All acute internal medicine services surveyed had undertaken measures to plan for increased demand during the winter. Some measures were adopted widely – more than 80% of hospitals had expanded the number of medical inpatient beds available, and 80.4% had added extra clinical staff. There was considerable variation in the physician teams used to provide senior physician input for medical patients, for additional inpatient beds that had been added due to winter pressures and for medical inpatients on non-medical inpatient wards. Approaches varied from dedicated teams specialising in general internal medicine, to shared responsibility across physicians specialising in acute medicine, other medical specialties and consultants with responsibilities for other general internal medical wards.

There is a striking variability in the range of approaches to winter pressure planning. From the 93 centres included, there were 91 different responses to the nine questions describing preparations for winter pressure.

The adoption of most planned measures did not seem to vary based on hospital size, although larger hospitals more commonly moved doctors in training. Although hospital size may affect the ability to introduce some planning measures, as there may be greater resource available to allocate to extra beds or to areas of pressure, there was no clear relation to hospital size for most approaches described here. The variability seen suggests decisions made in planning may be more complex, involving multiple factors, and cannot be easily categorised or evaluated without more detailed information.

Many of the units who took part in this survey were under pressure. A quarter of units reported their ambulatory emergency care facilities being used for inpatient beds. This may reduce the ability of acute medical units to deliver SDEC, which in turn may worsen pressure on services and demand for inpatient bed availability. These areas providing SDEC should therefore be protected, including during periods of winter pressure [17].

On the day of the survey, more than half of units reported that patients had to wait in emergency medicine department corridors, and more than a quarter of units had patients in the acute medical unit without an allocated inpatient bed. Providing care in inappropriate settings, such as corridors, is more likely to occur in times of pressure and poses extra risk for patients. Patients are more likely to have a prolonged wait in the emergency medicine department following a decision for inpatient admission at times of high bed occupancy within the hospital – in winter bed occupancy may frequently exceed 95% [18]. Boarding in the emergency department, waiting for inpatient bed availability, has been shown to be associated with poorer outcomes, including increased length of hospital stay and mortality [19, 20]. Plans for times of pressure should aim to avoid or reduce this practice [12].

Although adaptations for winter pressure undertaken in acute medicine services in the UK have not been previously described, variation in planning for winter has been demonstrated in emergency medicine departments [12]. Previous work has also suggested particular areas where patients may be at higher risk, including where medical patients are treated on non-medical wards [21], where care is provided in hospital corridors rather than appropriate clinical areas [12], or where SDEC facilities are reduced [17]. There is, however, little empirical evidence to support the use of specific planning measures in preference to other measures for medical inpatient services. The heterogeneity in strategies for winter planning that we describe here likely reflects this uncertainty, with no current consensus regarding the most effective way to maintain performance in times of increased service demand.

The results of this survey describe pressure on services that deliver care for urgent medical admissions to acute hospitals within the UK, where increased pressure on services during winter is well recognised [2]. Seasonal variation in demand and in disease is a trend that is seen internationally [8], although excess seasonal mortality is higher in the UK than several European countries, including Germany, Norway and the Netherlands [22, 23].

Survey responses were received from 88.6% of hospitals that took part in SAMBA in 2020, equating to 41.3% of eligible hospitals within the UK [24]. Although this response rate allows identification of variation in the organisational approaches taken to winter pressures in acute medicine services, there may be differences between participating and non-participating hospitals. While the size of hospitals participating in SAMBA is comparable to the acute hospital services nationally [25], covering urban and rural locations across the UK [14], there may have been specific differences in the units that did not participate.

Prior to undertaking this survey, the extent of variation in practice in planning for winter pressures in acute services was not known. We were unable to assess how the adoption of specific planning measures impacted on delivery of patient care within this study due to the nature of the survey. As SAMBA is a single day of care survey, it was not possible to assess trends over time. Longitudinal data may help individual units evaluate the impact of any changes made to mitigate the effect of winter pressures and allow comparison year on year. Factors initially expected to influence variation in adoption of winter planning strategies were assessed here, including hospital size, AMU size, and number of medical admissions per day, however these did not appear to affect the measures chosen, except for redeployment of junior doctors. The underlying reasons for the variation seen here, and the interaction of this variation with the performance of acute care systems at a patient and organisational level, requires further in-depth exploration. The day of care methodology employed within SAMBA cannot provide the analysis of these complex interactions that is needed to fully explain this variation, however these novel findings form a base to guide further study. In order to recommend particular strategies to mitigate the effects of increased periods of pressure, more detailed information is needed on why particular measures were chosen by each unit, and how these impact clinical performance. This may help to expand the evidence base needed to guide winter pressure planning, which is currently lacking.

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