Case Study

Read the following case and answer all the questions that follow.

The acute patient's journey

When an acutely ill patient needs to be treated urgently, the whole healthcare system

has to respond in a co-ordinated manner. For example, if a patient attends local

doctor's (general practitioner's) clinic with abdominal pain and the doctor assesses

this as a probable acute appendicitis, the patient needs to be admitted to hospital for

surgery immediately. First the local doctor might phone a house officer (doctor) at the

local general hospital to agree the probable diagnosis, so that the patient can be

'surgically accepted' by the hospital. An ambulance will be immediately requested, to

take the patient to hospital. However, the target response times may be breached if

the ambulances in the area are allocated to other emergencies.

When an ambulance arrives to take the patient to hospital, the local doctor usually

gives the paramedical letter of admission to take with the patient. This contains any

immediate patient information that the hospital staff may find useful, including drugs

that have recently been prescribed for pain relief. Ideally, ambulance paramedics

should be given the same information so that they know what treatment has already

been given, to avoid duplication. This does not always happen, especially if the doctor

is unable to meet the ambulance crew.

When the ambulance arrives at the hospital, it is normal for the patient to be taken to

either the accident and emergency (A&E) department or to a specialist 'surgical

assessment unit'. First, the patient will have to be booked into the system by a

receptionist and the ambulance staff will not be allowed to leave before this is done.

This is to ensure that accurate information about the patient's condition is given to the

hospital staff receiving the patient. The booking procedure needs to establish the

patient's identity accurately, so that the correct patient's notes can be retrieved from

the hospital's archives. Other details, such as the patient's next of kin, are also

required, so that relatives can be informed, particularly if the patient is extremely ill.

The patient's arrival will be cross-referenced with the call to surgically accept the

patient.

Once the patient has been booked in, they will be assessed for the urgency of their

condition. This 'triage' will usually be performed by a senior nurse. A house officer

(doctor), supervised by a senior house officer, will then hopefully provide an accurate

diagnosis. The first steps in the diagnosis will usually involve basic blood tests and X-

rays. Most hospitals have their own emergency X-ray units attached to A&E, staffed

by radiographers. These often become very busy with patients, especially where

specialist fracture clinics share the resource. Each X-ray needs to be assessed by a

radiologist and a report typed up by a medical secretary. When blood is taken, the

most common tests might be analysed using small testing machines located near the

A&E department.

Most samples are sent to central pathology labs, where they are

processed alongside the hundreds of routine samples that each lab has to deal with Page 3 of 4 BLC301/03

each day. Skilled pathology technicians operate the equipment and ensure that the

results are accurately obtained. Pathologists assess the results, which are usually

reported on a computer printout. Urgent results are sometimes telephoned through.

Only a few departments have electronic reporting of this type of information. Often one of the biggest hurdles for the patient is to be found a bed within the hospital.

This is the responsibility of a specialist team of bed managers. Wards are divided into

medical and surgical units with male- and female-only wards. Given that most

hospitals in the UK work with 90 per cent or more occupancy of beds, finding a space

for up to 50 acute admissions per day can be a real challenge. Acute admissions

typically comprise 30 per cent of all admissions and so emergencies compete with

elective cases for bedspace. The space available partially depends upon the surgical

lists that drive the elective admissions. Commonly, Mondays and Wednesdays see

most elective surgery and so these are frequently the most difficult days for unplanned

admissions. In many hospitals, medical wards overflow at times. This can result in

patients' medical outliers' being placed on surgical wards, further restricting space.

One bed manager highlighted other problems:

Requests for beds should come through us. This does not always happen, as patients

can be admitted via the 'back door' by consultants etc., without telling us. It can be

confusing when we think we have free beds but we haven't. We continually monitor

where beds are available on the computer and by doing a ward round. We conduct a

census on wards to find free beds not recorded on the computer.

When a patient needs urgent surgery, a theatre slot needs to be found.

This can be complicated as the theatres usually have particular elective clinical specialisms

booked for each half-day session, with just a few slots reserved for emergencies.

Theatres are not all equipped in the same way: theatres specialising in orthopaedics,

for example, need specialist pieces of equipment. There are also issues to address

when assembling the most appropriate surgical team of surgeons, anaesthetists,

nurses and support staff, since not all staff are multi-skilled or available. Staff time

taken by emergency surgery inhibits other activities such as ward rounds. The theatres

also have to ensure that there is a readily available stock of sterilised equipment, and

it usually takes 24 hours for used equipment to be cleaned and resterilised. Patient welfare is also enhanced by the array of support services. The catering services need to provide patients with three meals a day. Cleaning services need to

ensure that all areas are kept as clean as possible. This is a difficult task because they

must not interfere too much with the daily workload. The traffic of thousands of staff,

patients and visitors bring in dirt and waste incessantly. Cross-infection caused by

poor hygiene requires a massive co-ordinated preventive programme.

Hospitals also need efficient discharge procedures. If patients are discharged later in

the day, they may occupy the bed unnecessarily. Delays can be caused by poor co-

ordination with pharmacies, as patients wait for take-home drug prescriptions to be

prepared for them. If these are not ready by 5.00 p.m., pharmacies often close for the Page 4 of 4 BLC301/03

day, forcing patients to stay an extra night on the ward. Other delays can be caused

by waits for porters or transport. Relatives often only pick patients up in the evening,

once they have come home from work, causing a bed blockage.

Question 1

Differentiate operations in a hospital from operations in an iPhone production

factory. (25 marks)

Question 2

Explain reasons that cause delay in the admission, treatment and discharge

process. (20 marks)

Question 3

Suggest FIVE (5) quality tools to measure the performance of the hospital.

Explain how the tools are applied and their objectives. (25 marks)

Question 5

Explain the reasons why private hospitals' charges are expensive for a simple

appendicitis surgery from operational perspective. (30 marks)