Admitting a patient to hospital as an emergency is an important aspect of General Practice care. Oftentimes a patient is admitted with seemingly dramatic symptoms only to be discharged well the next day. Hospital doctors have rapid access to diagnostic tests and may be able to quickly rule out serious illness and this is one good reason we admit patients. It is difficult therefore to make an objective measure of when it is appropriate to admit a patient to hospital, as the GP is often put in a position of needing to admit to rule out a serious condition.
This template link may help you to examine the reasons that you admit a patient to hospital and may highlight issues for discussion. Try to analyse your next 10 emergency admissions. You may wish to include your reflections on the issues identified and learning points on MARS, and include your analysis as additional supporting documentation.
|Clinical scenario and time of day||Reason for admission||Outcome|
|1pm house call to 78 year old lady with a chest infection (3rd call this week)||Confused with chronic chest (COPD) increasing SOB and productive cough not responding to antibiotics||2 ½ weeks in hospital i.v. antibiotics, nebuliser, oxygen and steroids. Discharged home with no change in medication|
|9 am 62 year old man who had chest pain all night attended surgery, cardiac sounding pain now gone but some increase in SOB||Possible MI||MI excluded no ecg changes – possible angina awaiting exercise tolerance test|
|2.30 pm 13 yr old girl with abdominal pain for 24 hours worsening with vomiting tender in RIF||? appendix||Observed on ward for 2 days discharged - ? mesenteric adenitis|
|11pm OOH session 4 year old child with high fever vomiting and cough- unwell on examination nil else||Young child clearly unwell with high fever – needed observation and exclusion of underlying septicaemia||Not my patient but I was able to ascertain that she had been admitted and was undergoing tests (bloods cxr etc) final outcome unknown|
|10.30 am 56 year old patient with a swollen r calf tender but not hot||? DVT||D-Dimer negative no diagnosis|
|4.30pm 74 year old lady with coffee ground vomit – no PH of GI symps but has been on meloxicam for OA||? haematemesis||Indeed had bleeding gastric ulcer – discharged on high dose omeprazole needed 2 unit transfusion|
|11.30 am Residential home patient acutely confused – probable UTI – incontinent and offensive urine||Needed admission as residential not nursing home patient||UTI responded quickly to antibiotics home in 4 days|
|1pm 63 year old patient with metastatic bowel ca – poor pain control and anaemia||Palliative care in local hospice||Admitted for 1 week 3 units transfused initially stabilised on a syringe driver then discharged on high dose MST and anti-emetic|
|1.30pm sectioning meeting with patient well known to me – acute psychotic episode||Section of mental health act invoked||Admitted to hospital – prolonged admission for stabilisation|
|6 pm 8 month old with symptoms of bronchiolitis – I had seen this patient 4 days ago with a cold and had not prescribed||Symptom control||2 day admission with bronchiolitis|
Are there any issues raised by the 10 cases above?
These 10 cases took 16 working days to collect including one evening session in the OOH (admittedly a “base” session). I also note that most admissions were late morning/early afternoon – this must place great strain on hospital admissions unit. I think all admissions were appropriate despite negative findings in many of the cases. The one case that struck home was the lady with the metastatic bowel Ca, she had lost symptom control and had been feeling unwell for 3 days before she called me. She had not wanted to bother the doctor or the palliative care nurse involved in her care
Are any learning needs highlighted?
We discussed the lady with the pain at our multidisciplinary team meeting and highlighted the issue around her not wanting to bother us – she had been OK when seen 1 week prior to admission and a further visit was planned a week later. The upshot of the meeting was that there was not much that could have been done as it is always stressed to patients that they can contact either the surgery or the palliative care team at any time – we reviewed the information supplied to patients by the palliative care team and this strongly reinforces that message. The other issue is the gastric ulcer probably related to meloxicam – I understood that this was a cox 2 inhibitor and therefore safer than traditional NSAIDS however when I looked this up I discovered that NICE advocates their use in older patients but that recent evidence in the BMJ casts doubt on this. I will consider this more carefully in future.