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9. Admission to, utilisation of and discharge from services

Maintaining capacity in the healthcare system is clearly a key step in the surge response to pandemic flu but physical measures to increase capacity are likely to be relatively limited. Increasing capacity through the prioritisation of services has already been discussed in chapter 7. However, in conjunction with prioritisation of services, another way of creating capacity is through careful management of admissions and discharges.

Between 16 percent and 52 percent of non-elective admissions to hospital are not considered to be appropriately placed. ²⁵ This implies that the care could have been provided in other settings, for example in primary care. Up to 10 percent of total bed days in some hospitals are utilised by patients awaiting diagnostic assessment in the acute phase, a situation which would be particularly inappropriate in a pandemic.

Using the stepped level of care model discussed in the previous section, a generic approach can be taken to the key issues of:

• access or admission to a service or level of care
• ongoing utilisation of and discharge from a service or level of care.

9.1 Access to a service or level of care

During a pandemic, the routine admission threshold for a service or level of care has
two elements:

• a patient or client must, as a minimum, meet all the criteria that would normally be used to determine access to the service when there is no pandemic; and
• the service must be running.

However, if a number of services have been deferred, the routine admission threshold may need to be raised so that care can be rationed. With increasing demand, the introduction of specific inclusion and exclusion criteria for levels of care may also be necessary. One major problem with trying to raise admission thresholds is that there is no commonly accepted universal scoring system which can be applied across different illnesses. One approach that service providers should consider is the use of generic admission assessment tools in combination with illness specific admission tools, where appropriate. The use of any severity assessment tool does not replace clinical judgement.

9.1.1 Generic admission assessment tools

Service providers should use generic admission assessment tools appropriate to their service to help guide the placement of patients or clients in the appropriate level of care. Although these protocols are not designed for 'gatekeeping' processes, they may help bring in to focus the reasons for and expected patient benefits from admission, and the potential to achieve this benefit at a lower level of care. A few examples of the tools available for different levels of care are discussed below.

At the acute level of care, a number of tools exist to evaluate the appropriateness of acute hospital admission and stay in adult and paediatric practice. There are several protocols available including the modified Appropriateness Evaluation Protocol ( AEP), Oxford Bed Study Tool, Milliman USA and InterQual Severity Discharge Criteria. ^{26, 27}

The AEP for use in adult practice is based on the level of service provided and factors associated with severity of illness ( appendix 6). An adult version of the AEP has also been proposed for use in community hospitals ²⁸ ( appendix 7). Similar tools exist for use in paediatric practice. ^{29, 30} To date, these tools have been used primarily in the analysis of factors which lead to 'inappropriate admission'. To minimise paperwork during a pandemic, an aide-mémoire of selected AEP parameters on admission checklists could be used.

Within the critical care setting, SOFA scoring ³¹ may be used to guide access to and discharge from intensive care and is discussed further in chapter 10 on critical care.

The Decision Support Tool for NHS Continuing Healthcare ³² is designed to ensure that a range of factors that have a bearing on the quality and quantity of care required to meet an individual's needs are taken into account when deciding on the need for healthcare. It considers an individual's needs across 11 domains, namely behaviour, cognition, psychological and emotional needs, communication, mobility, nutrition, skin and tissue viability, breathing, drug therapies and medication, and altered states of consciousness. In a pandemic, the tool could be used to help health and social services focus resources for maximum population health gain.

Following Hurricane Katrina, a patient classification scheme related to community care has been proposed, in which patients are classified into priority groups ( appendix 8). ³³ Using such an approach can again focus attention on the specific elements of the service being provided, and the implications of service restrictions.

Health care providers should be aware of the need for transparency in their decision-making approach to admission of patients during a pandemic.

9.1.2 Illness specific admission tools

During a pandemic, there may be patients who are either too ill or not ill enough to benefit from a specific level of care. If the available resource is insufficient for demand then scoring above the routine admission threshold value may not be the sole consideration in determining admission, but scoring below the routine admission threshold without other clinically mitigating factors would not justify admission.

A number of medical specialties already apply illness specific scoring systems in conjunction with clinical judgement to determine access to services eg pneumonia and CURB-65 ( appendix 9). These illness specific scoring systems may also be of benefit in a pandemic.

One of a range of physiological 'track and trigger' systems whose use is being promoted in acute hospital settings is the Modified Early Warning Score. ³⁴ An adaptation of this, the P- MEWS score ³⁵ has been proposed as a method of assessing severity and assisting triage from primary into secondary care inpatients with community-acquired pneumonia ( appendix 9). It includes physiological data for a MEWS-type score and patient data - age over 65, social isolation, chronic disease or impaired performance status. The use of these types of scores may permit national or regional setting of admission criteria based on physiological derangement.

Current admission criteria for influenza in adults and children are described in Clinical management of patients with an influenza-like illness during an influenza pandemic³⁶ ( appendix 10). As a pandemic develops, information from clinical surveillance and outcome schemes will be used to modify criteria for admission and management of patients with influenza as appropriate.

Robust communication structures should be in place to disseminate guidance on the use of both generic and illness specific admission tools, as the use of such tools in a pandemic is an area of ongoing research and development.

9.1.3 Use of inclusion and exclusion criteria

If a service is functioning but the available resource is insufficient for demand, and alternative means of increasing capacity have been exhausted, then access to the service may have to be temporarily restricted through prioritisation of patients. This would be done through the application of inclusion and exclusion criteria for levels of health care. If the patient or client:

• meets certain inclusion criteria for access to the service
• does not meet exclusion criteria for access to the service,

then the patient or client would gain access to the service if the service had been prioritised to run and capacity existed (Figure 12). Where possible, efforts should be made to mitigate any adverse impact to the patient or client who is excluded from the service.

Inclusion and exclusion criteria may need to be altered as a pandemic progresses, to allow matching of resources to a national or local demand. Healthcare organisations should have a robust mechanism for dissemination of such criteria, and ensure that healthcare staff can apply them, should such restrictions become necessary.

It is currently not feasible to have a detailed list of exclusion criteria for all aspects of healthcare services. Even within the acute hospital care sector, no single, cross-specialty, objective scoring system exists which can generate a score to guide exclusion from admission. Further work is required to see if outcomes from disease specific scoring systems can be equated, so that e.g. individuals with scores associated with high mortality receive symptomatic and palliative care only.

Figure 12: Patient or client assessment for access/admission to a service when inclusion and exclusion criteria are in operation

Currently, exclusion criteria have been proposed for admission to secondary care from primary care and accident and emergency care, and admission to critical care ³⁷ from secondary care ( appendix 11). These focus on excluding those who:

• have an underlying illness with a poor prognosis even without the concomitant acute illness which has resulted in the presentation to the service e.g. those with advanced cancer, immunosuppression, end stage organ failure of the heart, liver or lungs
• have a poor prognosis or chance of survival even if they receive the treatment
• require a level of resource which cannot be met in a pandemic.

An essential element of this approach is the availability of facilities within either the secondary care or the primary and social care sectors to support and comfort those people for whom no further interventions are considered appropriate. Issues relating to this are discussed in chapter 13 on palliative care.

In the most extreme situation, where there are competing patients for insufficient resources, allocation may be required on a first come, first served basis. This should only take place after assessment of:

• the patient's need for the resource
• their potential to return to their baseline health state
• the overall resource needs of the patient
• the underlying health and prognosis relating to the underlying disease.

An incremental approach to the restriction of services and the prioritisation of patients is vital, and must be tailored to the severity of the pandemic to minimise any potential harm.

Ardagh has proposed a set of questions to help clinicians prioritise access to healthcare resources which have one or more competing patients (Table 8). ³⁸

Table 8: Prioritising access to healthcare ^*

9.2 Ongoing utilisation of a service or level of care

The need for ongoing utilisation of the service must be regularly assessed. As already discussed, a number of tools exist to evaluate the appropriateness of acute hospital admission in adult and paediatric practice. The modified AEP can also be used to determine the appropriateness of utilisation of an acute hospital bed using the 'day of care' criteria ( appendix 6). Healthcare staff should use these sorts of tools to focus on the level of service being provided, and whether this level is still required or if a less intensive level of care is more appropriate. If demand for healthcare is of a level at which exclusion criteria are in operation, these criteria should apply not only to those seeking access to a service, but also to those currently using the service.

If the individual's condition has changed such that:

• they now meet exclusion criteria for access to the service, and
• there is insufficient capacity to accommodate all those competing for the resource,

then they should no longer receive that service if there are others who meet the inclusion criteria and do not meet the exclusion criteria.

An example of how the approach to ongoing utilisation of a service might be applied to acute hospital care at the peak of a severe pandemic, when inclusion and exclusion criteria are in operation, is shown in Figure 13 and discussed below.

Figure 13: Example of the use of inclusion and exclusion criteria
Patient assessment for ongoing secondary care when inclusion and exclusion criteria are in operation.

Box 1: After meeting the criteria for admission to secondary care and treatment is commenced, it is important that each patient should have regular, formal periodic assessments to determine whether they are fit enough to be discharged (Box 2) or need ongoing treatment.

Box 3: If an inpatient's condition has changed such that they would now meet the exclusion criteria for secondary care, they should be discharged with symptomatic or palliative care (Box 4).

Box 5: If a patient is not responding to treatment, or deteriorating despite treatment, referral to critical care may be required. If so, the inclusion and exclusion criteria for admission from secondary care to critical care should be applied (Box 6). Otherwise, therapy is continued (Box 7) and the patient reassessed at an appropriate time interval.

9.3 Discharge from a service or level of care

A range of discharge strategies may be required during a pandemic (illustrated in Figure 9, chapter 8). Following assessment of an individual, it may be clear that they no longer require the service and therefore can be discharged. Discharge guidelines for adults and children with pandemic flu are described in Clinical management of patients with an influenza-like illness during an influenza pandemic ( appendix 10). ³⁹

Prompt or rapid discharge from high level resource facilities will be vital during a pandemic. This can only be achieved through good liaison with other partner agencies. All service providers must address mechanisms to ensure that rapid discharge of patients/clients can occur during a pandemic. Due attention should be paid to vulnerable patient/client groups and local geographical constraints in the planning process.

With increasing pressure on services during a pandemic, there may be insufficient capacity to accommodate all those competing for the resource. The threshold for discharge from a service may then need to be altered. Wherever possible, action should be taken to mitigate any negative effects from an altered threshold for discharge.

As a pandemic progresses, the identification of patients or clients for safe early discharge from the service - so called 'reverse triage' or 'risk-balanced early discharge' - may be necessary. Reverse triage in the hospital setting has been discussed, as a means of allowing a refocus of resources to those in even greater need. ⁴⁰

'During overwhelming disasters, health systems must be considered lifeboats with insufficient capacity to minister to all, and thus decisions regarding who is best served by the lifeboat must be made. Under this tenet, inpatients, disaster victims, and others with acute care needs must be considered on equal terms and compete for limited resources.'⁴¹

The underlying principle of reverse triage is that the potential medical benefits to incoming patients should ideally be greater than the potential risks of not receiving care for those discharged. A pandemic may necessitate such an approach to patient care in the health and social care arena. With such an approach, there has to be a level of risk tolerance of a consequential medical event as a result of discharge. An event may occur for a wide range of reasons including medical deterioration of the patient, a new medical problem or the untoward effect of the withdrawal of a continuing treatment.

Even under routine conditions, up to 19 percent of patients in the two week period following hospital discharge experience adverse events. ⁴² Kelen et al. have proposed a system of patient categorisation, developed by an expert panel based on risk tolerance relating to a consequential medical event ( appendix 12). ⁴³ Such an approach may help in maintaining a population perspective on the balance between restriction of admission to a service and early discharge from a service.

The concept of cessation of certain services from one group of patients to favour another group is a difficult one for many health and social care professionals whose focus in normal practice is on the welfare of the individual patient or client.

It is important to remember the key points of the underlying ethical framework for pandemic planning, which are that: ⁴⁴

• everyone matters
• everyone matters equally - but this does not mean that everyone is treated the same
• the interests of each person are the concern of all of us, and of society
• the harm that might be suffered by every person matters, and so minimising the harm that a pandemic might cause is a central concern.

Dependent on the magnitude and duration of a pandemic, the accepted routine standard of care may change to a 'sufficiency of care'; that is, the standard of care is different to that delivered under non-emergency conditions, but is sufficient for need.

9.4 Alternative provision of care

Alternative provision of care at a less resource intensive level is the preferred option for those who do not gain admission to a service. Wherever possible, action should be taken to mitigate any negative effects from failing to gain access to a service. It is recognised that most ill people will remain at home with such support as relatives/neighbours/friends/volunteers and health and social care can give, but that some will be unable to do so. This will be especially true for those who are unable to care for themselves and do not have family members/friends/carers ('flu friends') able to support them in remaining at home.

Unless some form of support is available in the community for people who are unable to self-care or access care from their own homes, then it is likely that:

• patients in the secondary care setting will not be able to be discharged rapidly
• patients not considered a priority for hospital care will have nowhere to go
• primary and secondary care services will rapidly become overwhelmed.

The option of some form of accommodation or facility for the provision of intermediate care (covering the aspects of care normally given by these services) should therefore be considered. This will require planning in the context of local needs and available resources, with close liaison between healthcare and social services.

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