David Oliver: What’s wrong with acute “zero day admissions”?BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1241 (Published 20 March 2018) Cite this as: BMJ 2018;360:k1241
All rapid responses
High quality, patient centred and sustainable medical care must always consider the most efficient use of our limited resources from both a workforce and financial viewpoint. Whilst we agree that there are many benefits to inpatient care including a calmer environment and expedited access to consults, investigations and treatment, there is a not insignificant risk of overdiagnosis and overtreatment of patients who could otherwise have been managed efficiently in an ambulatory setting. Particularly as our population ages with multiple comorbidities and polypharmacy, there are real risks of delirium associated with unfamiliar surroundings leading to protracted admissions, redirection of resources, and risks of aggression against staff treating agitated patients.
In the last one year at our healthcare facility, which operates a 7 day per week consultant driven general medicine care model, we have estimated that approximately one in ten patients are discharged from hospital within 24 hours of admission. The principal diagnoses in these zero day admissions comprise respiratory tract infections, self-limiting peripheral vertigo, and cellulitis. The associated infection risks and potential for drug and clinician error of inpatient care of conditions that could be managed in an outpatient setting are not insignificant. These “zero day admissions” present huge challenges to an overburdened health system however also provide enormous opportunities to improve quality, access and cost through the provision of innovative ambulatory models of care.
Competing interests: No competing interests
The increasing burden on limited healthcare resources globally of an expanding and ageing population with multiple comorbidities puts priority and urgency on balancing safe and high quality healthcare with access and cost. The drive and need for community based innovative models of care that are integrated and patient centred is greater than ever before. Care models directed not only at the individual level, but also specific diseases and populations have shown benefits and cost reductions.
We agree with Oliver that the four hour national emergency access targets have encouraged a safety conscious approach towards greater admissions to short stay and rapid assessment units, as well as the general wards. We however don’t agree that “zero days” hospital admissions provide true patient centred care, but rather are a marker of ambulatory sensitive conditions presenting in emergency departments. The multiple care transitions in a short time interval before “zero-day” patients are discharged lends itself to not only a huge burden of cost, but also unnecessary treatments, investigations and increased clinical risk. Additionally, the presence of these patients can adversely affect time to treatment and outcomes for sicker patients. The last thing that health systems need now is easier access to short hospitalisation of patients for problems that can be managed effectively and safely in the community.
Aligned with principles of “right person, right care, right time, right place”, we should continue instead to strive for moving care into the community whenever possible. Partnerships between hospitals, primary care and community health stakeholders are pivotal to the continued development of appropriate, cost effective and patient-centred integrated care models. Whilst community resources may not currently have capacity to provide all that is required, neither is the inpatient care model able to cope with an expanding workload that is being presented to it. Rather than building larger hospitals, we need to become part of a community wide health system. The community is where most patients want to have their care, not in hospitals. Hospitals are hazardous places for patients; particularly those that don’t truly need to be there. Risks include falls, injuries, diagnostic and treatment errors, and hospital acquired infections. Furthermore, whilst there is some evidence that consultants at triage involved in rapid decision making impacts favourably on length of stay and care diversion back to the community, the unfortunate reality is that most health systems do not have specialty consultants available at the emergency department. Appropriate care in the community offers additional opportunities (particularly for those with underlying chronic illness) to optimise continuity of care, tailor care to the patient’s environment and preferences, better engage with carers and identify ongoing health and wellbeing supports that can avert future acute deterioration.
We would argue that the simpler approach of admitting patients within the four hour emergency targets for conditions which can be easily managed through rapid access clinics, community care and outreach services is not the better approach. It is not patient centred, cost effective or sustainable. Primary care is where ambulatory-sensitive care needs to be for it to be truly patient centred and sustainable and hospitals should be reserved for patients with complex and complicated health problems. “Zero days” admissions not only bring imbalance to the triangle of our health care priorities of quality, access and cost, but threaten to fracture it.
Competing interests: No competing interests