So far I’ve mostly talked about avoiding the avoidable in hospital expense only at the start, the admission stage, of a hospital stay. But the problem arises at the other end too, when a patient has to stay on because the discharge process is delayed. 

There are two main reasons why this might happen.

OK, so why can’t I just go home?

The more obvious one is that the discharge has not been properly prepared. Tests need to be carried out to confirm that the patient is fit to go home, but the results haven’t been received – or perhaps the tests haven’t even been ordered. Possibly the patient needs to take medications home and the necessary prescription hasn’t been sent through to the hospital pharmacy. Or, even more simply, the discharge needs the approval of a doctor who simply isn’t available, called away to an urgent conference which perhaps, and entirely coincidentally, is taking place next door to a prestigious golf course.

This kind of problem occurs everywhere. Recently I read a 2014 study of two hospitals in Brazil. It found that in one of the hospitals, delayed discharged represented a 23% extra occupancy rate, a figure that climbed to 28% in the other. That means a massive proportion, around a quarter, of the beds in those hospitals were occupied at any one time by people who should already have left.

The other main reason for a delayed discharge is particularly familiar in a nation such as England. Patients can’t leave because there’s nowhere for them to go where they will receive the ongoing care they need. This is particularly acute for older people who may be living alone with no one available to act as carer. They can only be discharged once there is a social worker or community nurse available to help them, or perhaps a bed in a care home.

Delayed discharges generate two problems. First of all, it’s bad for the patients: people generally recover better in their own beds than in hospital and, in any case, simply by staying on patients are exposing themselves to unnecessary risk, if only of infection from other patients around them.

Secondly, the delayed discharge is bad news financially. Acute hospital care is the most expensive care and, even though costs will be lower towards the end of a stay by which time the patient requires less treatment, the mere fact of occupying a bed is expensive. That’s without taking account of the impact on other patients who might have benefited from being admitted to a bed blocked in this way.

A recent study (February 2016) for the NHS in England by a team headed by Lord Carter of Coles, Operational productivity and performance in English NHS acute hospitals: Unwarranted variations, put a figure on the impact of delaying discharges: “the cost of these delays to NHS providers could be around £900m per year.”

That’s close to 2% of the total expenditure on acute care.

How do we fix these problems?

Both require management action, naturally. For instance, my wife worked until two or three years ago in the Discharge Planning team of our local hospital. Here, nurses, social workers and hospital staff worked out of a single suite of offices, preparing the plan to discharge a patient from the moment he or she was admitted. That meant that the agencies involved in post-hospital care had the greatest possible notice that their services would be needed. They could, therefore, assign staff or find suitable accommodation, at least as far resources allowed, in the most favourable possible conditions, rather than in a rush at the end.

Equally, steps can be taken in plenty of time to ensure that all necessary processes are carried out, the appropriate tests or medications ordered, and the paperwork prepared for someone to sign who will be around at the right time.

Computer systems can help, of course. The kind of pathways management software I’ve been talking about in this series can be used by hospital staff as it can by people in primary care. It can issue alerts not just to physicians but to nurses and care assistants: “for this patient to be discharged tomorrow morning, you have to request this test today,” for instance.

When it comes to helping with groups like my wife’s former colleagues, what’s needed is ways to improve collaborative working between different systems. Social work management software needs to interwork with nurse management and general hospital systems. Fortunately, none of that is impossible and over the last few years, great strides have been taken towards making it happen.

What that means is that avoiding the avoidable can now be tackled at both ends of a hospital stay: discharge, with its own specific problems, as well as admission.

Supporting clinical decisions for physicians

Clinical decision support software can be invaluable in a triage service: it will remind staff of conditions that fit the symptoms a caller is describing and prompt them to ask the relevant questions to check on the possibilities, or propose sensible actions.

Isn’t that exactly what we want for doctors too? Shouldn’t they be prompted to consider all possible explanations of a patient’s condition? Might they not also need an occasional reminder?

Things, sadly, are not that simple. As long ago as 1999, the Journal of the American Medical Association carried an article on ‘Why don’t physicians follow clinical practice guidelines?’ They found a number of barriers to the use of guidelines (that’s guidelines in general, irrespective of whether they’re drawing on software support). They may not be aware of their existence. They may be put off by the sheer volume of guidelines out there. They may, quite simply, not have the time to consult them.

Systems should support delivery of patient care, not distract from it

That last objection is one I’ve heard from General Practitioners (family physicians) in Britain. On average, they have ten minutes for each patient consultation, which means the useful time is around seven and a half minutes. Pulling a book out to check on a guideline simply takes too high a proportion of the available time. “I would never consult a guideline,” one GP told me.

Most British GPs use a computerised system these days. Even then, though, they don’t want to have to call up their decision support system and work through it to see whether it has anything to suggest. “I don’t want to have to check my system to be told that a patient coughing blood needs to be checked for possible cancer. If I didn’t know that, I shouldn’t be in this job.”

They also don’t like it if their screen is full of popup alert windows. They need their screens to contain the information that’s useful to them. They don’t want it cluttered.

Despite all that, we all know that diagnoses are sometimes missed. Recently, it was announced that heart attacks are missed in one-third of British women who have had one. Why? Because it’s with men that physicians first think of heart attacks. With women patients, the first thought is much more likely to be cancer. That’s despite the fact that experts point out that women are as likely to suffer a heart attack as men are.

So what’s the answer for a clinical decision support supplier?

First of all, although there does have to be an alert to doctors concerning the presence of decision support information, it needs to be discreet – it mustn’t take up too much space on screen. It just has to be eye-catching enough for the physician, whether a GP or in a hospital, to realise that the system has something to suggest. He or she can then choose to consult it.

Secondly, once the physician has gone into the decision support system, it should not require him or her to select a specific pathway – say lung cancer rather than congestive obstructive pulmonary disease. Instead it should be assembling the symptoms and findings already recorded and, if they are compatible with either condition, propose further questions to ask, or tests to carry out, in order to eliminate one or other of the possibilities.

Thirdly, it has to be constructed to as to save the physician time, not cost more. So as well as supporting the clinical decision, it should also support the process itself. For example, for a GP, does a letter have to be produced for a referral to hospital care? Then the system should produce it. That way the physician doesn’t have to flick between systems and, if anything, the use of it will save time that can be used for the consultation itself, listening to the patient or providing advice.

What does that all mean? That there is indeed a vital role for a clinical decision support system to play in supporting physicians. But it needs to be highly intelligent in design, to ensure that while it benefits patients it does not do so by distracting physicians from their main purpose: helping in every way possible to alleviate suffering and reduce ill health.

That’s one of the most exciting and satisfying challenges that healthcare information work provides today.