How can emergency admissions be safeguarded at times of major hospital reorganisation?

Neil Pettinger and colleagues show how one trust dealt with the problems of two major hospital moves When Lanarkshire's acute hospital services were reorganised earlier this year, the trust faced the challenge of keeping services going while two hospitals were temporarily unable to accept emergency admissions.

The new Hairmyres Hospital in East Kilbride opened in March, replacing services previously located at the old Hairmyres and Stonehouse Hospitals. Then two months later, Wishaw General Hospital opened, replacing services previously based in Law Hospital, Bellshill Maternity Hospital and Hartwoodhill Hospital.

Lanarkshire Acute Hospitals trust provides services through three district general hospitals to 550,000 people in Scotland's western central belt. Private finance initiative contracts worth£170m were signed in 1998 to provide two new acute hospitals to replace outdated facilities in Lanarkshire. The trust had to ensure continuity of inpatient emergency services to Lanarkshire residents, despite two periods when those services would be provided by two hospitals instead of three. During the moves we needed to confine the displaced patients to Lanarkshire hospitals, and minimise the impact on hospitals in adjacent health board areas.

The new Hairmyres Hospital was set to open on Sunday 25 March 2001, and Wishaw General Hospital on Tuesday 29 May. The Hairmyres Hospital move, to new premises on the same site, was to happen over 72 hours. The Wishaw General Hospital move, which involved transferring several miles away, would take 96 hours, with both moves starting and ending at 7am.

The volume of emergency admissions varies on different days of the week.We analysed the sequence of days when the impact on emergency services would be the least, and found that Friday, Saturday and Sunday were least likely to generate large volumes of emergency admissions.

Although these quieter days were included in both hospital migration plans, several factors influenced the final decisions about when to close.

It was easy enough to determine the mean number of emergency admissions per day for each Lanarkshire hospital, but we decided early on that it would be inadequate simply to plan for this number of patients. The mean number of daily emergency admissions, when distributed normally, is exceeded on half of the days in the year. It was just as likely that more than the mean number of emergency admissions would be displaced during the move.

We therefore planned for the equivalent of the mean-plus-one standard deviation of emergency admissions to be displaced during each hospital move. By adopting this methodology, the trust was insuring itself against a substantial element of risk.

The ultimate contingency was to take patients by ambulance to those hospitals with available beds.

Once the projected numbers of displaced emergency admissions for each closure period had been reached, we needed to work out how many beds were needed. A year's admissions data was examined by specialty, as were length-of-stay profiles within each specialty.We were then able to project the likely effects on different specialties of closures starting on different days of the week.

Next, we had to decide where the beds should be.

Initial analysis suggested the impact during both closures would most likely be felt by one of the Lanarkshire hospitals - Monklands. But it was unrealistic to expect one hospital to bear the brunt of emergency admissions during both moves.

In consultation with GPs, Lanarkshire primary care trust and the Scottish Ambulance Service, each GP practice within an area affected was allocated a 'preferred' hospital to which displaced patients could be admitted over this period. For both hospital moves, a fairly even split of displaced activity was organised: about half to go to each remaining Lanarkshire hospital.

In each move, the strategies for identifying additional emergency beds were different. For the Hairmyres move, Law Hospital opened up extra beds and wards to minimise the impact on its own elective surgery. This was not an option at Monklands Hospital, due to pressure on space. The two existing surgical wards had to be cleared in the days running up to the closure. This was achieved by a switch in the mix of elective inpatients and day cases.

For the Wishaw General move, Monklands Hospital used the same strategy as in the Hairmyres move.Hairmyres Hospital was able to use beds in the old hospital that had recently been vacated.

This was not simply a data analysis exercise. It was critical for all the key players in the moves to be fully involved in the planning. Lanarkshire's PCT, neighbouring trusts, health boards, local councils, the Scottish Ambulance Service, other emergency services and the local health council were just some of the organisations involved. An extensive communications exercise ensured that the public, GPs, the police and others were told about the plan.

In the run-up to the closures, daily emergency admissions and bed availability were monitored.

On the home straight: the Hairmyres move The table (above right) shows the level of emergency admissions throughout Lanarkshire in the weeks leading up to the closure.Hairmyres admissions were around the mean daily emergency admissions and well within the mean-plus-one standard deviation. During the closure, the total admissions to Lanarkshire hospitals were marginally higher than mean levels. But Monklands received its full anticipated share of patients, with Law taking only a third of its expected share of displaced patients. In the days following the opening of Hairmyres, admissions rose above the pre-closure mean, but not by a significant level.

Since emergency admission numbers were as planned or lower, there was no significant bed pressure at Monklands or Law.

Some Hairmyres patients were expected to be admitted to Glasgow hospitals, as these were the nearest inpatient facilities for a part of the Hairmyres catchment area. This happened only to a limited extent, and did not prevent these hospitals from serving their normal catchment population.

Mirror image: the Wishaw General move During the Wishaw General move (see below right) emergency admissions in the pre-closure period throughout Lanarkshire were again as expected.

While Law Hospital admissions were marginally higher than the mean, they were lower than the mean-plus-one standard deviation calculation.

Admissions during the closure period closely mirrored the Hairmyres move, with Monklands again taking its planned share of the projected admissions, but the other hospital (Hairmyres) receiving less than half of its predicted share.

Everyone who needed inpatient emergency admission during the two closure periods was admitted, and every patient who attended alternative accident and emergency departments saw a doctor. Patients admitted to the remaining Lanarkshire hospitals were transferred to their new local hospital within days of it opening - unless they were due to be discharged soon.

The trust and all others affected regarded the hospital moves as major successes. Directly after the Hairmyres transfer, a workshop was held to see what lessons could be applied to the Wishaw General move. All partner organisations completed questionnaires. It was agreed that the same planning principles would remain in place for the Wishaw move. In particular, the plans based on patient activity projections at mean-plus-one standard deviation were kept.

A system was set up before the moves to monitor patient activity, bed occupancy, emergency and elective admissions, A&E attendances and delayed discharges. This information was issued daily to all relevant managers and partner organisations.

During the closure periods, the key performance indicators were collated and issued three times a day.

These factors created a feeling of confidence in the plans. The monitoring showed that enough beds were available in the other hospitals, that they were not becoming overloaded, and that patients referred by GPs were being admitted to hospital in line with the original plans.

Neil Pettinger is head of planning, Graham Johnston is management services officer and Jonathan Todd is information services officer at Lanarkshire Acute Hospitals trust.