Medically safe for discharge (MSFD): reducing doctor input in MSFD patients across geriatric medicine wards at a DGH in Somerset

ABSTRACT

ContextMusgrove Park Hospital is a district general hospital in Taunton, Somerset, in the South West of England.Issue/ChallengeIncreasingly NHS hospitals are under capacity pressures. Since the COVID pandemic, Musgrove Park Hospital is struggling with high numbers of medical admissions, coupled with increasing lengths of patient stay. This is multifaceted but largely due to a lack of social care packages and pressures on community services.Assessment of issue and analysis of its causesThe pressure on social care has resulted in increased numbers of patients in acute hospital beds that do not have a ‘criteria to reside’. These patients are deemed medically safe to be residing in their own homes or residential care. They do not require inpatient medical care and therefore a routine daily doctor review.ImpactThis project looked to trial a system where medically safe for discharge (MSFD) patients are identified by the medical team (senior doctor) and are flagged as not requiring daily ward round reviews. These patients are discussed daily at board rounds and continue to receive nursing care and therapy input. The MDT are encouraged to escalate concern about a ‘MSFD patient’ to the medical team who will then review as clinically indicated. This would allow rationalisation and re-prioritisation of doctor-time to the most unwell patients.InterventionWe initially trialled this project on Mendip, a 19 bedded care of the older person (COOP). A rapid PDSA cycles allowed the creation and improvement of a sticker to identify MSFD patients. This A6 sticker was placed in the medical notes as soon as a patient was deemed MSFD. It included an option for highlight any ongoing issues that would otherwise be addressed as an outpatient, and signalled that the patient would not be included on daily ward rounds.Data collected during the 3 week trial period showed 46% of bed days were occupied by MSFD patients. An average of 8 MSFD patients were not reviewed each day, with 0.6 unplanned reviews of these patients needed due to MDT concern, saving an average of 7.4 patient reviews per working day. In addition, 3.3 hours/day were saved, allowing rationalisation of doctor time and resources to understaffed, busier wards whilst not causing detriment to patient care. This equates to half a doctor per day per medical ward.Involvement of stakeholders, such as patients, carers or family membersCreating a MSFD process required multi-disciplinary working from medical teams alongside nursing and therapy colleagues, as well as the wider hospital management team. There were no complaints from patients or family members as a result of this change, and no adverse outcomes to patient care were noted either.Key MessagesThe use of a MSFD process has helped our hospital to address the challenges of capacity and demand for limited NHS resources, with respect to both the physical bed-space and precious doctor time. This has enabled reallocation of that saved time to care for and treat more patients, as well as provide education to the next generation of medics.Lessons learntThe current NHS bed crisis will not be solved by a ‘quick-fix' as the situation is complex and multi-faceted. However, projects like this enable the resources we do have to be used effectively and efficiently. We were fortunate to have buy-in from the hospital management when our trial was still in infancy which enabled rapid testing and development of the process, due to support from members of the MDT throughout the hospital. This may not always be the case for other projects.Measurement of improvementData was collected to measure the number of patients being seen each day on the ward, and the time saved from not seeing MSFD patients. We balanced our intervention by measuring the number of complaints from patients or families, as well as the number of unplanned reviews from patients who became sick. The work on Mendip was presented to the hospital clinical leadership group alongside the date we had collected to support its efficiency and safety, who subseque tly approved the standard operating procedure we wrote to formalise our work. This is currently being rolled out within the care of the older person department at Musgrove Park.Strategy for improvementThe next step of the project is to establish MSFD ward. This cohorts the patients who would otherwise be discharged into the community if their pathway/care was available. The ward will require reduced doctor input, allowing medical staff to be redistributed to busier parts of the hospital, with the ultimate aim to run this as a ‘doctor-free' ward, similar to the care provided in the community.