In part 2 of this series I took out my big spanner of ARIMA time series modelling and developed two predictive models for excess non-COVID death for NHS England for the period 2020/w6 - 2022/w33 using a couple of key covariates and the all important series I’m calling Bed Loss Fraction (BLF). Please refer back to part 1 to understand what I’m on about!
In doing so we discovered that non-COVID death is likely subject to certification errors with more deaths pronounced as COVID than the models suggest. This may arise from over-reliance on PCR tests that readily give rise to false positive test results, and it may arise from over-zealous physicians. Whatever the reason the models enabled allowances to be made for certification errors.
This slight correction enabled a more robust assessment of the likely impact of bed loss on non-COVID excess death, which was found to peak 3 - 4 weeks behind bed closure. A cumulative curve was furnished revealing bed loss associated non-COVID death to currently be running at just over 26,000 cases. That’s a lot of death and yet is only part of the story: we have still to estimate the impact of bed loss on COVID death.
In part 1 of this series I pointed out the rather curious decline in bed occupancy over the last 13 years and I wasn’t convinced this was due to improving health of the nation. I suspect a squeeze has been put on beds, so get that cake sliced and the kettle on for we’re going to delve into NHS England quarterly data, all of which may be found here.
Whose Bed Is It, Anyway?
First a quick word about bed types. We have day beds and we have night beds; then we have beds by speciality, for which the NHS suits decree headings of: General & Acute (G&A), Maternity, Learning Disabilities and Mental Illness. Then we have all manner of bed model for specialist purposes, with the mechanical ventilation bed rising to fame during the pandemic. Where a bed is located also matters, since we can have beds in high dependency units (HDU/ICU) and beds on general wards (both day wards and night wards). Then there are beds in places like the Coronary Care Unit and Stroke Unit. In the UK day-to-day bed management is the responsibility of the matron, though the Clinical Nurse Manager (big boss of Division nursing) will have a say, as will the General or Divisional Manager (big boss of cheque book). Then we’ve got the dreaded bed managers - a hospital-wide team whose purpose seems to be to make the life of the Clinical Nurse Managers as stressful as possible. Those beds you’d earmarked for elective cardiac surgery next week? Well, they’ve now been allocated to general surgery and will be full of kidney cases thanks to the bed management team. That sort of thing. Beds, beds, beds, beds, beds.
But it’s not just beds. If you can’t discharge folk back home or get them transferred to another provider then your beds block back. If your beds block back in the wrong direction irate nurse and medical consultants in Accident & Emergency soon let you know because their precious beds need fast turnaround and that requires a supply of G&A beds. Imagine a sausage machine on full pelt running out of skins halfway through Friday evening with no way of turning the machine off.
Then there’s the nurse to patient ratio. You can’t fill beds if you can’t meet the mandatory requirements for staffing for low and dependency care. Beds will go empty if a shift crumbles (nurses calling in sick or failing to appear) and/or the agency or nursing bank can’t supply sufficient of nurses at the right grades. I’ve seen senior nurses work straight through two shifts and more to cover for unavailable colleagues, this being commonplace for a busy city hospital. The Clinical Nurse Manager will ‘call it’ if staffing drops to critical levels, so unsupported beds are roped-off and even whole wards can be closed down. Please bear this in mind when looking at the following charts: a bed may be deemed ‘available’ but the nursing power to staff that bed may not!