Hospital admissions OOH
A GP working in OOH is likely to admit a number of patients to hospital each shift – particularly if performing a “mobile” session. There will also be a number of factors that influence the decision to admit that may not necessarily be present in an in-hours consultation. Some factors you may wish to consider are:-
- Lack of prior knowledge of patient
- Lack of support (nursing, lab results, relatives etc.) OOH
- Difficulty in examining patient (if seen in a poorly lit home with no examination facilities)
- “Things seeming worse at night”
- Alcohol +/- drugs
- Your own time needs – e.g. 5 patients waiting for a call
There are probably many other circumstances that impact on this decision. The following section may help you to analyse pressures on you to admit a patient and also allow you to discuss a mix of cases seen in an emergency situation.
Record 10 consecutive cases Out Of Hours in which admission was considered. A conscious decision not to admit is as important as a decision to admit.
This tool can be used equally successfully by a GP working in hours as a locum or by a partner in a practice although the data may take longer to collect
Please note this example is only a five stage audit, however it should be fairly simple to convert to an eight stage audit by repeating the data collection at an interval.
Hospital Admissions OOH Template
Learning points identified from these cases
Action to be taken/changes to be made
Hospital Admissions OOH Example
Learning points identified from these cases
The 10 cases took me 3 sessions to collect (18 hours). I feel that the vast majority of these cases demonstrate appropriate clinical care. There are however four cases that I would have perhaps treated differently had they been my own patients In-Hours.
I remember the consultation with the 18 month old child and the aggressive father vividly. I felt intimidated and took the easy option to extricate myself from a sticky situation. I did highlight the issue with the aggressive father to his own GP and indeed once I had left the house I phoned the Paediatrics SHO and warned her. The child did not need admission from a medical point of view but I believe I had very little option. I don’t often get problems with aggressive patients OOH but this case reminded me that every so often there are personal safety issues. There is an event planned for next year dealing with the aggressive patient and I will make every effort to attend.
The 74 year old man with the cough that I admitted was probably not the best choice. I was at the end of my shift and tired, it was easier to admit. I have reflected on that decision and will make an effort not to do that again.
The 67 year old diabetic lady with the UTI and loss of diabetic control raises two issues for me. Firstly I did not have the correct equipment available (ketostix) – I have since addressed this with the OOH Medical Director and they are now part of the standard equipment (oddly enough they would have been available at base). The second issue is a personal learning point – I really did not feel confident in adjusting this lady’s insulin dose (the real reason for admission). I have had similar issues In-Hours and have identified diabetes in general as a learning need but now with more and more Type-2 diabetic patients converting to insulin I need an update in management.
The 52 year old man with 3 episodes of short lived chest pain threw me a bit and as they sounded cardiac in nature my instinct was to admit. On reflection these episodes were all related to rushing up a certain hill near his home and lasted less than 3 minutes each – I should probably have given a GTN spray, advice to take it easy and referred him to his own GP the next day. I am a little confused with the acute investigation of possible new angina and as such probably need to read local protocols.
Action to be taken/changes to be made
From the above I would like to make the following changes:-
- Attend an event on dealing with the aggressive patient
- Learn more about diabetes – specifically issues around insulin use in type-2 DM
- Examine my referral pattern again to pick out patients I may admit as “an easy option”
- Find local or national protocols regarding management of new onset angina