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NHS services are under extreme pressure. Recent testimonies from healthcare professionals, patients and journalists have highlighted the scale of these problems, which go significantly beyond the usual increase in pressure over the winter period. One key area of concern is a lack of hospital bed capacity, which as noted by the Nuffield Trust, is an important indicator of wider pressure on the system: "Hospitals cannot operate at 100% occupancy, as spare bed capacity is needed to accommodate variations in demand and ensure that patients can flow through the system. Demand for hospital beds peaks at different times of the day, week and year. There must be enough beds to accommodate these peaks. A lack of available beds can have widespread consequences in a health system.”[1] An absence of spare bed capacity can significantly impact a hospitals ability to provide safe and timely care. This also has consequences for other parts of the system, such as increased ambulance waiting times because of handover delays. There are multiple causes of these capacity issues: Longer-term structural challenges – such as the number of hospital beds relative to the population and workforce shortages.[2] Medium-term issues – for example the impact of delayed discharges. Short-term problems – such as increases in admissions of patients with seasonal illnesses. In this blog we will consider two specific issues stemming from this lack of hospital bed capacity and consider their impact on patient safety: Increasing cases of patients being cared for in hospital corridors and non-clinical areas, commonly referred to as ‘corridor care’. Current proposals to reduce the number of patients waiting to be discharged. Increasing cases of ‘corridor care’ ‘Corridor care’ can be broadly defined as care being provided to patients in corridors, non-clinical areas or unsuitable clinical areas because of a lack of hospital bed capacity. In recent years this has become an increasing occurrence as pressures and demands on the NHS mount, particularly during the winter months. In February 2020, the Royal College of Nursing (RCN) highlighted its concerns about this becoming normalised, publishing a survey of its members that found that over 90% of respondents said that ‘corridor nursing’ was being used at their Trust.[3] [4] In March 2020, the Royal College of Emergency Medicine (RCEM) also raised this issue as part of a broader campaign around improving emergency care, highlighting the need to significantly increase the number of hospital beds in the NHS.[5] However, during the height of the Covid-19 pandemic, infection control and social distancing rules restricted the use of ‘corridor care’ in hospitals.[6] When providing guidance for emergency care after the initial Covid period, the RCEM reiterated the threats to patient and staff safety from crowding in emergency departments and emphasised the need to avoid a return to corridor care becoming the norm.[7] However, in recent months we have seen growing concerns about a significant increase in care being provided in corridors and non-clinical settings.[8] [9] [10] [11] [12] Patient safety risks Corridor care raises significant patient safety concerns. It can present problems providing appropriate care, as these unsuitable spaces can make it difficult to administer specific treatments, such as intravenous medication, or the ability to access oxygen, medication and lifesaving treatment in an emergency. It also makes it more difficult to monitor patients, which can result in delays in providing further treatment if their condition begins to deteriorate. The constraints on space that working in these conditions impose may mean that relatives are not able to be accommodated, reducing their ability to support patients whose condition may not otherwise be closely monitored. This lack of space can also result in physical hazards, with the potential for escape routes becoming blocked in emergencies.[13] Corridor care also has particularly negative impact on patient dignity and confidentiality: “Our overflow corridor never has fewer than 20 patients on it; people who are too unwell to sit in the waiting room. The corridor is made up of trolleys of patients lined up, top to toe, along a wall. It’s busy, it’s noisy and there’s no dignity there. Patients stuck there are being toileted behind staff holding up sheets on the corridor.”[14] Working in these conditions has a significant impact on healthcare professionals too, who know that they are not able to provide the best care possible to their patients. This can affect their mental health and wellbeing creating the risk of moral injuries: the distress experienced when circumstances clash with one’s moral or ethical code.[15] “Tonight I’ve come close to tears whilst apologising to patients for the standards of care we are able to provide. In my 22 years of being an A&E doctor I’ve never seen things so bad. It’s the same everywhere.”[16] Preventing avoidable harm Patient Safety Learning believes that corridor care should be avoided whenever possible. It is vital that this is not normalised. However, in the current circumstances, in some cases this is clearly unavoidable. In these situations, it is important that: Risk assessments are carried out for service redesign and for individual patients, with mitigating actions being taken to maintain the safest care possible. Trusts have clear guidance and apply learning from examples of good practice that prioritise patient safety. Trusts have plans in place to ensure the introduction of corridor care is only a temporary measure. Staff and patients report any incidents of unsafe care so that action can be taken swiftly to address harm or near misses. There is close oversight by Trust leadership, including the Board, to ensure that patient safety safeguards are in place if corridor care is needed and that this is minimised and not normalised. We also believe more research is needed to fully understand the consequences of corridor care in terms of patient outcomes as well as patient safety. There needs to be more research undertaken to evaluate the impact of this. Reducing the number of patients waiting to be discharged Having considered the patient safety impact of corridor care because of lack of hospital capacity, we now turn to current proposals aimed at increasing capacity by reducing the number of patients waiting to be discharged. Hospital discharges can be complex. To enable a safe and timely transfer of care, they require good co-ordination between hospital and community staff to arrange clinical assessments and to ensure the home or community setting has the appropriate equipment and care plans. A delayed discharges refers to a patient who no longer meets the clinical criteria to reside in hospitals and, therefore, should be discharged to non-acute settings. The Department of Health and Social Care has recently stated that there are around 13,000 patients meeting this description.[17] These patients may end up spending a significant amount of time waiting to be discharged for a range of different reasons: Lack of available places in care and nursing homes. Delays putting in place specialist support, such as home care or short-term rehabilitation, required following discharge. The need to ensure specific criteria for a safe discharge are met for patients who need to access ongoing mental health services and support. The need to ensure that complex needs are met prior to discharge, for example in some cases concerning patients with a learning disability, where these processes may involve a range of different professionals and specialist assessments. Reducing the number of delayed discharges is not a new policy idea, but in recent weeks it has received increased attention as this has been identified as a key measure to increase hospital bed capacity resulting in several new proposals aimed at achieving this. Patient safety risks Any measures aimed at increasing the speed of hospital discharges must have at their heart considerations of how this will impact on the safety of patients and the need to prevent avoidable harm. Below we consider some of the proposals that have recently been made in relation to this and their potential impact on patient safety. 1. Discharging patients without care packages The Welsh Government has recently issued new guidance to Health Boards to discharge patients who are well enough to leave even if they do not have a package of care in place.[18] A package of care is intended to meet a patient’s ongoing care needs, which may relate to healthcare, personal care or care home costs, following discharge. Without this in place, there is a significantly increased risk of avoidable harm, particularly for patients returning to their own homes. Not having in place required adaptations, equipment or access to rehabilitation could result in patients struggling to support themselves, increasing the risk of avoidable harm and re-admission to hospital. Commenting on this proposal, Dr Amanda Young, Director of Nursing Programmes at the Queen’s Nursing Institute, also highlighted concerns that: “… patients being discharged from hospital without appropriate care packages, or inadequate support or reablement, results in poorer outcomes in the short and longer term. Discharges may occur late in the evening with no advance warning to community services, in order to free up hospital beds. Vulnerable people may arrive to cold homes, alone, with community services unaware this has happened until the following day or even the day after.”[19] This also opens up the potential for inconsistent decision-making, transferring significant risk to individual healthcare professionals who may be under significant organisational pressures to make discharge decisions that they don’t believe are safe. 2. Funding additional care home beds The Department of Health and Social Care has announced £200 million in funding to buy thousands of extra beds in care homes and other settings to help discharge more patients who are fit to leave hospital and free up hospital beds.[17] The Scottish Government has also announced a similar package, stating it will provide £8 million in funding for additional care home beds.[20] While these announcements have been welcomed in some places, there are concerns about the ability of the social care system to fulfil this, with a key problem being staff shortages. In England alone it is estimated that there are 165,000 vacant posts in social care.[21] Serious concerns have been raised about how appropriate care can be provided where additional beds may be available but staff are not.[22] [23] In many cases this could lead to this additional bed capacity not being utilised, due to lack of staffing, or is utilised despite under-staffing, increasing the potential risk of avoidable harm. Considering this new funding in the context of these workforce shortages, Martin Green, Chief Executive of Care England, said: “… there has been little consultation with the social care sector on how this can be achieved. Yet again, the Government has talked to the NHS and pretty much nobody else, and this is why their policies never work.”[24] There is also a question about whether patients subject to these accelerated discharge processes will receive the appropriate support they need. Integrated Care Boards will be tasked with using this new national funding for hospital discharges to purchase bedded step down capacity plus associated clinical support for patients.[25] However, concerns have been raised about the potential for rushed placements stemming from this, without appropriate access to rehabilitation and enhanced healthcare, which may increase the risk of patient harm.26] The British Geriatrics Society has noted that this could disproportionately impact older patients: “When older people leave hospital in poor health, they need rehabilitation and support to recover. Without it, their health deteriorates further – already on average 15% of older people being discharged from hospital are readmitted within 28 days. With each admission their level of frailty and care needs increase, generating even more demand for health and social care at home or in a care home.”[27] There have also been practical concerns raised questioning whether this funding can be effectively distributed, and extra beds provided quickly enough, to reduce the current pressures. There are further concerns too around how this is being targeted, with the provision of funding being “decided on a ’weighted population basis‘, rather than adjusted to reflect the current share of delayed discharge patients”.[28] [29] Preventing avoidable harm Patient Safety Learning believes that decisions on the introduction of new measures aimed at accelerating hospital discharges and freeing up hospital bed capacity must have patient safety considerations at their core. Whether they involve discharging patients at an earlier stage without care packages, or increased funding to move patients into care homes, all elements of these changes must be considered through a lens maintaining the safety of patients. This includes ensuring: Patients return home, or move to a care setting, with the correct medications and medical devices. Appropriate handover of information for patients is provided when moving from hospital directly into care settings. Appropriate equipment/adaptations being in place for patients returning home. Patients and their responsible carers have access to timely clinical advice if there is deterioration in the patient’s health, and guidance on the signs and symptoms that may indicate this. Patients and their families are decision makers in their own care and have access to information and advice to enable this. Concluding comments The shortage of hospital bed capacity has a wide range of consequences across the healthcare system with implications for patient safety. Here we have focused on the need to ensure that in two specific areas – managing the increase in cases of corridor care and reducing the numbers of patients waiting to be discharged – patient safety is being placed at the heart of decision-making processes around both. In addition to the areas we have identified, ensuring this happens also requires patient safety leadership at a national level. While far from a desirable state of affairs, corridor care is taking place in parts of the NHS and will continue to do so for the foreseeable period, meaning its impact on patient safety must be understood and mitigated where possible. We believe there needs to be recognition of this from NHS England and the Department of Health and Social Care, along with a proactive effort to share and disseminate knowledge and good practice in this area to prevent avoidable harm to patients. We also believe it is important that there is both a recognition and inclusion of patient perspectives and experience of these issues. This particularly applies to hospital discharge processes, which too often are either discussed as purely a capacity problem or worse disparagingly an issue caused by ‘bed-blockers’.[30] [31] It is vital that we hear and listen to the patients and family members voices on changes aimed at accelerating discharge processes. We need to recognise that these situations involve individuals with specific ongoing healthcare needs who, as well as the safe provision of care, deserve dignity and respect. Share your views and experiences We would welcome your views on the patient safety concerns raised in this blog: Are you a healthcare professional who has experience of delivering corridor care and would like to share your story? Are you a patient or family member who has experience of corridor care or a delayed discharge process? Do you work in social care and have experience of, or concerns about, accelerated discharge processes from hospitals? You can share your views and experiences with us directly by emailing content@pslhub.org or by commenting below (register here for free to activate your membership). References Nuffield Trust, Hospital bed occupancy: We analyse how NHS hospital bed occupancy has changed over time, 29 June 2022. Nuffield Trust, Hospitals at capacity: Understanding delays in patient discharge, 3 October 2022. RCN, ‘Corridor care’ in hospitals becoming the new norm warns RCN, 26 February 2020. RCN, Corridor Care: Survey Results, 26 February 2020. RCEM, RCEM launches new campaign to end corridor care as data shows more than 100,000 patients waiting over 12 hours in A&Es this winter, 3 March 2020. Health and Social Care Select Committee, Delivering core NHS and care services during the pandemic and beyond, 1 October 2020. RCEM, Covid19: Resetting Emergency Department Care, Last Accessed 11 January 2023. Birmingham Live, ‘Worst I’ve ever seen it’: Doctor speaks out about horrors of patients in corridors as NHS crisis deepens, 3 January 2023. Health Service Journal, Trust that banned corridor care ‘reluctantly’ brings it back, 4 January 2023. iNews, Striking paramedics tell of patients having seizures in hospital corridors and relentless 16-hour shifts, 11 January 2023. BBC News, NHS A&E crisis: Staff making ‘difficult decisions in unprecedented times’, 7 January 2023. This is Local London, BHRUT boss apologises to patients ‘care for in corridors’, 11 January 2023. Health Service Journal, NHSE issues fire risk warning over ‘corridor care’, 29 November 2022. The Guardian, It’s beyond dreadful. We’re now running A&E out in the corridor and wating room, 12 January 2023. Health Education England and NHS England, Understanding moral injury a short film, 15 January 2021. The Guardian, ‘It feels terminal’: NHS staff in despair over working at breaking point, 4 January 2023. Department of Health and Social Care, Up to £250 million to speed up hospital discharge, 9 January 2023. Wales Online, Doctors claim hospital discharge guidance could see patients die, 6 January 2022. Nursing in Practice, Welsh hospital patients to be discharged to community with care package in place, 6 January 2023. Scottish Government, Additional Winter support for NHS, 10 January 2023. Skills for Care, The state of the adult social care sector and workforce in England, October 2022. The Times, Fears over plans to move patients into care homes, 10 January 2023. The Independent, Staffing ‘crisis’ means £200m extra care beds plan won’t work, health bosses warn, 10 January 2023. Community Care, Care home discharge plan risks inappropriate placements and neglects the causes of crisis – sector, 9 January 2023. NHS England, Hospital discharge fund guidance, 13 January 2023. The Health Foundation, Hospital discharge funding: why the frosty reception to new money?, 13 January 2023. British Geriatrics Society, Protecting the rights of older people to health and social care, 10 January 2023. Health Service Journal, New discharge fund risks being ‘political theatre’, warn NHS leaders, 9 January 2023. Health Service Journal, Revealed: How much is each ICS getting from the £200m discharge fund, 13 January 2023. Daily Mail, Hospitals are discharging bed-blockers into hotels to free up space on wards, 5 January 2023. iNews, NHS discharges patients into hotels to ease bed blocking and A&E crisis, 4 January 2023.