Apply psychology and education

I am a full time, out of hours general practitioner. I admit patients to hospital for two reasons.¹ Firstly, if my top differential diagnosis has a illness trajectory that might result in the patient coming to harm if he or she is not admitted. Secondly, if the functional state of the patient is such that nursing care is required. The decision to admit is made by me with all my failings and lack of knowledge and experience. One GP’s absolute admission is another’s telephone advice.

Much could be done to reduce admissions if all parties continued to reflect on all admissions. I follow up many of my admissions but usually have to ring the patient and the relatives. Getting information from hospitals is difficult, and they sometimes even refuse on the basis of confidentiality. If admitting GPs regularly had constructive feedback of admissions, including events after admissions and outcomes, then perhaps they would admit fewer patients or even change the timing of admissions. More case driven education could transform admissions. Local databases of admitting reasons (rather than diagnoses) and outcomes could be established and continual local research be done. This in turn could be used to back up all parties if things went wrong. Perhaps we need to blur the line between primary and secondary care, and maybe urgent care (primary care) doctors need to work on admitting units.

Up to 10% of inpatients may have an adverse event while in care. At the moment, the iatrogenic harm of hospitals is rarely used as a reason not to admit, but when the decision is marginal this could further affect admission rates, especially in elderly patients.