ADMISSION AVOIDANCE
Is it me ? When I was a house person , house dog, house plant , whatever the politically non correct name my senior chose to give me that week we took admissions directly . That’s right to those younger than me we held a bleep, answered promptly if we could ( else got shouted at by switchboard and our free calls to relatives in Australia stopped ) and spoke to the admitting GP directly . Now as a junior and inexperienced in the vastly superior ways of working in the community I would sometimes be frustrated with the quality of referral to hospital , one DR in particular known as DR RED PEN because of his choice of coloured biro was a regular culprit. But I was young and impressionable , these were the days of my 96 hour per week contract and I regularly worked 120 . You can almost hear people reading this saying “yeah, yeah, course you did” I hate to say it, but it is true .
Those hours and contract were wrong but it did give you a huge amount of exposure and forge some good habits and make you appreciate how difficult it is to do . See I have worked in a high pressure medical admitting environment for several years and know it is tough , know that the quality of referrals are important and that for quick flowing good medical care in hospital the speed and accuracy of decision-making round an admission is vital .How many accepting clinicians have worked in General Practice and understand the reverse pressures?
And that being said how many of you as GPs would just admit someone to make life easier, or that you thought you could manage in any other way , I would suggest very few of you . The reasons for that are multiple .
One is above because you know how crap it is to receive a poor admission having done the job . Though I must apologise to DR RED PEN because , as it turned out most times in the end it was appropriate and my experience at the time didn’t allow me to understand the pressures they were working under or the clinical acumen they had (humble pie eaten)
Two, and perhaps the most important one is we like our patients (well most of them,joke ) and the last thing we want to do is put them through the stressful and often ridiculously gruelling process of admission to hospital , which are , as we know, some of the most dangerous places on earth .
Three, have you tried dealing with the ambulance service recently , never mind looking at response times. the financial and clinical pressures they are under is immense and to be honest we are looking at a community rickshaw for exactly this purpose to try to speed up the process . No, don’t be ridiculous they can’t go on the bus ,we are a rural community, there are no buses.
Four and the reason I am writing this piece, is an apology to the hospital admissions person , I use that phrase because it varies from speciality and area .
I do my best to be a good GP , be patient advocate , manage our scarce resources and treat and investigate patients in a clinically appropriate manner as per my personal , ethical and professional responsibilities. Now here come the shocking headliner that will blow most STPs .or whatever else they are called away .
IT IS NOT MY JOB TO AVOID HOSPITAL ADMISSIONS !!
Do you get that, my role is many but part of that is not to keep patients out of hospital , my role is to manage patients in a way I feel is clinically appropriate with 25+ years of experience . Now some may disagree and I am happy to be educated but can only do what I can do with the regular 12-14 hours a day I work.
Recently I had a rather frustrating afternoon , several urgent visits, multiple secondary care problems to sort out , sick notes that hadn’t been done, meds that hadn’t been given on discharge, frontal lobotomy not stitched up , you know the usual stuff . In the midst of all this a patient who I had seen previously and liaised with a consultant about re their management , they were getting worse, had seen a partner that morning, who had tried to admit them but left a message on the wrong answer phone as it wasn’t clear which he should use, and asked me to chase up in the afternoon . Fair enough , we have a good team way of working but I didn’t get round to it till 4 ish . I chased and I chased to try to do the right thing, phone calls to secretaries, bleeped multiple registrars who didn’t answer, long waits . Eventually got the right secretary who said the consultant was at another hospital , rang said hospital put through to multiple wrong clinics and secretaries, eventually spoke to said consultant ( who is excellent) , they decide to admit to the hospital they were in as medical admission .
Fair enough , I’ll be nice and admit patient as I’m sure consultant busy, this is even though I now have 2 emergency visits backed up , one of which is 8 miles from practice (yes this is rural GP) and whose daughter is struggling to rouse and doesn’t want admission and given this article i’m very glad about that . I ring medical admissions and get them on my second attempt , hey it’s a record. Answered by very nice sounding person who didn’t introduce them self , and when asked “ who are you “ gave me a name but no job title ( hands up which GP hasn’t given a full life history only to hear the words” I’m only the ward clerk i’ll get staff for you “ . We elicited this was the admissions co-ordinator and I went through the admission , patient details, clinical details and “no I haven’t seen the patient today, but my partner has “, “ yes the consultant wants them in today” and the questions continue . Now I can only suspect that I am not the only GP who feels like this and to be honest the admissions procedure seems to ask a full medical history now, the official answer for this is to make sure the patient is admitted to the “appropriate “ place . Well here’s the crunch , I’m an experienced clinician , the consultant has asked for it and look at all the reasons above, if they need to come in then please don’t delay things anymore and just accept them . We used to use a phrase which was to “see and sort“ because for whatever reason the GP can no longer manage this patients conditions in the community and they need more intensive care/investigations . If I feel the patient is acutely unwell I will send to the Emergency department and I can probably work out which ones those are else please just accept the admission and don’t make us fight for it .
The tensions right through the system are palpable and here is the bit I’m not proud of .
After the coordinator ( who was calm beyond belief) had asked and put me on hold for the second time , we are now in to over 1 hour to admit a patient , they came back on and said the consultant on admissions was querying things . At this point I lost my rag a bit and mumbled under my breath and I must add not directed at anyone “ oh for flips sake” or words to that effect, totally unacceptable for which I apologised profusely immediately . I stated it wasn’t directed at anyone and especially not the coordinator but it was sheer frustration for me, the patient , the system and the patient who was unrousable 8 miles away who was being delayed from being seen . The coordinator quite rightly said that it was unacceptable but accepted it was not directed at them , I apologised again and explained re the pressures we are all working under . Eventually we agreed the two consultant would speak to each other and I apologised once more to which she gently stated it showed a lack of professionalism .
I didn’t respond , I put the phone down gently, shut the door on my consulting room and let the tears well , I was disappointed in myself for letting it get to me, disappointed that the patient had such a delay but mostly, hurt ( which I will get over) for being told it showed a lack of professionalism . Everything I and my colleagues do in general practice is about putting patients first, not systems, tick boxes or protocols .Professionalism is not about swearing or not , although I completely accept I was in the wrong , it is about caring , acting always in the best interest of the patient , going the extra mile, never giving up , respect for experience and so much more .
I gathered my thoughts, and my kit and went off on the emergency visit knowing the day was getting ever longer , 8 miles from the practice I walked in to a fantastically caring household who looked after their elderly relative , sat there the patient now wide awake and looking well , “ Hello Dr. what brings you here” the patient said .
I smiled and then I laughed, that is why I do this job and that is what admission avoidance is all about but what would I know ? after all I’m just a GP.
Thank you for reading , the next one will be a bit lighter in mood I promise .
any feedback welcome via twitter:- @imjustagp