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Flexible healthcare infrastructure can alleviate A&E pressure

3 November, 2020
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As A&E attendances rise and healthcare capacity continues to be limited by the need to accommodate Covid-19 patients, a temporary minor injuries unit (MIU) or urgent treatment centre (UTC) could help reduce pressure in the short to medium term, and add vital extra capacity for treating patients.

As A&E attendances rise and healthcare capacity continues to be limited by the need to accommodate Covid-19 patients, a temporary minor injuries unit (MIU) or urgent treatment centre (UTC) could help reduce pressure in the short to medium term, and add vital extra capacity for treating patients.

The worry is that the second wave may cause A&E departments to be overwhelmed once again this winter season. While the new model for making appointments that the government is trialling should reduce waiting times for emergency cases, a wider approach to improving patient flow will be needed.

A long term issue

Growing pressure on emergency departments is a long-term issue, driven by a range of demographic and other factors, but the scale of the problem has increased over time culminating in a peak during last winter. Over the last five years, attendances at major A&E departments in general hospitals have risen by more than 10%, with the rise between 2018 and 2019 the most significant at 4.9%.

With bed occupancy at over 90% nationally, many facilities were at maximum capacity before the pandemic, meaning there is very little flexibility in the system to cope with temporary surges in demand, such as that from Covid-19. It is estimated that the requirement for social distancing has also cut NHS England’s bed base substantially.

Rising demand in combination with limited, and reducing, capacity has led to waiting times increasing substantially over time. Nationally, 23.8% of patients in major A&E departments waited more than four hours last year, compared with 8.5% in 2014, with similar trends seen in Scotland and Wales.

This is now an urgent issue. Overcrowding can mean a higher risk of transmitting the virus, and the need for separating patients with suspected Covid-19 from non-Covid patients is adding to the immediate pressure. Whatever the metric used to measure A&E performance, it’s clear that the situation as we enter the winter season is less than ideal.

Reducing A&E demand

The underlying increase in healthcare demand will not weaken over time, and in the longer term, adding more capacity in the form of more ward space and newbuild hospitals will also be key.

Urgent and emergency care services were already undergoing transformation to achieve a simplified and integrated system and improved patient flows, but the emergence of Covid-19 has accelerated the pace of change. Given the current situation, A&E is unlikely to be the most suitable place for patients with certain conditions.

The new scheme, which involves NHS 111 workers directing patients to the most clinically appropriate service, should reduce crowding in waiting rooms, lower risk and cut unnecessary A&E attendances. But this may also provide challenges in terms of physical space and capacity across other parts of the healthcare system. The people diverted away from A&E departments will need somewhere to go.

Improving patient flow

Creating a co-located MIU or UTC at the same site as the A&E department allows hospitals to share resources within the site and patients to be treated in the most suitable environment, leading to reduced waiting times and more effective patient flow. A reduction in onward pressure on inpatient beds is also possible, as patients are seen and treated quicker and are less likely to be allocated a bed.

But adding capacity in the form of a new building or a permanent extension can be difficult due to site restrictions, and the reorganisation of an emergency department or the construction of an MIU or UTC unit can take time.

A flexible, co-located mobile or modular MIU or UTC can be set up quickly adjacent to an existing A&E department to relieve immediate pressure.  By using a temporary solution, a new way of working can be achieved very quickly while a more permanent reconfiguration is taking place.

A co-located MIU

One hospital that has done this is the Royal Infirmary of Edinburgh, which set up an MIU in 2019. The hospital’s management found people were waiting in A&E for treatment for conditions which could be treated elsewhere in the healthcare system, placing the department under pressure and leading to longer waiting times for patients.

NHS Lothian wanted to help more people to be treated quickly, effectively and in the most comfortable environment possible, so a decision was made to create an MIU close to the hospital’s A&E department, which could treat people with less serious injuries. The resulting facility was created using a mobile laminar flow operating theatre in combination with modular buildings.

The complex provides all space needed to deliver a full MIU service, including a reception and waiting area, treatment rooms, clean and dirty utility spaces and a changing room. An important requirement was for the unit to be accessible from the existing A&E department, something which was achieved through the construction of a purpose-built walkway bringing the two departments together.

Once installed, the facility had an immediate positive impact. Within its first hour, more than 20 patients were diverted from A&E and since opening, between 80 and 100 patients have been treated in the MIU each day for range of minor injuries such as fractures, soft tissue injuries and bites. The on-site MIU is also reducing the amount of time people are waiting to be seen, and relieving pressure on bed spaces in the main hospital.

Flexible healthcare benefits

Mobile and modular temporary units can be used to provide additional clinical space on either a short- or long-term basis. The flexible nature of temporary mobile or modular MIU units means they can be modified over time as requirements change and capacity. They can also be decommissioned, moved or repurposed once a more permanent solution is in place.

Flexible solutions also allow hospitals to test out scenarios and prove business cases before investing significant amounts of money in a new or remodelled permanent building. As well as trialling new processes or working practices, the temporary unit can also be used to trial new technology, allowing hospitals to improve and futureproof systems.

However, modular solutions do not have to be temporary; modern modular builds can be completely bespoke and designed to fit seamlessly with an existing building. Installing a modular unit is much quicker than building in a traditional way - the build time for a modular unit can be reduced by almost 50% - and there is less risk of adverse weather or other external factors causing delays.

An urgent need

Covid-19 is putting a system that was already stretched and under pressure. The number of patients attending major A&E departments in general hospitals has near doubled in the past 20 years, with our ageing and fast-growing population a key factor. This patient category also uses more bed days than other people following an emergency admission.

Cutbacks in primary, community and social care have also indirectly caused an increase in preventable A&E attendances and admissions, such as those related to minor injuries, alcohol or drug intoxication, dementia and mental health, and the general shortage of beds has the potential to cause blockages elsewhere, including in A&E departments. A more permanent solution is required to adapt to the new conditions and ensure overall capacity is able to meet projected demographic growth.

However, as we approach winter, there is not enough time to wait for long-term solutions to be implemented. There is a serious risk of overcrowding, making social distancing difficult and increasing the risk of transmission, and practical solutions need to be put in place now.

A co-located modular MIU or UTC can add flexible capacity, allowing hospitals to implement recommended changes without having to wait for major works to be undertaken or a new building. All hospitals are different, and a temporary solution provides the opportunity to test new concepts to see how it will work for them before committing to substantial investment.

Get in touch to find out more about our modular solutions for on-site MIUs or UTCs.

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