Mr Speaker and Honourable Members,
I rise today to share information regarding bed capacity and discharge policies at the Bermuda Hospitals Board (BHB).
There have been stories circulating in the community on this topic, and I believe it to be helpful to improve our understanding of the process and its impact.
Mr Speaker,
Ensuring that every person who needs an inpatient acute care bed has a timely admission to the care they need is not only important for the patient, but also for the smooth running of any hospital.
If there is not an available bed, then someone who has arrived in the emergency department needing to be admitted has to wait. At times of extreme pressure, there might not be available beds for an elective surgery. It is very frustrating and often stressful to be the patient who needs the bed at those times.
Mr Speaker,
BHB, like hospitals world-wide, is capacity constrained and works hard for every patient to have the earliest, safe discharge. This is only possible if partners inside and outside the hospital work together to achieve the goal of an earliest, safe discharge.
At BHB the biggest impact of having high bed occupancy is that patients who come to the emergency department and need to be admitted, must wait until the individual who has been discharged from an acute care bed leaves the ward and the room is cleaned. While these patients wait, they are using an Emergency Department bed which, in turn, impacts the availability of patient rooms in Emergency for new patients to be seen. This can cause longer waits for people with minor illness or injuries, or the need to use areas outside of patient rooms to ensure care is delivered for those whose care needs cannot wait.
Mr Speaker,
To contextualize this, January 2023 was a busy time for BHB, which is expected as the winter months see more respiratory illnesses, often resulting in increased emergency visits and higher admissions.
In the month of January alone there were 2,766 emergency attendances. The average length of stay in the emergency department for all patients was 3 hours and 59 minutes from arrival to leaving the emergency department. For patients who were admitted in January, however, it took on average 17 hours and 38 minutes from the moment their emergency care was completed to when they left emergency for the unit.
While it is not acceptable to have patients waiting for an excessive period, it is important to note that BHB ensures these patients receive a standard of care similar to those on a ward, by sending an additional inpatient nurse and doctor to emergency.
Mr Speaker,
Considering the acute care wards, an average length of stay in the acute care units was 11.3 days in January, which was higher than both December, when the length of stay was 9.4 days, and February, when the length of stay was 8.2 days.
The average length of stay figure for acute care units can give an indication of how ill people are, but it is also an indicator of how efficiently discharge processes are working.
The average length of stay goal at BHB is comparable to overseas hospitals at seven days for most patients, although with some conditions such as stroke, the expected length of stay is longer. The goal is always to discharge patients as soon as they are medically fit. Being in hospital is critical for certain care needs but is not a good place for people who no longer need acute care.
Mr Speaker,
Spending a long time in hospital can lead to an increased risk of falling, sleep deprivation, catching infections and sometimes mental and physical deconditioning.
BHB usually runs at about 92% capacity or more. It is not unusual for hospitals to run at this level, and it would be very expensive to have too many beds that are staffed and ready for use but empty. If people hear BHB is running at 100% capacity or more, that means the hospital is very full, but there is still a lot of admitting and discharging that takes place during this time.
Between November 2022 and February 2023 there were over 960 discharges from BHB’s three acute care units, which house 90 beds. Over 60% of those people discharged met the BHB goal of seven days or less and nearly 90% were discharged within two weeks. However, for 7.6% of the people discharged over this time, it took between 14 and 21 days to be discharged. For over 2% it took between three or four weeks, and 4.8% of the people discharged over this time had been in hospital for over a month, with a small group in an acute care bed two months or more. Having even a small number of beds unavailable makes a huge difference every day.
Mr Speaker,
Challenges with the discharge process at BHB are as follows.
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A small number of patients need additional support in place before they can be safely discharged. This is one of the many ways our aging population impacts hospital services. Seniors have more complex care needs and it may not be possible just to discharge them home without additional services being in place, or it may not be safe to discharge them home at all and they may need a nursing home placement. If there are no nursing beds available, if home care services cannot be funded or are not available, or if a family is delayed in submitting financial assistance forms, this can all result in an individual being in a hospital bed longer than needed.
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Another common scenario is patients waiting to be picked up by their loved ones after they have been discharged. While delays of a few hours or a day or two does not seem so bad, there is still a direct impact on someone else’s care. A patient may be waiting in the emergency department for that room to be free so they can be moved up to the ward. If a patient is discharged first thing in the morning, but a family member waits until the evening to pick them up, then that 10 to 12 hours is how long the person in emergency must wait, and there is always additional time required to clean and prepare the room for the next patient.
BHB has a goal to have all patients who are ready for discharge to be picked up by 11am. This is no different than a hotel having strict check-in and check-out times. If hotel guests left when they felt like it on their day of departure, when you arrived at a hotel you would not know when your room would be available, and you would have to wait. Picking up loved ones ready for discharge by 11am can make a big difference for patients who are waiting for a bed.
Mr Speaker,
There are a number of planned admissions to the inpatient acute care unit, such as an elective surgery. The vast number of admissions, however, are unplanned through the emergency department. This means each day, the hospital does not know how many people will need beds, when they will arrive, nor what is wrong with them.
Unexpected peaks will therefore cause pressure to the bed flow within the hospital.
Peaks in unplanned admissions can impact elective surgeries. Recently improved processes in surgery have helped to reduce the impact of unplanned admissions on planned surgeries.
Between April 2022 and January 2023, only 0.6% of planned surgeries, or 37 in total, were postponed due to there being no bed available in ICU or an acute care ward. The biggest cause of surgery cancellation is actually patients not showing up or calling to cancel themselves. Over the same time period, 142 surgeries were cancelled by patients and 84 surgeries were cancelled because the patient was unfit for surgery, as assessed by the surgeon or anaesthetist.
Mr Speaker,
The causes of reduced bed capacity in a hospital can be multiple and complex but can be greatly assisted by on-time pickup on the day of discharge, improved availability of nursing home placements and by families making provisions for home care. It should never be forgotten, however, that while it can be common to refer to this as ‘bed blocking’, behind the issue are many vulnerable individuals with complex care needs who may be impacted by social or financial factors. These are our parents, our grandparents, our unwell or injured loved ones.
BHB is here to provide necessary high quality care, and needs all of our help to do so in a manner which is fair and efficient.
Thank you, Mr Speaker.