shows that they are mostly over 60 years of age and the peak age
is 75 plus. Note that general medicine is now a geriatric
speciality.The study population here is a group of 215 patients of the ML practice who were admitted to hospital as either adult (medical) or paediatric emergencies during the winter season of October 1998 to March 1999. Some patients were admitted more than once, and the study therefore covers a total of 255 admissions. Of these, 207 were of adult patients and 48 were of children.
The age distribution of adults admitted
shows that they are mostly over 60 years of age and the peak age
is 75 plus. Note that general medicine is now a geriatric
speciality.
These are shown below
with admission rates quoted per 1,000 patients registered with each respective practice. Admission rates vary year on year for individual practices, sometimes by as much as 25%. Overall, most admission rates fell into the range of about 14 to 20 admissions per 1,000 registered population
Note that the year on year variation for each Practice is similar to the within year variation between Practices. This means that one year's figures are a highly misleading basis for comparison of Practice usage of secondary care.
These are shown below
as for adult patients above. Rates of admission to paediatric wards fall into the range of 4 to 7 per 1,000 patients registered. Year on year variation in rates is evident.
We have no explanation for the exceptionally high rate of paediatric admissions by Practice 5, which does not apply to adult medical admissions by that practice.
It is important to note that the age distribution of paediatric admissions concentrates on the under threes, and thus variations in the age distribution profile between Practices may have a large effect on admission rates per (crude) 1,000 base Practice population.
The age distribution of 41 paediatric patients (48 admissions) admitted during the winter of 1998/1999, to both Bassetlaw Hospital and to King's Mill Centre.
Patients may be admitted to hospital at the request of their GP or by a GP colleague working for a GP Co-op out of hours. Other patients admit themselves, either calling an ambulance or going direct to the Accident and Emergency department. In some cases, despite a diligent search of the GP medical records, the origin of the admission was not known.
52 % of the paediatric admissions and 54 % of adult admissions were directly arranged by a GP. Taken together 53.7 % of all admissions were arranged directly by a GP. Even if all those whose origin of admission was "not known" were actually admitted by a GP, which is unlikely, at least 42 % of patients were admitted without any GP involvement in the decision to admit.
|
Admission route |
Medical |
Paediatric |
Total |
|
GP |
99 |
20 |
119 |
|
Co-op |
13 |
5 |
18 |
|
from OPD |
4 |
0 |
4 |
|
A and E |
27 |
14 |
41 |
|
999 |
23 |
1 |
24 |
|
Self |
9 |
2 |
11 |
|
Not known |
32 |
6 |
38 |
|
Totals: |
207 |
48 |
255 |
Of the 255 admissions included in this study 187 patients were admitted only once during the winter season of October 1998 to March 1999. But 28 patients were admitted more than once. Of these 28 re-admissions, 7 were children and 21 were adults.
Of the 7 children re-admitted during the study period all 7 were admitted twice each. 2 cases were re-admissions with the same (unresolved) episode of illness. 21 adults had 54 admissions. Of these 54, 13 were re-admissions with the same (unresolved) episode of illness
Thus 15 of 255 admissions were re-admissions for a continuing, unresolved illness. This is 5.9% of the total admissions. There is no benchmark against which to judge whether this number is either excessive or normal, but it would be a mistake to assume that all or even any of these cases were discharged from hospital "too early". Several common relapsing illnesses, such as unstable angina and severe chronic obstructive airways disease, are both persistent, unpredictable and recurrent. Some re-admission with unresolved illness must be an inevitable component of hospital acute in-patient care.
Of the 28 patients who were admitted more than once, 21 were admitted twice, 4 three times, 1 four times and 2 five times. Overall 28 were admitted a total of 68 times.
Careful review of the GP medical records revealed only 2.35 % of admissions (that is six admissions, all adults) which might have been avoided by different GP management prior to admission. This judgment of 'avoidability' was confined to GP clinical management of the immediate illness(es) for which the patient was subsequently admitted. It should be emphasized that these 6 patients were ill, and the reasons for admission were valid, but it was judged that (even without the benefit of hindsight) different management by the admitting GP might have allowed for safe and effective care at home throughout the illness.
On review of the GP medical records a subjective retrospective judgment was made, for each admission, as to whether the patient might have been admitted to a Nursing Home rather than to hospital.
Patients admitted to Nursing Homes remain under the clinical care of their own GP, unless admitted to a Home outside the GP's practice area. Community laboratory investigations are available. The nursing care is comparable to that available in a hospital, but some treatments, such as oxygen therapy and repeated nebuliser therapy, may not be available. In addition, some hospital based investigations, such as chest X-ray, CT scan, venography and various biopsy procedures, are of course not available in a Nursing Home.
It was judged that 10 admissions could definitely have been avoided by Nursing Home admission. A further 8 cases were less clear cut, but for these also Nursing Home admission might have been appropriate.
Thus, at best, 18 of 255 admissions (7 %) might have been avoided by use of Nursing home care.
These patients form a large group of those admitted during winter months. In the community the incidence of respiratory illness varies widely from one year to the next, and it is this group which is likely to be responsible for variations in year on year admission rates.
In this study, of the 48 children admitted, 21 had respiratory illness (48 %). 37 of 207 adults admitted (17.9%) had some type of chest infection.
From which it follows that if the winter incidence of chest infection that is severe enough to need in-patient care were to double, then the overall number of adult admissions will rise by around 18 %.
Some adult patients were admitted at first contact with their GP, and some were admitted at second or subsequent consultation. The age distribution of patients who consulted more than once before admission was similar to that of patients admitted at first contact. This suggests that the admitting GPs (of the ML practice) do not operate a policy, either intentional or unintentional, of "keeping at home" older patients in an attempt to avoid admission.
However, in this study only one patient was admitted from a Nursing Home, and this was a re-admission of a patient who had been discharged to a Nursing Home from a hospital bed.
It is local Health Authority policy that patients with severe chest pain suggestive of heart attack should be admitted directly to hospital by 999 call. Of the 207 adult admissions 38 were admitted with chest pain. Of these 38, 30 were admitted directly, without any GP consultation.