A Naïve Junior Doctor’s Opinion on “Admission Avoidance”

Daniel Sommer is a Foundation Year 2 Doctor at Charing Cross Hospital in London. He is an aspiring Geriatrician. He tweets at @danielf90 shutterstock_115739950

Hello everyone, my name is Dan and I’m a junior doctor and an aspiring geriatrician (read my last blog post here). My new job is working as part of my hospital’s OPAL (Older Peoples’ Assessment & Liaison) team and I absolutely love it. We run a rapid access day clinic that GPs refer into and we review every patient over the age of 70 who is on the acute medicine unit routinely (usually after the consultant post-take ward round but sometimes we’re asked to intervene earlier). I felt compelled to write something about admission avoidance in the elderly because I hear so much about it in the media and my working experience does not correlate with what I read.

Patient MS is 82 and has dementia. She had a recent long stay in hospital following a pneumonia requiring prolonged rehabilitation and was discharged with a large package of care from social services. On discharge it was decided that if this package of care didn’t work then the patient was to be placed in a residential home from the community. Two days after discharge the patient was brought to A&E because she was found on the floor having fallen. The ED registrar refers to the medics as a “failed discharge” (a term I really dislike – but that’s for another time) and was “eye-balled” quickly by the medical registrar who determined that the package of care must not be working. The OPAL team was called to see if we could arrange an emergency residential home placement to “avoid an inappropriate admission” on a Friday afternoon. We work really hard and within 2 hours we had managed to convince the powers that be to find an emergency community bed that the patient could be transferred to. We approach the medical team with glee that we managed managed to achieve the impossible but we were greeted with sheepish faces. “Oh….yeah…well, we looked at the bloods and….”. The patient had a severe acute kidney injury and a huge inflammatory response.

Patient MS was initially denied a thorough acute assessment by an experienced medical team who thought they were doing the right thing by pushing this lady very quickly out of hospital “for her own good”. This patient presented with a classic geriatric syndrome that we know can represent all sorts of acute medical problems.

Admission avoidance is a well-meaning idea (or political movement) that is designed to keep older people out of hospital because hospital is “bad” for them. Every new service for older people that is being commissioned seems to need to meet a primary outcome of “fewer admission of older people into hospital” otherwise it is a failure. I think this is a misguided aim and a terrible primary outcome measure. Carers, patients and social workers do not have medical degrees. If they are concerned that somebody is acutely unwell, they are right to send the patient to hospital to be thoroughly assessed, whether the patient is 20, 50 or 80 (or 90). It is my belief that we will never reduce the number of older people attending hospital and nor should we. It is ageist and a complete travesty to deny any section of society access to the health service.

Patient MS actually made it to hospital (jumping through all those pesky admission avoidance hoops and hurdles) and still she was initially let down by the system. So what is the solution? Well firstly, we need more geriatricians reviewing patients at or near the front door (either in the ED, a specialist acute frailty unit or the acute medicine unit) who will triage appropriately. Secondly, doctors need more education about classic geriatric syndromes (i.e. that it’s not “atypical” for an older person who is septic to present afebrile with a fall) and how to assess & manage them. Thirdly, we need to change our outcome measures.  In my (humble and naïve) opinion, the aim should not be to stop older people coming to hospital it should be about supporting early and appropriate discharge.

A virtual ward is not a failure if their patients end up in a real medical ward. It is a failure if they can’t be supported out of hospital as soon as they are medically fit to leave. Please, let’s focus on giving the frail elderly the best of both worlds – appropriate acute care in hospital when necessary and supported independence in the community at all other times.

5 thoughts on “A Naïve Junior Doctor’s Opinion on “Admission Avoidance”

  1. Well said Dan- totally agree with you about the need for proper assessment which may indeed need rapid admission and prompt discharge. We just need to make sure that the tariffs and funding streams reflect that (so as to free up resource to invest in the community teams who will expedite discharge)and that there is still the option for specialist assessment and support at the patient’s home – so we could try and avoid the ambulance journey and 2 hour wait in the ED for patients like MS.

  2. having looked after a lady admitted to my care home to avoid hospital admission who died because she actually had septicaemia (something which would have been picked up immediately following admission bloods in hospital – bloods are not done at all for care home admissions) I agree the system is inadequate.Saves money though…..

  3. Thank you Dan, that’s about the best representation I’ve seen of geriatric treatment in ED, and in other departments.

    The ‘best’ for patient perspective is too conflicting with the ‘I’m rushed off my feet’ and the ‘I can’t find another bed’ perspective.

    One very specific problem I’ve seen is that there is a presumption that the frail old wreck being presented is in her normal state. ED must see plenty of people with dementia. My mother has the onset, but apart from being forgetful and losing track of time is really quite with it. But she’s had infections that have gone undiagnosed because here ‘not so with it’ state was presumed to be her normal state.

    A heck of a lot is missed and the balance of ‘best’ for the patient against hospital issues is a recipe for bad care. The patient not only doesn’t get good care but ends up being shuttle back and forth between home an hospital, when the right attention on the first visit would have had the patient in and sorted.

    My experiences, as relayed here: https://britishgeriatricssociety.wordpress.com/?s=ron+murphy&submit=Search

  4. Well said Dan – quite often it seems that because of pressures to avoid admission we do not see beyond the ‘mechanical fall’ (whatever one of those is) or the fact that someone has ?dementia (about 24 hours from ? to actual i believe) Being cynical I think that as ever older people are bearing the brunt of the pressures on our services and losing out as a result
    Absolutely agree that more geriatricians are required both at the front door and beyond

  5. Hi Daniel,
    I don’t think it is an either or. So I agree and disagree with your conclusions.
    Numbers are meaningless without context. This is why we often hate those measurements as some are not used within context.

    I think there are many things we can do to prevent people, particularly elderly people, needing hospital attendance. How many … geriatricians work in community settings? … do weekly rounds in care homes? How many GPs with a particular interest in geriatrics do we see doing regular visits in care homes? … plans exist for elderly people that tell every health + social care professional and family members what to do if … (most common things) happen, and what NOT to do?
    Do we have a Buurtzorg model for community nursing in place where community nurses can support the people in the way they need it without being bogged down by paperwork?

    If we do all of those things, many less people will need to go to hospital and you would have the time to see them all quickly and given them the right treatment so they can go back home and receive the support they need as you discussed with them before discharging the person.
    I think we would all be happier.

    Also: worth wile watching: http://vimeo.com/95243749

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