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Acute hospital admission systems: problems experienced by general practitioners   Back Bookmark and Share
Conlon Catherine
This study was undertaken to examine the existing system of access for general practitioners in arranging acute admissions to three general hospitals in the Southern Health Board (SHB) area. One hundred and twenty eight patients were admitted to the three hospitals over a one week period. General practitioners were surveyed on the process of admission for each patient. Response rate was 118/128 (92.2%). Hospital A had 53 admissions, Hospital B had 41 admissions and Hospital C had 24 admissions. In total, 30/118 (25.4%) admissions took over one hour to arrange, of these 23 (76.7%) were admitted to Hospital A, 4 (13.3%) were admitted to Hospital B and 3 (10.0%) were admitted to Hospital C. The admission sister was responsible for confirming the route of admission in 102 (86.4%) of cases. In Hospital A, 23/53 (43.4%) patients were referred to Accident and Emergency (A&E) for assessment prior to admission, 4/41 (9.8%) were referred in Hospital B, and 2/24 (8.3%) in Hospital C. In the light of current findings, possible alternatives to the current acute admissions system are discussed.
Author : Conlon Catherine , Long B, Flaherty P, Murphy M

Abstract

This study was undertaken to examine the existing system of access for general practitioners in arranging acute admissions to three general hospitals in the Southern Health Board (SHB) area. One hundred and twenty eight patients were admitted to the three hospitals over a one week period. General practitioners were surveyed on the process of admission for each patient. Response rate was 118/128 (92.2%). Hospital A had 53 admissions, Hospital B had 41 admissions and Hospital C had 24 admissions. In total, 30/118 (25.4%) admissions took over one hour to arrange, of these 23 (76.7%) were admitted to Hospital A, 4 (13.3%) were admitted to Hospital B and 3 (10.0%) were admitted to Hospital C. The admission sister was responsible for confirming the route of admission in 102 (86.4%) of cases. In Hospital A, 23/53 (43.4%) patients were referred to Accident and Emergency (A&E) for assessment prior to admission, 4/41 (9.8%) were referred in Hospital B, and 2/24 (8.3%) in Hospital C. In the light of current findings, possible alternatives to the current acute admissions system are discussed.

Introduction

The system of access to acute hospital beds for General Practitioners (GPs) in Ireland varies between Health Boards, between hospitals within Health Boards and between specialities within hospitals. Focusing entirely on the problems experienced by GPs in admitting their acutely ill patients, however, fails to consider the other side of the story. It is the responsibility of the hospital personnel to plan their services so that a balance can be achieved between carrying out elective work while ensuring that enough beds are available to deal with non-routine admissions.l The unpredictable nature of acute admissions makes forecasting the necessary bed capacity to deal with unexpected peaks in demand very difficult.2 This study examined the problems encountered by GPs in admitting patients to three general hospitals in the Southern Health Board area, and the general practitioner's perception of patient satisfaction with the procedure of admission. Specifically, the purpose of the study was to examine the procedures that occurred in getting a patient from the general practitioner's surgery or the patient's home to a hospital bed. The National Health Strategy Document "Shaping a healthier future"3 emphasises the importance of providing a "seamless service," i.e. improved linkages between hospitals, Health Boards, community care services and GPs. With this in mind it is felt that this study was timely. 

Methods

In the Southern Health Board area in which this study was undertaken, an acute hospital admission can be arranged either through the bed bureau or through the admissions office of the individual hospital concerned. The bed bureau operates as follows; a GP wishing to admit an acutely ill patient contacts the bed bureau and provides details of the patient, his current problem and previous hospital experience. The GP provides the patient with a letter, and leaves a contact number with the bed bureau, the latter then arranges the admission when a bed becomes available. Acute GP admissions to three general hospitals in the Southern Health Board area were examined over a one week period. The study started on November 2nd 1995 and ended on November 8th 1995. Permission was sought from the participating hospitals to obtain from the admissions office in each hospital, details of all acute general practitioner admissions to the hospital over the previous 24 hours. A telephone questionnaire was administered to each referring general practitioner within 24 hours of the general practitioner having arranged the admission (in the case of admissions over a weekend, on the following Monday), and details of the admission procedure sought. The questionnaire covered items such as length of time taken to arrange the admission, who confirmed the bed was available, how many hospitals were contacted to arrange the admission and was the patient admitted directly to the ward or required to attend in A&E for assessment prior to admission. An acute admission was defined as any patient for whom the general practitioner requested immediate admission to hospital or immediate assessment with a view to admission. Length of time taken to arrange the admission was defined as the length of time between the initial contact with the hospital by the general practitioner and when a bed was confirmed, or when the general practitioner was advised to send the patient to A&E for assessment. The data were analysed using EPI INFO5. 

Results

There were 128 admissions to the three hospitals over a one week period. Details of the admission were obtained in 118 (92.2%) of cases, 53 (44.9%) were to Hospital A, 41 (34.8%) were to Hospital B and 24 (20.3%) were to Hospital C. In total 30 (25.4%) admissions took over one hour to arrange. Of these 23 (76.7%) were to Hospital A, 4 (13.3%) were to Hospital B, and 3(10.0%) were to Hospital C. The number of hospitals contacted to arrange the admission was examined. One hospital was contacted in 108 (91.5%) cases, two hospitals were contacted in 9 (7.6%) cases, and three hospitals were contacted in 1 (0.9%) case. The admission sister was responsible for arranging the admission in 102 (86.4%) cases, in 16 (13.6%) cases, a member of the medical team was consulted prior to the admission being arranged. In 15/16 (93.8%) cases in which a member of the medical team needed to be contacted to arrange the admission, the patient was admitted to Hospital A. The frequency with which patients were referred to A&E for assessment prior to admission was examined. This occurred in 29/118 (24.6%) cases, 23 (79.3%) of these were to Hospital A, 4 (13.8%) were to Hospital B and 2 (6.9%) were to Hospital C. Of 13 patients admitted through the Bed Bureau, 8 (61.5%) took over one hour to arrange admission and 7 (53.9%) were referred to A&E for assessment prior to admission. 

Discussion

This is the first reported study of acute admission procedures for a series of patients to general hospitals in Ireland. This study confirms the view that attempts by GPs to arrange acute hospital admissions in the study area examined is fraught with difficulty. Difficulties occur in; (i) long delays in confirmation of an admission with the hospital admissions office and (ii) deferral of many patients to A&E for assessment prior to admission. These difficulties lead to anxiety and stress on the part of the general practitioner, and are perceived by the general practitioner to lead to patient dissatisfaction.4

There are two aspects to this problem. One involves effective health service planning so as to ensure that sufficient beds are available to deal with non-emergency admissions. The second involves ensuring that, within given levels of bed-availability, a system exists which ensures minimum delays 

  • for the general practitioner in arranging an admission, 
  • for the patient in gaining access to an acute bed, when this is deemed to be required by the general practitioner.
This study attempts to examine the second aspect of this problem only. 

One must ask why there is an increased likelihood of delay in admission and referral of patients to A&E for assessment prior to admission to Hospital A compared to Hospitals B or C. Hospital A is a major tertiary referral centre, for a catchment population of over half a million people5; all major trauma and orthopaedic trauma from the region is referred there. All three hospitals are located in the city within a radius of three miles. Thus any assessment of delays in admission to Hospital A must be considered in the context of the procedures operating in all three hospitals providing acute emergency services to the region. Three areas are identified which require careful evaluation in efforts to reduce delays in the admission of patients referred by GPs to acute hospital beds. 

Firstly the role of the bed bureau needs to be examined. Currently a bed bureau exists, but this operates in conjunction with other systems, which reduces the efficiency of the system. The disadvantage of this system is that the patient may be required to wait for a bed when, in fact, an immediate bed is required. This study demonstrated that in circumstances in which the bed bureau was used to arrange admission, delays occurred in the time taken to arrange the admission and there was a high referral rate to A&E for assessment prior to admission. If this system is to operate effectively it must;

  • be the sole means of admission and have full knowledge and control of all beds available for acute GP admissions in the hospitals that it serves, and
  • the system must ensure that the GP is informed at the time of arranging the admission whether or not a bed is available, and if not, what alternative is proposed. 
The development of A&E services at one major site with a change in role at the other two sites is another option. Previous studies in the United Kingdom6 have identified that the closure of a department does not result in all the patients who did attend the department attending the remaining departments within the catchment area, but in fact the number of A&E attendances drops by 40%. The option of developing A&E services at one major site has been considered by a recent review group of A&E services in the Southern Health Board.7 Such an arrangement would result in the region of 20,000 extra new patient attendances per year, thus arrangements would have to be made with the other two major hospitals in terms of acute medical and surgical emergencies transported by ambulance. In view of the fact that all three hospitals studied are within a three mile radius of each other, this would seem to be a realistic option. 

A third option involves utilisation of systems which would reduce the possibility of patients being deferred to assessment for A&E prior to admission. A&E is recognised as being an inappropriate place for a large number of patients who have been referred as acute admissions.7 Introduction of an Admission Ward which would hold patients between A&E and Hospital wards would provide an alternative inpatients being deflected to A&E for assessment.8 Efficiency could be ensured by the use of agreed admission and discharge protocols between specialists and GPs. Consideration needs to be given to the incorporation of all three options proposed, i.e. amalgamation of the three A&E units into one, with an admission unit for acute general practitioner admissions in the remaining unit; and all admissions either direct to a hospital bed or to the admission unit to be arranged by a Bed Bureau serving the three hospitals. Any change in the current admission procedures would require careful implementation and evaluation. This study has highlighted inefficiencies which exist within the current system, and offers practical suggestions on means in which accessibility to inpatient hospital care could be improved, thus improving the quality of the health service in keeping with the goals of our time.3Correspondence:

Dr Catherine Conlon, 

Dept. of Public Health,
Southern Health Board,
Wilton,
Cork.

References

  1. Jenkins C, Bartholomew J, Gelder F, Morrell D. Arranging hospital admissions for acutely ill patients: problems encountered by General Practitioners. British Journal of General Practice 1994;44:251-254. 
  2. St. George D. How many beds? Helping consultants to estimate their requirements. British Medical Journal 1988;297:729-731. 
  3. Shaping a healthier future. A strategy for effective healthcare in the 1990s. Dublin: The Stationery Office, 1990. 
  4. Cooper CL, Rout U, Farragher B. Mental health, Job satisfaction and job stress among General Practitioners. British Medical Journal 1989;298:366-370. 
  5. Central Statistics Office. Census 91. Summary Population Report. Dublin: The Stationary Office, l991. 
  6. Medical staffing at accident and emergency departments. British Association for Accident and Emergency Medicine, 1993. 
  7. Southern Health Board. Report of the review group on accident and emergency services in Cork. Southern Health Board, 1996. 
  8. Maimaris C, Kirby N. The impact of the observation ward on acute admissions at Guy's Hospital. Health Trends 1991;23:33-35.
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