With estimates ranging from 0% to 50% responses to my question show very different impressions about how many admitted patients could be looked after in the community. I wonder if the explanation is that there is more variation between our ED patient populations than might be obvious. Some Departments seem to see lots of elderly patients who are sick and need admission, whereas others seem to see lots of elderly patients who are not sick and could be dealt with in the community. As they will all just be classified as 'majors' there may be an important variation in case mix that we are not at present capturing.
I also sense that there is also a difference in views on the desirability of higher level medical intervention in elderly patients - should we be admitting an elderly, dementia suffering, bed bound, nursing home patient with pneumonia for iv fluids / antibiotics, or should we be aiming to deliver a 'good death' in the community. 'Appropriateness' of hospital admission will depend on our belief about best care of the patient. This is a social rather than a medical decision, but society is not having the debate.
This has been a useful conversation for me - I don't think that I had really appreciated the variation in case mix between EDs. It may be that we need several solutions rather than one!
Tim.
PS. If any of the younger members of the list end up treating me when I am elderly, demented, bed bound and have pneumonia - please don't give me the iv fluids and antibiotics.
------------------------------------
Prof. Timothy Coats
Professor of Emergency Medicine,
University of Leicester, UK
0116 252 3263
-----Original Message-----
From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Matthew Dunn
Sent: 13 June 2013 13:59
To: [log in to unmask]
Subject: Re: Attendances and GPs
> I profoundly disagree that most elderly patients need ED management. We
> might THINK they do, but that doesn't make it true. There is certainly
> a place for easy access OPD assessment, but ED???
>
I think the problem is that you have elderly patients who are at high risk of dying within the next few weeks and that risk of dying within the next few weeks can be reduced substantially by medical intervention. That doesn't mean you'll necessarily be prolonging their life by more than a few months. However, these are high risk patients who by a particular endpoint stand to benefit from ED treatment. The question is whether that endpoint is appropriate, but to an extent that is a decision for the patient.
>
> Here's the mindset of an experienced GP (or enlightened younger GP):
> "This person has chronic unwellness, or worried wellness, or advanced
> age. Based on my clinical impression, emergency secondary care is
> unlikely to find a cause or cure, even though they might make me, the
> patient and the family feel something is being done. Now, how can I
> help with your symptoms?"
>
That is indeed the input that GPs can have: assess the patient's chronic condition; discuss matters with the patient; give them an open and honest view of their likely prognosis and how this may or may not be modified by medical intervention; and in discussion with the patient decide on what is appropriate care in the event of deterioration or new acute illness. However, the time for that assessment and discussion is not when the patient has deteriorated or developed that new acute illness; it is while the patient is relatively stable.
Matt
This email has been scanned for viruses; however we are unable to accept responsibility for any damage caused by the contents. The opinions expressed in this email represent the views of the sender, not South Warwickshire NHS Foundation Trust nor NHS Warwickshire unless explicitly stated. If you have received this email in error please notify the sender. The information contained in this email may be subject to public disclosure under the NHS Code of Openness or the Freedom of Information Act 2000. Unless the information is legally exempt from disclosure, the confidentiality of this e-mail and your reply cannot be guaranteed.
This e-mail, including any attached files, may contain confidential and / or privileged information and is intended for the exclusive use of the addressee(s) printed above. If you are not the addressee(s), any unauthorised review, disclosure, reproduction, other dissemination or use of this e-mail, or taking of any action in reliance upon the information contained herein, is strictly prohibited. If this e-mail has been sent to you in error, please return to the sender. No guarantee can be given that the contents of this email are virus free - The University Hospitals of Leicester NHS Trust cannot be held responsible for any failure by the recipient(s) to test for viruses before opening any attachments. The information contained in this e-mail may be the subject of public disclosure under the Freedom of Information Act 2000 - unless legally exempt from disclosure, the confidentiality of this e-mail and your reply cannot be guaranteed. Copyright in this email and any attachments created by us remains vested in the University Hospitals of Leicester NHS Trust.
|