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Rapid Responses: Rapid Responses published:
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Psychology and education
- Graeme Mackenzie (8 January 2008)
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Pressure on Time and Beds and a Desperate Need for Improved Communication
- Keith Donaldson (10 January 2008)
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Hospital versus Hospice
- Hugh Mann (11 January 2008)
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Develop alternatives to hospital admission before attempting to relocate acute services into centralised super hospitals
- Richard Venn, Lui G. Forni (16 January 2008)
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Reducing hospital admissions and readmissions
- KHALID ALKHOULY (4 April 2008)
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Graeme Mackenzie, OUT OF HOURS GP North Cumbria
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As a full time out of hours GP, emergency admissions are my bread and butter. I am not an academic and can only report my impressions. To simplify, I admit for two reasons. Firstly because my top differential diagnosis has a illness trajectory which might result in the patient coming to harm (in my view of the illness trajectory) if not admitted. That is to say, hospital admission will prevent an adverse outcome. Or put another way, if there is an adverse outcome, I won't be to blame. Secondly the functional state of the patient is such that nursing care is required. I suppose one could lose the second one because I am stating that without the nursing care there will be a similar adverse outcome as in the first reason. Of course it is not as simple as that. The decision to admit is made by me with all my failings and lack of knowledge and experience. One GP's absolute admission is another's telephone advice. I feel much could be done as regards reducing admissions if there were continuing reflection of all admissions by all parties. However we all know that the primary: secondary care interface is somewhat adversarial. I do follow up many of my admissions but usually have to ring the patient and the relatives. Hospitals are hard work to get any information from and sometimes even refuse point blank on the basis of confidentiality. If admitting GPs regularly had constructive feedback of admissions, including events after admissions and outcomes, then perhaps some of us would admit signficantly fewer or even change the timing of our admissions. In essence more case driven education could transform admissions. One could build up local databases of admitting reasons (rather than diagnoses) and outcomes and have continual local research. This in turn could be used to back up all parties when things went wrong. This would be a signficant shift in culture. Perhaps we need to blur the line between primary and secondary care and urgent care (primary care) doctors maybe need to work on admitting units. An additional point is that up to 10 % of in patients can have an adverse event while in care. At the moment, the iatrogenic harm of hospitals is rarely used as a reason not to admit but when the decision is marginal, this could further impact on admission rates, especialy in the elderly. Competing interests: None declared |
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Keith Donaldson, GP partner Hermitage Medical Practices, 5 Hermitage Terrace, Edinburgh, EH10 4RP
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I was fortunate to work only twelve days in December. During this short time, when I might normally admit 3 or 4, I was personally involved with the acute admissions of 10 patients, nine over the age of 65. I was wholly responsible for the admission of 7. Of the other 3, one was seen be me but admitted by a partner and the out of hours service was involved in the admission and re-admission of the remaining two. Three of the ten patients suffered re-admissions, two of them more than once. The total number of re-admission episodes was five – there were thus 15 admissions for 10 patients. Therefore 33% of these acute admissions were re-admissions. The re-admissions of two of the patients were unavoidable due to their unresolved clinical conditions. From examining the discharge documentation of the third and discussing the complex case-mix with involved hospital and community staff, the sequence of events seems to have been due at least partly to a lack of holistic care during the hospital stays. Three patients, including one of those re-admitted had received intensive support at home for several days in an attempt to avoid admission during a local hospital red alert. These three patients were the only ones in the practice to be receiving this level of support at the time. It failed to prevent any of their admissions. Of the remaining five admissions, three seemed entirely justified and crucially, because case-mix and social factors were not major issues, they were dealt with uncontroversially under standard protocols. The ninth patient seemed uncontroversial initially. Symptoms suggested the need for urgent assessment in a protocol driven rapid access clinic. In conversation with the clinic it transpired that some clinical complexity overstretched their protocol. While acute admission was not necessary, no other appropriate out-patient service existed to provide timely assessment. The specialist advice was standard acute-admission, despite the red alert. Subsequently I needed to discuss the in-patient diagnosis and recommended management on discharge. Having left two telephone messages, I have now waited well over a week for the responsible consultant, or a deputy to call me back. The final patient, the other to have been admitted by the out-of- hours service, had a glaring discrepancy between the dose of medication recommended on the immediate discharge slip and the pills dispensed by the ward. It was only by physically checking the boxes of tablets that this came to light and another potential re-admission averted. GPs are trying really hard to keep patients out of hospital, but it is not easy. To their credit hospitals have produced some excellent clinical pathways, which prevent many acute admissions, but they tend to be inflexible. Local authorities have established community support networks - in my experience usually stretched to the limit - to try to keep vulnerable people at home. This small audit suggests that these resources may still have major limitations. Furthermore, there is the impression of unmanageable pressure on time and of a lack of available hospital beds with a consequent understandable, but inordinate rush to discharge patients, resulting in the compromise of comprehensive and holistic medical care during admissions. Consequently, in this audit 33% of acute admissions were re-admissions. When the current local hospital facilities were being planned in the last decade, I was one of many voices, from both the primary and secondary care communities, who voiced our concerns about the inadequacy of acute medical bed provision: we were not heard. The old immediate discharge slip is obsolete, and as in this audit, often contains clinical inaccuracies, and transcription errors, which the GP must clarify. But the responsible consultant may not be specified or is identified wrongly, or only by a set of initials, meaningless outside the hospital and without any contact details. If the GP requires further information, once contacted, the consultant may have no knowledge of the patient, having never personally seen them. If the ward is contacted, the medical and nursing staff presently on duty often have no recollection of the patient, whose medical record has disappeared into the administrative maze. The end result is the same, inadequate information and compromised patient care due to poor communication. In the past, it seemed that consultants effectively assumed full responsibility for the patients under their care whilst in hospital. A detailed referral letter was entirely appropriate along with the initial summary discharge slip, to be followed several weeks later by a comprehensive letter. Now GPs are painfully aware that they retain full clinical responsibility before, during and after an acute admission. Consequently, to provide ongoing care for patients, particularly when their clinical condition has not entirely stabilised a comprehensive, detailed and accurate discharge letter is required at the point of discharge. If GPs can produce such letters, in print, for the hospital at the time of a patient’s admission or emergency out-patient appointment, it cannot be beyond the wit of man (and IT departments) for hospitals to produce the equivalent at the time of discharge - not 2 months later, after the patient may have been re-admitted several times. I would venture to suggest that sorting out these basic problems at the primary – secondary care interface, which affect mainly the more vulnerable and less politically vocal elderly population, will not only improve outcomes, but is of far greater priority than introducing populist and politically driven broad based screening programmes and extended GP access, both with a dubious evidence base. Reference: Purdy S, Griffin T. Reducing hospital admissions BMJ, 2008; 336: 4 - 5 Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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Traditional medicine distinguishes between sickness that is curable and sickness that is incurable. A curable sickness is treated in a hospital with curative care; while an incurable sickness is treated in a hospice with palliative care. For example, a curable sickness, such as pneumonia, is treated in a hospital with antibiotics, fluids, and bed rest; while an incurable sickness, such as metastatic cancer, is treated in a hospice with pain medicine and tranquilizers, but no anti-cancer drugs. Curative care is designed to fight sickness, while palliative care is designed to make patients more comfortable. This distinction between curative care and palliative care is somewhat misleading, because both rely on pharmaceuticals, and both ignore the relationship between diet and health. Regardless of whether a sickness is curable or incurable, physicians must promote health and not simply treat symptoms with pharmaceuticals. Competing interests: None declared |
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Richard Venn, Consultant Anaesthetist & Intensivist Worthing Hospital, BN11 2DH, Lui G. Forni
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Purdy and Griffin are to be commended on their excellent editorial regarding reducing hospital admissions (1). Reducing hospital admissions or preventing avoidable admissions is of course an admirable goal for quality patient-centred health care but the evidence for cost effectiveness is variable and transferring care into the community does not necessarily reduce costs (2). There is however, a considerable evidence base for the use of emergency observation and assessment wards within acute hospitals which can reduce hospital admissions (3). The observation ward was a feature of earlier healthcare models in the UK prior to losing favour in the eyes of health policy markers in favour of specialisation with little thought as to the consequences. We have been arguing these concerns locally in West Sussex over the last two years. What really does concern those of us involved in acute service provision is the scale of the proposed reduction in hospital admissions proposed by policy markers. The dramatic reductions proposed are the products of pure fantasy and devoid of any evidence base. We have argued locally that the use of healthcare resource groups (HRGs) in isolation to predict future requirements for acute hospital admissions is meaningless even if the resources in the community were available as alternatives to hospital admission. Patients do not present to acute services with an HRG code. They present with a symptom(s) such as breathlessness for which the diagnosis is varied and may, in many cases be multifactorial. Consequently the need for an acute hospital admission will depend on co- morbidities, patient expectations and the availability of alternatives in the community. An HRG code is a post discharge label prone to error due to medical uncertainties in diagnosis and the code derivation being made remotely by personnel not involved in the delivery of acute healthcare. The policy markers locally have agreed that healthcare predictions based on HRGs are unhelpful although elsewhere they continue to function prominently such as in the recent report ‘A Framework for Action’ (4). We urge all health policy markers to read this editorial and to stop wasting money on hugely overoptimistic predictions made by management consultants which may well be wrong. This has certainly proved to be the case in West Sussex. Listen to those involved in acute care and put management energies into developing the infrastructure and support to provide alternatives to hospital admission in the community before any moves to relocate acute services to centralised super hospitals . Only then will you have the evidence which will allow you to make decisions on the future of acute hospital services. Richard Venn, Consultant Anaesthetist & Intensivist Lui G. Forni, Consultant Nephrologist & Intensivist Worthing Hospital BN11 2DH 1. Purdy S, Griffin T. Reducing hospital admissions. BMJ 2008;336:4-5 2. Making the shift: key Success Factors. A rapid review of best practice in shifting hospital care into the community. University of Birmingham, NHS institute for Innovation&Improvement.July2006 www.hsmc.bham.ac.uk/news/MakingtheShift6881.pdf 3. Cooke M, Higgins J, Kidd P. Use of emergency observation and assessment wards: a systematic literature review. Emerg Med J 2003;20:138-42 4. http://www.healthcareforlondon.nhs.uk/pdf/aFrameworkForAction.pdf Competing interests: None declared |
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KHALID ALKHOULY, General Surgeon 10 Woodland Hill, Perth Andover, NB, E7H 5H5
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Editor There are too many secondary clinical end points to consider when we look at reducing hospital admission or readmissions as: symptoms experienced at home, complications, the receipt of information on return to normal activities or on lifestyle issues and visits to the general practitioners. Randomized trials of multidisciplinary specialist nurse programs where nurses trained in assessing and managing chronic heart failure (CHF) in older, high-risk patients providing individualized and coordinated care assessing readmission rates have been conducted.1,2 CHF programs managed by nurses may include a range of activities for the monitoring, assessment and treatment of patients.3,4 Disease management programs for CHF can encompass community outreach programs where patients receive home visits from a nurse, physician and/or pharmacist, as well as clinic-based visits for patient follow-up. A nurse call patients after hospital discharge to monitor patients’ adherence to treatment plans, assess patients’ health and arrange medical/emergency follow-up as required. Heart failure patients often require readmission within the first year after discharge. Monitoring patients after discharge is one approach to reducing hospital re-admission. 3 A nurse home visitation intervention resulted in a decrease in the rate of unplanned hospital readmissions and associated health-care costs, prolonged event-free and total survival, and improved quality of life among patients with chronic CHF.5 Pulmonary rehabilitation is cost- effective for patients with relatively high utilization of emergency and hospital-based services.6 Cost comparison suggests that hospital outpatient rehabilitation is currently the most efficient form of delivery.7 References: 1. Rich, M. W., Vinson, J. M. et al (1993). 'Prevention of readmission in elderly patients with congestive heart failure: results of a prospective, randomized pilot study', J Gen Intern Med, 8 (11), 585-590. 2. Rich, M. W., Beckham, V. et al (1995). 'A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure', N Engl J Med, 333 (18), 1190-1195. 3. Riegel, B., Carlson, B. et al (2002). 'Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure', Arch Intern Med, 162 (6), 705-712. 4. Taylor, S., Bestall, J. et al (2005). 'Clinical service organization for heart failure', Cochrane Database Syst Rev, (2), CD002752. 5. Stewart, S., Marley, J. E. & Horowitz, J. D. (1999). 'Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failure: a randomized controlled study', Lancet, 354 (9184), 1077-1083. 6. British Thoracic Society. Pulmonary rehabilitation. Thorax 2001;56:827–834. 7. Golmohammadi K, Jacobs P and Sin D. Economic evaluation of a community- based pulmonary rehabilitation program for chronic obstructive pulmonary disease. Lung. 2004;182(3):187-96. Competing interests: None declared |
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