Hot Topic: Patient Flow

A Word version of this briefing aimed at health care professionals is available for LKS staff to share in their own organisations. Please feel free to reproduce it (with acknowledgement) for your own purposes.

Impact on library policy/practice:

• Skilled librarians can locate the evidence for different approaches to patient flow. The evidence may not always be accessible through bibliographic databases, but librarians have the skill to locate other sources of evidence such as case studies or reports
• Library staff can support the publication and sharing of patient flow initiatives, either as published documents or as poster presentations
• Library services can provide point of care information tools that can speed up the diagnosis and treatment of patients, and that can support junior medical staff to make decisions when there are fewer senior staff available

What does ‘patient flow’ mean?

Patient flow is about the avoidance of delays in transfers of care, from for instance hospital to home or from A&E to a ward. It can also encompass admission avoidance, but this will be looked at in a separate Hot Topic.

One definition is ‘the right care, in the right place, at the right time’.

Why has patient flow become a hot topic?

The majority of delayed transfers are still due to NHS delays (such as awaiting further non-acute NHS care) but the proportion due to social care (such as awaiting a care package in own home) has risen steeply since 2014. In October 2017 there were 170,100 total delayed bed days (3)

An audit by NHS Benchmarking showed that while only 5 per cent of people aged over 65 who are admitted to hospital stay for more than 21 days, that 5 per cent accounts for more than 40 per cent of all bed days (1). Longer stays in hospital are associated with increased risk of infection, low mood and reduced motivation, which can affect a patient’s health after they’ve been discharged and increase their chances of readmission to hospital (3).

When bed occupancy is higher than recommended, it can lead to difficulties finding beds for new admissions, with knock-on effects in other departments such as A&E. (4)

There is also an argument that due to the way the figures for delayed transfers are defined, there are many more cases of patients that could be cared for in other settings, such as forms of intermediate care. (4)

What are the consequences of poor patient flow?

Some of the consequences (2) are:

• A&E departments become crowded, stressful and unsafe
• Patients are admitted as ‘outliers’ to wards that are not best suited to manage their care, which may mean they have worse clinical outcomes
• Ambulatory care services, clinical decision units, even catheter labs and endoscopy units may fill with patients waiting for ward admission
• Inpatients are shuffled between wards to make room for newcomers
• Clinical outcomes are measurably worse, particularly for frail older people, who suffer more harm events and may lose muscle tone due to extended periods in hospital beds

What is being done to improve patient flow?

Three approaches for improving flow are: shape or reduce demand, match capacity and demand, and redesign the system.

There are lots of potential ways to improve patients flow that follow one of more of three aproaches, with one of the ideas being tried that of Accountable Care Organisations which bring health and social care providers together to take responsibility for the care for a defined population.

Other suggestions for improving flow in hospitals include (2),(6):

• Deploying ambulance managers (sometimes termed ‘HALOs’) to help manage the hospital–ambulance interface and release ambulances quicker
• Co-location of primary care facilities in A&E department to stream patients
• Using Clinical Decision Units outside of A&E for patients who can be discharged following a short period of observation, investigation or treatment
• Assessing patients for frailty when they present at A&E so they can begin to receive specialist care and get the right level of support when they are ready to be discharged.
• Using the SAFER patient flow bundle and ‘Red2Green days’ tools
• Using lean or Six Sigma approaches to quality improvement 

Further reading and references

1. NHS Benchmarking, 2017, Older People’s Care in Acute Settings: National Report
2. NHS Improvement, 2017, Good practice guide: Focus on improving patient flow
3. King’s Fund, 2018, Delayed transfers of care: a quick guide
4. Nuffield Trust, 2017, What’s behind delayed transfers of care?
5. BMJ Quality and Safety, Six ways not to improve patient flow: a qualitative study
6. The Health Foundation, 2013, Unblocking a Hospital in Gridlock South Warwickshire NHS Foundation Trust’s experience of the Flow Cost Quality improvement programme

Primary audience: LKS staff and their wider organisations

Date last updated: May 2018

Due for review: May 2019

Group member responsible: JC