Emergency medical admissions: taking stock and planning for winterBMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7119.1322 (Published 22 November 1997) Cite this as: BMJ 1997;315:1322
We need more logic and more honesty
Emergency medical admissions have risen by 50% since 1984 and now account for almost half of all NHS admissions.1 Through recurrent winter bed crises, disrupted elective admissions, growing waiting lists, and highly publicised interhospital transfers of seriously ill patients this continuing rise threatens the future of the NHS. Has anything changed since we last reviewed this problem?2
We now understand better the epidemiology of emergency medical admissions. Winter peaks principally reflect respiratory and cardiovascular illness.3 Nevertheless, twofold variations exist between individual hospitals in both admission rates and increases in rates.4 Whereas the proportion of the total population using inpatient hospital services has remained almost constant,5 the number of patients readmitted four or more times in a five year period doubled between 1981 and 1994.
Age and deprivation take their toll. People aged over 65 account for only 15% of the Scottish population but 37% of emergency admissions.1 This proportion may have grown because more elderly people live alone as family groups fragment, eroding informal support. Hospitals become “the carer of last resort.” Socioeconomic deprivation operates across the board, from illness behaviour through to use of tertiary services. Deprivation increases emergency admissions, particularly for cardiovascular disease, self poisoning, and asthma. These, along with non-specific conditions, dominate the emergency admission workload.1 4
Up to half of those admitted as emergencies have not been referred by their general practitioners.6 Accident and emergency departments therefore also act as gatekeepers. But rising expectations by patients and their families potentially erode the gatekeeper role of practitioners and hospital staff. Moreover, in accident and emergency departments junior doctors may practise defensively and lack confidence to resist an admission.
Primary care factors are clearly crucial, with considerable variations between individual practices—which are difficult to interpret in the absence of a “gold standard.” An American randomised trial suggested that increased access to primary care was paradoxically associated with significantly higher admission rates.7 More work is needed on the potential effects of the recently introduced out of hours care schemes and treatment centres.8
“Supply side” factors contribute powerfully. Hospital bed availability has effectively increased because lengths of stay have fallen faster than bed numbers. This may have contributed to the rise in 28 day readmission rate, which accounts for 14% of the increase in emergency admissions.1 Some readmissions may be inevitable when practising explicit risk management. Increased readmissions and reduced admission thresholds might also contribute to the observed decrease in fatality rates.
Measuring the appropriateness of admissions remains difficult and contentious. Patients' and carers' views are rarely elicited. Professional staff consider that up to 40% of admissions may be avoidable but only if appropriate alternatives to hospital care both exist and are available.9
Although various planned and acute responses to excess emergency admissions have now been described,9 disappointingly few have been evaluated. Acute responses include closing or redesignating wards in the short term, redeploying staff, and boarding patients elsewhere in the hospital. Such crisis management potentially risks sensationalist media coverage.
Planned responses have addressed every stage in the admission process from initial referral to discharge. Patients may be deflected before admission, by easy access to “same day” rapid assessment outpatient clinics,9 enabling senior clinicians to manage the referrals. Secondly, bed use may be improved: emergency admission units can triage patients to appropriate specialty wards, and consultants may be excused routine duties to handle acute admissions.10 Such schemes can increase bed occupancy and reduce length of stay, boarding of patients in inappropriate wards, and transfers between wards or hospitals, but may cause deskilling and increase stress for staff.10 Lastly, comes discharge planning, which should ideally start on the day of admission. Home visits immediately after hospital discharge may also reduce readmissions.11
Nevertheless, isolated changes have generally produced little effect, even when backed up with large cash injections. This is a complex closed system. Deflected patients tend to bounce back somewhere. The time has come for more logic, and more honesty.
A systems approach would suggest a comprehensive, integrated response coordinated across an entire community or region. This would include primary care as well as hospitals, social services as well as health services. Does Northern Ireland benefit from its unified budget? Would the rest of Britain? More openness implies involving the other stakeholders: social services, politicians, purchasers, primary care practitioners, patients, and the public. Consulted least, patients and the public probably hold the key. Greater honesty means recognising that we will get what we are prepared to pay for. Future debates will need to focus on the most contentious issue, prioritisation.
We thank Professors James McEwen and Graham Watt and Drs Phil Hanlon, Stan Murray, and Mary Blatchford for their helpful comments.