Judging the right number of beds for a hospital is no easy task, but an enormous amount of work by clinicians, planners and funders has gone in in the last few years for the new Dunedin hospital and politicians should be very wary of riding roughshod over the final recommendations.
Clearly there is a strong desire not to have wasted or idle capital by having beds that are not needed, but there are real, serious and ongoing costs of having too few.
In short, these are increased labour costs, overcrowding in the Emergency Department (ED), frequent cancellations of elective surgery, patients being accommodated on wards that are not "home" to the team or specialty, mixed gender rooms, premature discharge and higher rates of re-admission.
Costly workarounds
Building a hospital which is too small means expensive staff workarounds which do not add value to the patient’s care.
The resulting increased labour costs usually dwarf any short-term capital savings within 10 years, and then go on forever. Southland Hospital bears ample witness to this.
ED overcrowding
Emergency Department overcrowding is a scourge throughout New Zealand. The major contributing factor is the inability of inpatient specialties to promptly admit patients who clearly need their care to an appropriate hospital bed space.
Cancelled surgery
Deferring or cancelling planned surgery or other interventions requiring an inpatient bed is one of the few actions available to hospital managers to alleviate demand, but it generates enormous waste that can never be recovered, as well as very significant stress to patients and their families, and to staff.
Outliers
When occupancy rates rise to near-full capacity, an increasing number of patients are admitted to areas of the hospital that are not where patients with their specific condition are usually managed (home wards); they are usually referred to as "outliers". This matters because in a modern hospital there are very specific skill sets for both doctors and nurses looking after patients in a particular specialty, and it is impossible for every nurse in the hospital to be expert in all of these.
Repeatedly, research has shown that patients who are outliers are visited less often by the inpatient team looking after them, are sometimes "lost", have longer lengths of stay and have worse outcomes, including higher infection rates and, in some studies, higher risk of death.
Premature discharge
When a hospital is full or nearing maximum occupancy there is immense pressure to discharge as early as possible, and this can result in discharge before the patient is truly ready. This creates considerable tension and risk, particularly when the patient lives at a distance from the hospital, as two-thirds of the catchment population of Dunedin Hospital do. Support services are often more difficult to access, and needing re-admission creates significant transport difficulties for many, so clinicians will often hold on to remote or rural patients for a bit longer.
Optimal bed occupancy
It is generally accepted that occupancy rates of above 85% lead to inefficiencies and problems with accommodating acute demand, although this figure is based more on lived experience than on conclusive evidence, and has many caveats. Some parts within hospitals can run at 100% capacity (e.g. day surgery units), while others need large spare capacity as they cannot usually turn urgent cases away (maternity units or ICU). The smaller the unit or hospital the more spare capacity they need, as random variation in demand has a much greater effect.
Reducing bed demand
There have been major efforts for many years to get lengths of stay down, and it is a mantra that health bureaucrats trot out with monotonous regularity as the panacea for the shortage of beds. If only it were that easy we would have done it years ago.
The first impediment is the inability to provide the necessary inpatient care in as efficient a way as possible. This is because of rate-limiting steps, such as waiting for radiological investigations or the inability to access timely acute surgery or other procedures (coronary intervention, endoscopy, etc).
The second is the physical ability of the patient. What the wildly optimistic health planners that many of us had dealings with during planning for the new Dunedin hospital don’t seem to have grasped is that the population is becoming older, more frail, fatter and more co-morbid. Many, particularly elderly, patients have been just managing at home (or in fact not coping), and the acute event requiring admission to hospital becomes a triggering event.
When they are assessed in hospital it may be apparent that their needs are not being met, or they are unsafe in their own home.
Sometimes, families/whanau see this as the moment to engineer a change and may refuse to take them home or support a decision to return them to their own home.
Care in the community requires extensive supports, including a readily accessible GP, home help of various kinds, district nursing and other services, and these are in short supply and take time to organise. Rehabilitation beds are in critically short supply.
Placement in a rest-home or hospital-level care requires an extensive needs assessment (often with significant delays), defining the most appropriate level of care and then finding a place that is acceptable to patient and family and with suitable financial arrangements.
All are time-consuming and, in the meantime, the patient remains in an acute hospital bed, effectively blocking it. Until there are more lower intensity care beds allowing for this transition phase and more rest-home beds the problem will persist, and no amount of focus on in-hospital processes will make much difference.
All of this requires investment, something this government seems utterly allergic to (unless it’s roading), and without it, reducing the need for more inpatient beds remains a vain hope.
Hope is not a plan.
■ Mike Hunter is a retired consultant general surgeon and consultant intensive care specialist.
