David Oliver: What’s wrong with acute “zero day admissions”?BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1241 (Published 20 March 2018) Cite this as: BMJ 2018;360:k1241
- David Oliver, consultant in geriatrics and acute general medicine
Follow David on Twitter: @mancunianmedic
Emergency admissions in England now cost around £13.7bn, around 10% of the entire NHS budget, the National Audit Office (NAO) has reported.12 In 2016-17, 5.8 million people were acutely admitted to hospital: emergency admissions have risen by around 2% a year since 2013-14 despite considerable efforts to reduce them.
Some 79% of that increase was in patients who did not stay overnight, the NAO reported. These patients were admitted and discharged on the same day, without needing to be transferred to an overnight ward, and are often referred to as “zero day admissions.” They increased by 27% from 2013-14 to 2016-17.
The influential Health Service Journal reported this as “Revealed: ‘zero day’ stays driving emergency admission growth.”3 Much comment related to the average £600 tariff commissioners have to pay for such short stays—and to the possibility that many are unnecessary and that commissioners are in effect paying twice. They pay once for the emergency department visit and once for the patient assessment and discharge on the adjacent acute medical units.
I have reasons to question the narrative that this increase is undesirable or inappropriate. First, we lack evidence that admission rates across a hospital catchment area can be reduced at pace and scale.24 There are encouraging initiatives, where rates of increase can be attenuated, and condition specific models. But, in general, little science backs up the idea that current initiatives can reduce admission rates.
Second, severe staff shortages in primary care, community nursing, community health, and social care mean that alternatives to acute admission are not readily available. It’s not clear that rapid access to them can prevent emergency attendance.
Third, the national four hour target for emergency departments has of course created a workaround: patients are transferred to assessment units to avoid breaching the target.5 But those units are often overcrowded, and having to spend time there isn’t good for patients’ experience or outcomes.67 Why not transfer them into a relatively calmer, more conducive, bedded or ambulatory area for further assessment or initiation of treatment?
Fourth, and most important, we’ve now designed hospital “front door” arrangements to ensure that a consultant is present on take so that decisions are not routinely delayed. We have a much greater focus on prompt review by a senior doctor; ambulatory emergency care; rapid, supported discharge home; and quick access to diagnostics, occupational therapy, physiotherapy, and specialist medical opinions.
The national four hour target for emergency departments has created a workaround: patients are transferred to assessment units
Sometimes it does take eight, 12, or 16 hours to assess and stabilise a patient, initiate treatment, speak to the family, and arrange community stepdown support.89 This is good, not bad, medicine. As need is defined in real time by patients and their families, it’s bizarre to label a zero day admission “inappropriate” retrospectively, on the basis of eventual treatment. We shouldn’t be labelling good, patient centred medical practice as bad.
Competing interests: See www.bmj.com/about-bmj/freelance-contributors/david-oliver.
Provenance and peer review: Commissioned; not externally peer reviewed.