Identifying barriers to admission avoidance in an emergency care pathway

Abstract

Home ward Ealing was launched in October 2015 by West London Mental Health NHS Trust and partners in order to support the aspiration of health and social care commissioners to maximise opportunities to avoid unnecessary non-elective admissions. Home ward provides sub-acute care for Ealing patients in their own homes or in Magnolia Ward in Clayponds (community) Hospital. After nine months of operation, the overall number of referrals into the service has increased significantly compared with the predecessor service, however numbers of non-elective admissions continued to rise. Communication between the Home ward partnership and the emergency department indicated anecdotal concerns about delays in referrals for patients for whom an admission may have been avoided. A survey was undertaken of forty-four consecutive referrals between 20-30 June 2016 to Home ward from the emergency department to examine whether Home ward intervention was occurring early enough in the acute patient pathway to avoid admission, and to identify other avoidable delays contributing to inefficient care and poor patient experience. Results showed that only a small minority of cases were seen and discharged in under 4 hours, even though two thirds were identified and assessment initiated rapidly in pre-admission areas. 91% of attendances converted to trigger a short stay admission tariff due to patients being transferred to the Clinical Decisions Unit (CDU). Nearly half of patients were admitted to an observation ward before a decision was made to admit or discharge, suggesting potential benefit for including such a facility as part of the admission avoidance pathway. For the intermediate care population: if you reach the hospital, you'll find yourself in a bed. We concluded that opportunities in the ED to avoid conversion to a short-stay admission are limited, with most patients identified as potentially suitable for intermediate care being transferred to CDU before discharge decision was made. Greater emphasis on attendance avoidance (through GP and Ambulance Service liaison) may be more effective at avoiding admissions than work at the front door of the hospital.