree local daily discharge targets for each trust system and we nominated a senior Discharge “Flight Controller” for each trust, to troubleshoot and coordinate action at the most senior level.  This has had a fantastic impact, especially on local relationships and collaboration. It is likely that the biggest difference to discharge; according to our Place leads, is regular (sometimes twice daily) senior level meetings and a relentless focus on getting people out of hospital.

We still have a lot to do, especially as the pressure eases and hospitals restart elective activity.  We still aren’t discharging people as soon as we would like after they become eligible for discharge and we still have a high percentage of patients with very long length of stay compared to national average – a testament to the higher numbers of Covid patients in Cheshire & Merseyside.

Community and domiciliary services are still dealing with the discharge of patients admitted in the Covid peak, as well as the long-term management of patients from waves 1 and 2.  Community staff have been redeployed into trust discharge teams, where they have made a great impact, not only in terms of capacity, but also in providing assurance to acute staff about the ability to manage poorly patients at home – these staff will have to return to their normal duties soon. We could also do more to prevent patients from being admitted, especially with the acceleration of the North Mersey Telehealth offer to support the Oximetry at Home and Covid Virtual Ward services.

All of this is on the radar of the Cell and the Discharge Improvement Group for continued work between our MH/Community Trusts, Social Care, Primary care and the hospitals. We have a workshop planned to look at what is needed to ensure that we maintain momentum around this as the national discharge fund, which has helped integrated discharge management in the last year. Thanks, on behalf of the Cell, go to all those who are working so hard to get patients back home safely.

Oximetry at Home:

COVID Oximetry @home involves the remote monitoring of patients with coronavirus symptoms.

Patients use a pulse oximeter, a small monitor clipped to their finger, to measure their oxygen saturation levels three times a day.

They record their results using one of the following:

  • smartphone app
  • web portal
  • paper diary

The paper-based option is available at all sites for patients who are uncomfortable with or unable to use a digital solution to record their readings. Patients are supported by clinical staff locally, so if they need further treatment they can be admitted to hospital at the right time.

The World Health Organisation (WHO) now recognises and recommends pulse oximetry. Their clinical management guidance for COVID-19 has been update to include pulse oximetry as a new conditional recommendation for monitoring patients at home, as part of a ‘package of care, including patient and provider education and appropriate follow-up’. The guidance reinforces the importance of the COVID Oximetry @home pathway, with pulse oximetry recommended for symptomatic patients with COVID-19 and risk factors for progression to severe disease.

The cell has supported the successful roll out of Oximetry @ Home across Cheshire and Merseyside and supports all CCGs and providers to engage via a weekly CRG and a Remote Monitoring working group.

Currently, 689 patients are actively receiving monitoring via C&M COVID Oximetry @ Home services.

The data identifying patients who test positive for COVID via the pillar 1 &2 sites is now available to all CCGs with providers of oximetry able to be granted access by the CCG.

Total patient volumes shown are currently filtered to identify the ‘target population’ for oximetry as those over 65 and those with clinical high-risk factors. C&M patients in the target population of those over 65 and high risk 1-7 days after testing positive  = 463 ( down from previous week of  591).

The target cohort is expected to be increased to those over 50 soon, with a national new SOP pending.

Primary Care

Primary Care continues to show why it is so well thought of by our communities. Our practices are at the heart of delivering the vaccination programme which is progressing at pace. Around 75% of all vaccinations have been carried out in local vaccination sites run by Primary care Networks and pharmacies are also coming on stream to provide much valued additional capacity.

All this is being done as GPs see a steady and sustained increase in workload. While the public has often had the perception that GPs have been closed during the pandemic, that has not been the case.

Like other providers, practices have had to focus on essential services, so some routine services have been either reduced or moved to alternative modes of delivery.  However, time critical services and urgent work are very much still happening.  Some activity has increased because of lockdown – managing patients waiting for secondary care and in particular mental health presentations for both adults and children.

At the same time, work continues to develop PCNs.  There is a sense that the pandemic has helped practices within PCNs to work together more closely, not only in the vaccination programme, but also in setting up Covid hot hubs and in the Additional Roles Reimbursement Scheme.  The latter has seen a variety of professions – such as clinical pharmacists, social prescribers, physios – working together in PCNs, with more planned for the future.

Access to dental services

Healthwatch published a report regarding access to dentistry services.

NHSEI is leading on this locally and is aware of the national Healthwatch report. There is an understanding that there are indeed some dentistry access issues particularly in Cheshire. Tom Knight has pulled together a task and finish group to look into this and is working closely with local Healthwatch colleagues. There is also potentially an issue around public perception of dental services as many people believe dentists to be closed, and they are not. It was suggested at the North West Primary Care, Public Health and Health Inequalities Sub-Group that some public facing communications may be helpful.

Further detail will be shared over the coming weeks on these activities and on transition as the cell transfers its functions into either the HCP/ICS and community and mental health provider collaborative.