At midnight on 29 September 2022, there were 285 medically safe (discharge-ready) patients stuck in beds at Nottingham University Hospitals (NUH). Two years later there were 109.
The challenge
In December 2018, the number of medically safe patients in NUH beds at midnight peaked at 276, but routinely hovered around 200+ in the months either side of it at an estimated cost of £20 million per annum.
Historically, relationships across system partners were fraught with tension. System-wide reviews of discharge bottlenecks were often challenging, with parties routinely questioning each other’s data. The mutual mistrust was often rooted in conflicting KPIs such as the hospital measuring the timeliness of discharges and adult social care monitoring the speed of allocating social workers. Without shared goals or common data, conversations between organizations were sometimes adversarial.
Strategy
Nervecentre
Thanks to Nervecentre, teams across the ICS are able to access the relevant data and work together to discharge patients back into the community. Nervecentre provides live dashboards that group discharge-ready patients according to their pathway (i.e. Pathway 1, 2 or 3), creating smaller, more manageable cohorts. This is a live patient flow dashboard, and within it, each box represents smaller numbers of patients on a discharge pathway with responsibility for their progress assigned to an individual in the team. With a single click, staff can identify blocks in the pathway, prompting relevant action to resolve issues.
The dashboard below is a snapshot of the Nervecentre dashboard provided by Nottingham University Hospitals]
Nervecentre Live Patient Flow Dashboard
Implementation
Integrated Discharge Team (IDT)
In October 2017, an IDT was established consisting of hospital, community health and social care staff that would share the caseload – and, crucially, the same office space. Adopting a Discharge to Assess (D2A) model, the IDT had a clear mission: to identify patients likely to require supported discharge as early as possible in their hospital stay and proactively plan for their departure in order to reduce delays in setting up care packages or finding suitable placements. However, there was very little data to support and accelerate that journey. It was only possible to see the total number of discharge-ready patients – a figure that could sometimes feel daunting and difficult to then determine what actions were required.
The data
However, there was very little data to support and accelerate that journey. It was only possible to see the total number of discharge-ready patients – a figure that could sometimes feel daunting and difficult to then determine what actions were required.
To address this data gap, a “timing point” was set up on Nervecentre where multidisciplinary teams could document when a patient was considered medically safe (discharge-ready). This was a meaningful metric that everyone understood i.e. that a patient is medically safe when they no longer need an acute hospital setting for their ongoing care. Teams were empowered to record this metric using the digital system Nervecentre.
In addition, the ambitious goal for all patients to be discharged within 24 hours of their medically safe date was introduced. This enabled the identification of a cohort of patients that no longer needed an acute bed to commence planning for care packages/placements to be set up.
Shared understanding across the system
Starting to develop accurate data helped with the conversation across the system about understanding any delays and relevant actions that could be taken to address the delays.
When you’re able to identify a cohort of patients that no longer need an acute bed, you build a shared understanding that paves the way for collaborative problem-solving.”
- Mark Simmonds, Deputy Medical Director, NUH
In 2022, seeking to build on the ability to identify discharge-ready patients, the data set was enhanced to provide answers to the question: why are these patients still here? The rationale for this was driven by having complete visibility of blocks in the system – and granular understanding of why people are delayed – it would become easier to identify the root of the problem and align resources accordingly.
Through whole system engagement, Integrated Discharge Leads focused on understanding each organisation’s data needs – social care, NUH, community health – and creating a list of common data requirements that could be captured through Nervecentre.
This has prevented so many headaches and ended the blame culture. All our system partners triage live from Nervecentre. We trust it; we’re all part of the data collection, and all accountable for everything that’s put into the system. And because we all have access, everyone – from the executive board down to teams on the ground – has a real-time picture of what’s happening on the ground at NUH and why…Having one version of the truth has transformed our culture and our work.”
- Kay Parker, Integrated Discharge Lead, NUH
Image 1: Live patient flow dashboard
Outcomes
- Discharge delays at NUH are trending downwards.
- On 29 September 2022, the trust reported 285 discharge-ready patients in acute beds overnight.
- Two years later, that number has shrunk by more than 60 per cent to 109.
- Throughout 2024, the number of discharge-ready patients in NUH beds overnight has consistently hovered between 100-125, down from a winter-related high of 264 in March 2024.
- By Autumn 2024, NUH had fewer discharge-ready patients in its hospitals compared to Autumn 2023.
- Since 2017, the average post-medically safe length of stay has reduced by more than three days.
- These gains mean that more beds are available to those who need them most.
Our experiences at NUH show that the issue of discharge delays – a seemingly intractable problem that the NHS has struggled with for years – is solvable. The solution comes from having a high quality, shared data set, and tools that help teams action meaningful change. If you don’t have accurate data that’s visible to everyone in real time, you’ll fall short. But if you’ve got data you can trust, great things are possible. Five years ago, bed day losses were costing NUH around £20 million a year. Now, thanks to trusted, real-time data – and incredible collaboration across our ICS – we’ve halved those costs and have the latitude to go further. It shows that by being scrupulous around data – and having a fantastic system to record it on – you can get to a better place.”
- Mark Simmonds, Deputy Medical Director, NUH Nervecentre Live Patient Flow Dashboard
Contact
Email: [email protected]