Homerton Hospital, a 450-bed district general hospital in Hackney, east London, reviewed its bed management in 1997 in response to increasing emergency admissions and delayed discharges.
The normal activities of the accident and emergency department were hampered as it was often necessary to establish a temporary ward in that area. And ambulances sometimes had to be diverted to other hospitals because of a lack of beds. These problems lowered staff morale and brought adverse publicity.
The hospital serves an ethnically diverse and socially deprived community of about 200,000.
Three groups responsible At the time of the review, responsibility for bed and site management decisions was held by three separate groups in the trust. Administrative bed managers covered Monday to Friday, 7.30am-8.30pm, but did not cover weekends or bank holidays. This group did not have a clinical background and was largely office-based, collating information over the telephone.
A nurse-run night practitioner service operated from 8.30pm-7.30am, seven days a week, providing clinical support to nursing and medical staff in addition to bed and site management duties. This group consisted of experienced nurses of G-grade and above. They worked within clinical protocols that allowed them to undertake roles such as cannulation and the verification of expected death. They were viewed as an expert clinical and management resource by staff.
A daily site management rota also operated among senior departmental managers from 7.30am-8.30pm.
This was normally divided between an early and a late shift and cover would be provided from a diverse group, including senior nurses, service managers, the head of the works department and senior pharmacists. At weekends and on bank holidays this group would also have daytime responsibility for bed management.
Areas of concern
The review identified three areas of concern:
The inclusion of non-clinical staff on the site management rota meant there was no guarantee of access to advice on clinical issues or support during clinical emergencies at weekends and bank holidays. They were also often unable to relate to pressures associated with patient acuity and staffing shortages.
The administrative bed managers lacked clinical knowledge and, therefore, credibility among clinical staff.
Their lack of knowledge prevented them from preempting management problems associated with clinical conditions - for example, the failure to understand that a productive cough could indicate tuberculosis might result in such a patient being admitted to an open ward. Lack of clinical knowledge also compromised their ability to negotiate with medical staff about 'urgent' admissions or to make informed decisions about workload on the wards.
The participation of so many managers on the site management rota compromised continuity and reduced their ability to manage their departmental workload while they undertook this role.
Developing a new service
I was appointed as a senior night practitioner in February 1997 with a remit to develop a new 24-hour service to provide bed and site management, based on the existing night practitioner service.
After discussions and the development of job descriptions, operational guidelines and protocols it was decided that the new service - the clinical site management team - would consist of six G-grade nurses and myself as the H-grade manager.
The posts were funded from savings from the redundant administrative bed managers' roles and from senior managers' on-call payments, and through a general cost improvement programme.
Interviews were held in June and the service began in September 1997 after a month-long orientation and training programme. The posts required experience in an acute care setting at F-grade or above. But in fact most successful applicants had several years' experience at Ggrade or above.
The team covers the 24-hour period in two shifts, from 8am-8.30pm and from 8pm-8.30am, with most undertaking internal rotation. I provide additional daytime management cover. The service started with two staff during the day shift and one at night. A review of the service resulted in the adoption of a new shift running from 2pm-2am to provide support to both existing shifts rather than having two staff available 8am-8.30pm. This was in recognition of the workload during these hours.
Because team members are nurses, they are in a better position to interpret the information they are given about patients and are able to ask pertinent questions in order to ensure that patients are admitted or moved to the most appropriate ward.
These decisions are also based on their knowledge of staff shortages and patient acuity. The team spends a considerable amount of time on the wards, getting to know the patients, allowing team members to identify, at an early stage, patients who may be suitable for transfer from acute areas to other units.
The team has become skilled in ensuring the maximum use of beds and adept at taking reasonable risks when juggling emergency and planned admissions. It may, for instance, place an emergency admission in a bed allocated for an elective admission the following day if it feels the person is likely only to need an overnight stay.
Clinical credibility
The team has a high profile in the trust and its clinical credibility has increased the amount of information it receives about patients. This enables negotiation about patient admission, discharge or transfer. The provision of a 24-hour service means that the team can troubleshoot many problems and report pressures in the system to senior management at an early stage.
In addition to attending cardiac arrests and trauma calls, the team acts as duty fire officers. It is also part of the hospital's security threat assessment team, which assesses and manages people displaying threatening behaviour on the site.
The team's 24-hour presence allows it to address persistent out-of-hours problems, such as arranging the cleaning of side rooms that have been vacated at night.
Problems with this had led to a bed shortage. This issue was tackled by the team and a domestic is now allocated to this task, and contactable by pager. The Homerton site is undergoing substantial development and new building, and the team has co-ordinated much of the out-of-hours activity related to this work.
The improvement in bed management at the Homerton between 1996 and 1998 can be seen by comparing the number of times the hospital has requested the emergency bed service to restrict acceptance of admissions from other areas (see figure, right). Although there were more restrictions in October and November 1998 than the same months in 1996, the overall trend has been down.
Bed management has improved despite increased admissions and the loss of 22 beds. There were 4,879 admissions in January to May this year, compared with 4,221 in the same period last year. This has meant the Homerton has met its waiting-list targets.
Since the new service was set up, the trust has only had to ask for the diversion of ambulances due to bed pressures on three brief occasions (in March and April 1998). In previous years there were significantly more occasions when the hospital closed to emergency admissions. The trust can now more frequently assist nearby hospitals which require ambulance diversion due to bed problems.
The team's ability to identify potential infection control problems has significantly reduced the incidence of undiagnosed TB patients being allocated beds on the main wards.
On-call senior managers now receive fewer calls and better information about problems. The number of incidents requiring the presence of the on-call managers has been reduced because the team can resolve more problems themselves.
A report by management consultants on emergency admission arrangements noted that the team had significantly increased co-operative work between different parts of the hospital.
The continuing night-time provision of a clinical service has reduced the number of calls to medical staff by 225 per month. In conclusion, the clinical site management team has considerably improved bed management and provides a model that many trusts may wish to examine.
Key points
Allocating bed management to a team of nurses providing a 24-hour service has helped free beds and increased admissions at an inner-city hospital.
The team's 24-hour presence has reduced persistent out-of-hours problems.
Since the team has been in operation, the number of times ambulances have to be diverted to other hospitals has been reduced.
Diane Eamer is senior clinical site manager, Homerton Hospital.
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