Medical outliers – a ‘wicked’ problem
Background
The NHS is facing ever-growing pressures on secondary care with increasing presentations to emergency department and rising demands on inpatient services. Consequently, significant numbers of medical patients are receiving care in ward settings that are intended for the care of non-medical specialties as their primary function. Patients cared for in this setting are termed ‘medical outliers’.
At Great Western Hospital every effort is made to care for patients in the most appropriate setting for their needs, however, due to service pressures, particularly in the winter months, a significant number of medical patients are being cared for on non-medical wards. In recent years there has been a reliance primarily on locum staff to see these patients as part of a ‘medical outliers team’. Staff turnover has been high and continuity of care for these patients has been variable. As a result there have been concerns regarding patient safety and the clinical governance surrounding care for these patients.
We set out to establish a more formalised system for caring for medical outlying patients with the intention of improving key performance areas including patient safety, establishing clear clinical responsibilities and improving staff morale across the multidisciplinary team.
Materials and methods
Using Kotter’s 8 step change model as a framework, we established a working group and agreed on a vision for what the care of medical outliers should look like.1 Engagement from the relevant staffing groups was sought revealing a preference to continue with an independent medical outlier team model. The Royal College of Physicians (RCP) guidance on safe medical staffing was used as a template.2 Key areas in need of improvement were identified and included, day-to-day handover of clinical information, access for ward staff to the outliers team, continuity of clinician care and clear chain of responsibility for medical outlier patients. Outcome measures were agreed to monitor success including audit of handover process, audit of continuity of clinicians tasked to outliers and data collection of measurable parameters, including overall outlier numbers and length of stay of medical outliers vs medical inliers.
Results and discussion
We have applied a staffing model based on the RCP safe medical staffing guidance and emphasis has been placed on long-term allocation of staff to the medical outliers team (frequently for several months at a time but minimum 1 week). An active handover process of clinical information has been implemented and is now well-established and the medical teams are now contactable via dedicated telephones. Despite attendances to the hospital and total number of medical outliers increasing, length of stay has remained stable compared with last year and data collection is ongoing.
Great Western Hospital is facing a significant challenge, common to many district general hospitals, in terms of how medical outliers are cared for. Multiple interventions are required to help reduce the scale of the problem in the long term including assessing and streamlining patient flow pathways as well as the capacity of the medical bed base and staffing models. In the short term ensuring patient safety, high quality of care and maintaining the wellbeing of staff is paramount. By improving continuity of patient care and effectiveness of the handover process we have started to address some of these issues. Going forwards a model for a substantive team has been developed and recruitment is in process which will add to continuity of care and reduce reliance on temporary staffing further improving patient care. Other improvements in the medical bed base model are under development and will help further.
Conclusion
The challenges posed by the volume of patients being cared for at Great Western Hospital on outlying wards are complex. A focus on moving away from temporary staffing models to care for this patient cohort is key in ensuring high-quality patient safety and continuity of care. In the coming years the trust is aiming to ensure the numbers of patients cared for on outlying wards reduces and that the care of those patients is no different from that of inlying patients.
- © Royal College of Physicians 2019. All rights reserved.
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