Reducing emergency admissions for primary constipation: a pilot study to cut costs in an acute hospital trust.

Purpose

Constipation is a common condition that impacts quality of life, often causing psychological distress and incurring considerable healthcare costs in terms of unnecessary emergency admissions due to poor management.

Aintree University Hospital offers one of the only Specialist Physiotherapy led healthy bowel clinics (HBC) in the UK that assess, treat and manage patients presenting with functional bowel problems, including constipation. Patients referred into the service are directed straight to HBC and the majority will never see a medic. The service is run solely by Physiotherapists. We can refer for appropriate tests (transit marker studies, defecating proctograms, anorectal physiology and various blood tests). We independently interpret results and decide on appropriate treatment/management. Our service offers specialist assessment, medication management, lifestyle advice, pelvic floor re-education, Posterior Tibial Nerve Stimulation, rectal irrigation and cognitive behavioural therapy. The majority of our patients are managed conservatively as surgery is rarely an option.

From December 2013 to November 2014, Hospital Episode Statistics (HES) data showed that 301 patients were admitted to Aintree University Hospital with a primary diagnosis of constipation, 216 of these through the Accident and Emergency Department (AED), with an average length of stay of 3.3 days. The HBC Physiotherapists recognised that there should be a more cost-effective, efficient way to manage these patients and proposed a new pathway. The pathway allows patients to manage their symptoms in their own home with support from specialist Physiotherapists, enhancing patient dignity. Assessment identified 5 patients with potential red flag symptoms and allowed appropriate onward referral.

231
bed days saved
At an average local cost per bed day of £400
this equates to a total annual saving of £92,400.
Physiotherapists are well suited
to this type of extended role due to logical assessment processes and clinical reasoning skills.

Approach

To prevent unnecessary admission, a successful bid provided £16,000 to fund a 12-month pilot study to develop an innovative pathway, including an emergency constipation clinic linked to the main HBC. Patients are assessed by clinicians in AED and given a primary diagnosis of constipation. They are then given written advice and started on a Consultant approved laxative regime. AED administrative staff book an appointment directly into the emergency constipation clinic usually within 24 hours where they are followed up and assessed.

Outcomes

A new emergency pathway linked to an already established outpatient clinic prevented admission of patients presenting with primary constipation. As far as we are aware this type of care pathway is not available in any other NHS Trust. We have presented this pathway at various conferences and study days throughout 2018 but not to a widespread physiotherapy audience. This has led to discussion with Clinicians including some Specialist Physiotherapists from other acute trusts, who have since accessed HES data for their own trust and are interested in setting up similar pathways.

Cost and savings

Over the pilot study period, more than 70 patients were seen through the new pathway, which saved 231 bed days. At an average local cost per bed day of £400, this equates to a total annual saving of £92,400.

The project cost £16,00 per annum to run and set up. 

 As above for the first year. The service has continued to be funded annually and recent analysis has shown cost savings of £287,600 and 719 bed days from 2016 to 2019.

Implications

This pathway has already proven cost effective at Aintree University Hospital. Should this pathway become embedded nationally, we believe there will be an exponential increase in the financial and operational benefits and the number of bed days saved, with a significant impact on the NHS as a whole. This is recognised in the Bowel Interest Group Cost of Constipation Report 2019.

Top three learning points

  1. Early appropriate intervention can prevent admission reducing costs and bed days
  2. Detailed bowel symptom assessment by specialist clinicians can help identify potential red flag symptoms and allow appropriate management.
  3. Physiotherapists are well suited to this type of extended role due to logical assessment processes and clinical reasoning skills.

Fund acknowledgements

Aintree University Hospital - funded as Pilot Study.

Additional notes

This work was presented at Physiotherapy UK 2019

Please see the attached Innovations poster below.

For further information about this work please contact Zoe Crook.

Reference(s):

Article BLYTHIN, S., MCATEER, J., CROOK, Z. and WALKER, M., 2019. Reducing emergency admissions for primary constipation: a pilot study to cut costs in an acute hospital trust. Gastrointestinal Nursing February 2019, volume 17, number 1.

Bowel Interest Group (2019). Cost of constipation report. Second edition.