I read the "realistic (in current economic climate) amount of investment" as being woefully insufficient for the wants of society (certainly where I am in South Wales).
Of all the 'majors' which came through rapid assessment yesterday I only found two I thought were completely inappropriately facing hospital admission: one because 'unable to cope at home' hadn't been addressed months ago by the (non-resident) family with heads in the sand and another from a nursing home where they dialled 999 within four hours of a GP visting and deciding to treat and keep the patient in the nursing home. I returned the latter patient to the nursing home after lengthy phone calls and discussion with the relatives.
So, in your originally defined group of "sick elderly", less than five percent would be my generous guess.
The frail elderly form the majority of the medical intake (which the physicianly 'ologists hate), we have inadequate provision for this patient group from admission through to discharge and I believe it is entirely predictable that this problem is only going to get bigger.
Whilst the 'can't get a GP appointment' group do contribute to our footfall, they are not clogging the ED where I am. The 'can't get an OOH GP to visit a nursing home out of hours' group *does* add to the clogging up - which is part of the societal expectations of levels of care and reluctance of nursing home staff to manage end of life care in nursing homes that seem to plague us now. Once these patients are in a hospital bed the nursing home do all they can (it seems) to avoid accepting them back again (awful for the patients and the families, in my view).
Sarah
On 11 Jun 2013, at 21:33, Rowley <[log in to unmask]> wrote:
> I think you have rather limited our responses by choosing a population that can be defined as requiring close medical supervision and care.
>
> May I suggest that you define the population of interest as patients aged over 65? These present largely with falls of 2m or less (usually collapses or trips) or obvious medical conditions such as infective exacerbations of chronic airways disease. The consequences vary, but a significant proportion of this larger group are admitted ONLY because their home circumstances are no longer safe with their new disability or it is recognised that they have been gradually becoming more frail and need a more significant package of care.
>
> With this redefinition I suggest that as many as 50% may be able to leave hospital to a safe environment (and, indeed a proportion could be assessed in their dwelling, be found to need a higher care level and sent to that without ever coming to secondary care) if it were immediately available.
>
> From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Coats Tim - Professor of Emergency Medicine
> Sent: 11 June 2013 17:41
> To: [log in to unmask]
> Subject: Re: Attendances and GPs
>
> OK. My next question to the list:
> Of all the sick elderly patients who are awaiting hospital admission in your ED, what proportion do you think could be managed outside hospital given a realistic (in current economic climate) amount of investment in community care?
>
> Again this will vary, but my local experience is that they mostly need ‘hospital’ type interventions and would not be suitable for community care. I think that we can assume that relative’s expectations of higher level care for elderly people coming to the end of their life will not go away. What is your guess on the percentage of patients that could be managed at home from your ED if some resources are moved from hospital to the community?
>
> Tim.
> ------------------------------------
> Prof. Timothy Coats
> Professor of Emergency Medicine,
> University of Leicester, UK
> 0116 252 3263
> From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of James Connolly
> Sent: 10 June 2013 21:02
> To: [log in to unmask]
> Subject: Re: Attendances and GPs
>
> Tim
>
> I posted on this last week
>
> It is exactly this - a lot of complex multi co morbidity elderly patients ( or even younger chronologically with lots of co morbidity)
> Like you I think the message of lazy GPs is a smoke screen - few of these patients are suitable for community care and more importantly their and their families expectation of care is increasing - I spend large amounts of my shift with desperately ill elderly patients , giving them the best work up I can and planning their appropriate level of care, taking time with the family / ITU discussions etc..
>
> I like you am beginning to believe that no amount of tweaking the system can decrease the input of this population in to the department
>
> Unblocking the other end so there are discharges and so capacity may help somewhat
>
> I find the concept of the solution being to reduce hospital beds a little optimistic!!
>
> jim
>
>
>
> James Connolly
> [log in to unmask]
>
>
> -----Original Message-----
> From: Coats Tim - Professor of Emergency Medicine <[log in to unmask]>
> To: ACAD-AE-MED <[log in to unmask]>
> Sent: Mon, 10 Jun 2013 9:16
> Subject: Attendances and GPs
>
> Can I use the list to cross-check what I am seeing.
>
> The current government emphasis on ‘inappropriate attenders’ due to ‘lazy GPs’ doesn’t really fit with what I am seeing in my own ED – where we seem to be overcrowded with sick elderly patients who need a level of care that cannot be provided in the community, but they remain in the ED as there are no beds for them to go to. Patients with minor conditions who could have gone to their GP are certainly still attending the ED – but if they were removed I don’t think that it would really create much improvement in the current pressure (as most are either diverted or seen rapidly by nurse practitioners).
>
> If I am experiencing something different from the national picture then we may be right to emphasise failings in primary care. If the underlying cause of the current crisis is (as it seems from my perspective) the initial explosion of the demographic time bomb of a rapidly aging population – then we are talking about the wrong issue. If we are talking about the wrong issue we are playing into the hands of the politicians who would like an easy target (‘lazy GPs’) rather than tackle the politically very difficult, and potentially expensive, issues that surround how we look after old people, relative’s expectation of level of treatment, management of dying, end of life planning, resourcing the hospital care for the current rapid increase in our elderly population, and resourcing the social care required.
>
> I would be very interested in the list’s experience – is it really patients who cannot access GPs that are causing a crisis in your ED?
>
> Tim.
> ------------------------------------
> Prof. Timothy Coats
> Professor of Emergency Medicine,
> University of Leicester, UK
> 0116 252 3263
> From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Jel Coward
> Sent: 06 June 2013 17:43
> To: [log in to unmask]
> Subject:
>
> On 6 June 2013 09:22, PHILLIP OCONNOR <[log in to unmask]> wrote:
> Am I the only dissenter?
>
> Positively I agree with GPs doing a year of ED after their core training and immediately before GP land.
>
>
> That would be good. Similarly forcing ED career track trainees to do a year of GP. Do you agree?
>
> or bill the GPs for their non-urgent patients.
>
> Get lost. So wonderful for us to characterise colleagues as the bad guys - helps our egos, but not much else.
> There is a stack of stuff that GPs see that could appropriately be seen in A+E - should they bill you?
> There is a stack of stuff that GPs deal with that are bounces back from inadequate hospital care - should they bill you?
>
> Picking on each other goes nowhere.
>
>
>
> To your second point.......I agree that _forcing_ folks to work in places they don't want to be is counter-productive.
> Cheers :)
> Jel
>
>
>
> If I need a plumber at 1.00 am, he will charge me £120 call out fee, therefore that blocked sink can wait...
>
> Phil
>
> .
>
>
>
> --
> Jel Coward
>
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