Complex care patients within acute care beds

To the Editor

We follow with interest the articles pertaining to sub-acute care (Allison et al., 2014). We wish to highlight complexities in the general adult inpatient case-mix, which provides additional perspective to this important issue.

It has been observed (Thompson et al., 2004) and is our experience that about 10% of patients have a prolonged inpatient length of stay (LOS). These patients have illness courses complicated by multidimensional problems including treatment resistance, challenging behaviours, forensic issues or intellectual disabilities. They are often admitted to acute wards when existing supports fail; not necessarily because these wards can provide appropriate care but because no community service is equipped to manage them.

The complex subgroup of patients mentioned above have severely limited or complex rehabilitation goals and are better cared for under a disability paradigm. Without broader reforms like supported/rehabilitation accommodation a proportion of the acute inpatient unit (by virtue of its non-exclusionary nature) is thus diverted to disability support.

In the past such patients may have been referred to long stay rehabilitation wards. As Allison et al. (2014) point out, South Australia now has very low numbers of inpatient rehabilitation beds and supported accommodation, leading patients with exceptional needs to gravitate towards acute inpatient wards (South Australian Office of the Public Advocate, 2013: 26) with a disproportionate LOS. This inevitably impacts on the availability of acute beds.

Sub-acute (intermediate care centre) beds in South Australia are above the national average (Allison et al., 2014) and designed for a subgroup of people without major challenging behaviours for a LOS of around two weeks. While we acknowledge the adjunctive role of such beds, we are concerned that they are commissioned at the expense of general acute inpatient units, which are already 18% below the national average (Allison et al., 2014) and further affected by the blocks discussed. This tenuous acute bed base significantly increases upstream pressures in the emergency department and general hospital. Acute beds provide a safe, evidence based and ethical model of care. We agree with Allison et al. (2014) that resource allocation should first consolidate such a time tested non-exclusionary service. Sub-acute beds could then be a valuable addition to the repertoire of services available. However, based on the evidence presented, and in our experience, they cannot replace the range of functions of an acute inpatient bed.