ABSTRACT
Background: During the last financial year, 101 internal emergencies were declared in West Australian (WA) hospitals due to inadequate capacity. This number is predicted to increase as the WA borders open. Observational experience at our hospital suggests that a significant number of general medical patients are occupying beds for prolonged periods of time for non-acute reasons. These include: awaiting placement to aged care facilities or transitional care placement (TCP), transfer to mental health units and National Disability Insurance Scheme (NDIS) for further discharge planning. Aim: To quantify the amount of acute medical beds that are occupied by patients who do not require a tertiary hospital bed for management of their condition. So as to assess the impact on patient flow and justify the need for a step-down unit at a secondary facility. Methods: This was a non-blinded prospective study whereby general medical units were audited every 8 days over a 5-week period to capture variation across different days of the week. A General Physician trainee assessed all general medical patients and concluded whether a tertiaryhospital bed was required. Criteria for non-tertiary beds includes patients who were awaiting permanent placement, respite, NDIS or mental health unit beds. Primary outcome measured was the daily proportion of patients not requiring acute tertiary care. Secondary outcomes measured were the reasons for ongoing hospital stay, patient factors contributing to this and the length of stay attributable to non-acute care. Results: The average daily proportion of general medical inpatients that do not warrant tertiary care was 21.5% (range 16% - 23%). Those awaiting placement to residential aged care facilities, TCP or respite contributed the most to ongoing hospital admissions (55.9%). Other reasons included awaiting NDIS approval (17.6%), mental health unit admission (17.6%) and transfer to rural residences (8%). More than half of the patients were over 65 years of age (64.7%). 58.8% of these patients were independent with activities of daily living, while the remaining 41.2% required assistance. Most common presenting complaints includes falls (23.5%) and infection;pneumonia, urinary tract infection, cellulitis and sepsis of unclear source (23.5%). Dementia with behavioural and psychological disturbance contributed 11.8%, mental health was 8.8%, neurological presentations (CVA, TIA, seizures) was 8.8%, gastrointestinal issues contributed 5.9%, and other reasons totaled 8.8%. More than half of the patients had a psychiatric comorbidity (58.8%) and close to half had cognitive impairment (41.2%). Average length of stay for non-acute care was 19.2 days. Proportion of patients with lengths of stay less than 10 days and 10-20 days was equal (35.3%), 5.9% for 20-30 days, 8.8% for 30-40 days, 2.9% for 40-50 days and 11.8% for more than 50 days. Conclusion: This study highlights the factors contributing to the burden faced by WA Health including lack of available beds, disruption in patient flow, and ramping. To address this, we have identified a significant proportion of general medical inpatients that could be stepped down to an alternate facility. In the context of the COVID-19 pandemic, efficient bed flow is paramount to ensure timely patient care and appropriate allocation of resources.