winter planning:

England was hit by a bed crisis in December 1998 and January 1999. National newspapers reported patients waiting long hours to be seen, lack of intensive care beds and patients waiting on trolleys because no beds were available. Many causes were suggested, including influenza, high existing bed occupancy, shortage of nurses, low uptake of influenza vaccine, staff illness, competing pressures to reduce waiting lists, and government rationing.1,2,3

This winter, there will be a total of eight bank holiday and weekend days over the Christmas and new millennium celebrations. The British Association for Accident and Emergency Medicine has predicted a surge in emergency activity during the millennium period.4

The Department of Health has issued guidelines to health authorities and local authorities, trusts, social services and primary care groups to help plan emergency services.5 These recognise that the millennium holiday will put great strain on the NHS and local authorities and that these pressures may be compounded by the year 2000 date change. But there is no guidance on planning for the number of emergency beds that will be required.

Southend Hospital, Essex, has 781 inpatient beds serving a population of 325,000. Of these, 624 beds may be used for acute admissions - 209 in medicine and oncology, 196 in surgery, 165 in the department of medicine for the elderly and 27 in gynaecology. All medical admissions are taken by the department of medicine. There are also 50 obstetric, six intensive care and four high dependency beds, 10 ophthalmic and 55 paediatric beds.

Acute emergencies are assessed in 14 observation ward beds and then transferred to other wards, and elderly patients are assessed and day procedures performed in 18 medical assessment unit beds.

Mathematical model

We have used a simple mathematical model to try to predict the number of emergency adult beds required for the millennium holiday. The patient administration system provided data on emergency admissions, discharge of emergency patients and average length of stay. The cumulative bed number is the total number of emergency admissions minus the total discharge of emergency patients for a given period. We chose 17 December as the baseline reference day because activity seems to be fairly stable around this date.

Results

The cumulative bed number shows a similar pattern over the three years, falling before and rising after Christmas (see table).

By the first few days of the new year the number of patients increases. The maximum cumulative bed number in 1996-97 was 173 on 6 January; in 1997-98 it was 176 - also on 6 January - and in 1998-99 it was 209 on 4 January. That means that there had been 209 more admissions than discharges. On 25 December 1998 the cumulative bed number was zero, so 209 beds should have been empty on that day to cope with the eventual maximum cumulative bed number. But only 148 beds were empty on the wards of the main specialties on 25 December. This meant 61 patients had to be accommodated in other areas on 4 January.

Admissions patterns constantly change, with low numbers on 25 and 26 December and 1 January and very high numbers on 30 December and 2 January, and the possibility of high numbers on the 29 and 31 December, which must be planned for (see figure overleaf). To prevent a crisis, enough beds will have to be empty at the beginning of the holiday, unnecessary admissions must be avoided and medically fit patients will have to be discharged.

The most important factor increasing the cumulative bed number is the increase in the length of stay in the department of medicine (63 per cent in 1998-99). Other factors may delay discharge, including fewer doctors doing routine work, fewer ward rounds to plan discharges, lack of nursing staff to help mobilise patients and plan discharges, delays in routine investigations, fewer physiotherapists and less occupational therapy to help rehabilitation, medical patients being cared for on non-medical wards, high workload due to high volume of patients and high dependency of patients. Lack of primary care, community services, social services, family support and transport; and the expectation that care will be provided in hospital are also contributory factors.

To try to increase discharges, consultant physicians have agreed not to take holiday during this period and to do a 'post-take' ward round and then ward rounds at two and five days after admission. Timetables have been adjusted so that all teams do ward rounds on Wednesday 29 December and Tuesday 4 January.

Admission patterns over the new year

The change in the pattern of admissions over the Christmas and the new year could result from the prolonged holiday period. However, we have performed a similar analysis for the Easter periods and not found a similar rise in admissions. Many factors may increase admissions, including flu epidemics, cold weather, inexperienced medical staff assessing patients, lack of emergency outpatient appointments, increase in alcohol-related problems, along with lack of primary care, social services, community services and family support and the expectation that care will be provided in hospital.

Planning for the millennium holiday

Fewer staff will be in the hospital on 31 December - an extra bank holiday. A high number of admissions may be expected on that day, following two days of already high admissions. It has been suggested that liability to error is strongly affected by conditions such as high workload, inadequate supervision and poor communication.6 In terms of providing good quality healthcare, the choice of 31 December as an extra bank holiday cannot be supported.

Enough beds must be empty before the holiday, and we are assuming that a minimum of 209 empty beds will be required again on 24 December to cope with the millennium holiday. This is equivalent to having about seven wards empty on Christmas day. Managers and clinicians were surprised that so many empty beds would be needed.

To achieve this we estimate that we will need about 150 beds empty beds on Tuesday 21 December 1999. This can only be achieved by stopping all elective surgery in the week before Christmas and planning for the discharge of as many patients as possible. It will be possible to use one surgical ward for day-stay surgery in the week before Christmas, and to close wards and then progressively open them after Christmas according to the cumulative bed number.

If the plan to increase discharges is successful, the number of empty beds needed will fall. However, there is an extra bank holiday, and the 'millennium factor' may also increase admissions and length of stay. We believe that a requirement of about 209 empty beds is the best estimate possible.

Organising staff leave will be helped by planned ward closures. Some nursing staff work through agencies and there are concerns that they will not wish to work over the millennium holiday period.

The hospital can try to decrease admissions and length of stay, but community, general practice and family support must also be enhanced. The hospital is negotiating with social services, primary care groups and the community trust to ensure this. There also has to be a change in the perception that care should be provided in hospital during the Christmas period. Hospitals can become a point of refuge rather than a healthcare provider.

Over Christmas and new year 1998-99 there was a 45 per cent increase in admissions and a 63 per cent increase in length of stay in the department of medicine. Reducing these will help prevent a bed crisis, but this can only be achieved with increased resources in hospital, general practice, community health and social services.

Our millennium plans are based on the experience of the past three years. But the cumulative bed number allows a more quantitative approach and should help prevent a crisis. Meanwhile, further research is required to understand why the pattern of admissions and discharges changes over the Christmas period.

Dr Anthony Davison is director of medical services and Stuart Bowhay is business analyst, Southend Hospital.

Key points

During Christmas and new year 1999-2000 there will be eight bank holiday or weekend days. Emergency admissions are likely to be high during this period.

A mathematical model can be used to calculate how many beds will need to be empty on Christmas day in order to cope with an increase in emergency admissions afterwards.

In this study of a781-bed acute hospital, a minimum of 209 beds - equivalent to seven wards - will need to be empty on Christmas day.

This model is derived from information on the patient administration system and could be used by all hospitals to plan care.

REFERENCES

1 Warden J. Health secretary reports on winter bedcrisis. Br Med J 1999; 318 (7177): 145.

2 Woodman R. What caused the winter crisis in theNHS? Br Med J 1999; 318 (7177): 145.

3 Warden J. Conservatives blame rationing for winter crisis. Br Med J 1999;318 (7178): 216.

4 The British Association for Accident and Emergency Medicine. Coping with the Millennium: a strategy for accident and emergency services.

5 Health Service Circular 1999/095: Local Authority Circular (99)15. Winter 1999/2000: Emergency Services and Planning forthe Millennium holiday. DoH; 1999.

6 Vincent C. Framework for analysing risk and safety in clinical medicine. Br Med J 1998; 316 (7138): 1154-1157.