Simulation in Healthcare

Managing bed capacity with a seamless RRR service

Staying in hospital increases the risk of harm and causes patients to deteriorate.


Many of these stays can be safely shortened and patients can move on to better, more appropriate locations. (Nigel Edwards, Nuffield Trust)


A rapid review of the evidence of enhanced recovery programs by the National Institute of Health Research (Paton 2014) agrees, while the review found the evidence limited, it demonstrated “possible benefits in terms of reduced length of hospital stay, fewer postoperative complications, reduced readmissions and improved patient outcomes”. Just this week a multi-institutional US study showed that palliative care consultation teams reduce length of stay for patients with advanced cancer providing the intervention is early following admission (May 2015).


What if we understood length of stay as acute (doctor-led) and rehabilitation (nurse-led)? The Recovery, Rehabilitation and Reablement program (RRR) in the UK explores whether funds can be liberated (unbundled) from within national acute care PbR tariffs to incentivize rehabilitation and reablement services in a range of settings.


The aim of the RRR programme is to improve the quality of patient care and outcomes by delivering a seamless RRR service for acute admitted patients – based on their clinical and bio-psycho-social needs, rather than just their diagnosis or where the care is currently delivered. RRR pathway redesign should change the responsibility for care (and associated tariff) at the point when the patients’ needs change, not at the point when they change institutions.


Length of Stay is usually recorded “end to end” so it is difficult to work out from the data when the acute phase ends and the rehabilitation phase starts in order to test the impact of interventions. SIMUL8 worked with NHS Improving Quality to develop a simulation which would enable people to experiment with the “what ifs?” It’s a good example of where and how simulation can be used where there is no historic data to test a change.


To use the simulation in a hospital setting, physicians are asked for their clinical view of the likely distribution of an acute length of stay for a given condition. This is used to populate the “acute phase” and subtracted from actual length of stay data to determine the time distribution of the rehabilitation phase, giving some leeway for a transition between the two phases. The hospital inpatient bed is used for the acute and transition phase with a daily cost assigned for that bed and a differently costed rehabilitation bed for the rehabilitation phase. If there are insufficient rehabilitation beds, the patient stays in the acute bed. It aims to answer the questions:

“if I implement improved rehabilitation intervention schemes, what is the impact on my acute beds, and what rehabilitation resource do I need – and what does this all cost?”


If you’d like to try the simulation for yourself please visit NHS Improving Quality to download the model.

If you have any questions or feedback please get in touch with us.


Paton et al, Initiatives to reduce length of stay in acute hospital settings: a rapid synthesis of evidence relating to enhanced recovery programmes, HEALTH SERVICES AND DELIVERY RESEARCH VOLUME 2 ISSUE 21 JULY 2014.

May P, Earlier palliative care consultation may reduce hospital cost, length of stay, J Clin Oncol. 2015;doi:10.1200/JCO.2014.60.2334