A GP working in OOH is likely to admit a number of patients to hospital each shift – particularly if performing a “mobile” session. There will also be a number of factors that influence the decision to admit that may not necessarily be present in an in-hours consultation. Some factors you may wish to consider are:-
- Lack of prior knowledge of patient
- Lack of support (nursing, lab results, relatives etc.) OOH
- Difficulty in examining patient (if seen in a poorly lit home with no examination facilities
- “Things seeming worse at night”
- Alcohol +/- drugs
- Your own time needs – e.g. 5 patients waiting for a call
There are probably many other circumstances that impact on this decision. The following section may help you to analyse pressures on you to admit a patient and also allow you to discuss a mix of cases seen in an emergency situation.
To be able to follow up patient progress when admitting it would be wise to get patient consent for this at the time of admission.
Record 10 consecutive cases Out Of Hours in which admission was considered. A conscious decision not to admit is as important as a decision to admit. A template to facilitate the data collection is available here
This exercise can be used to identify learning or developmental needs, it could also be used to help inform your next PDP.
A completed example could look like this:-
|Clinical details||Reason that admission considered||Admitted Y/N||Was follow up possible||Discussion – could the outcome have been different|
|6 Month old child with high temp not feeding and vomiting||No obvious focus of infection 10 pm mum worried||Y||No||This child had been ill for 12 hours was getting worse – no calpol had been given. No obvious focus of infection and child v hot – some social pressure on admission (mum living alone not coping)|
|27 year old female with left sided pelvic pain and 5 weeks since LMP||Possible ectopic||Y||No||I believe this an appropriate admission – could not wait until morning due to risk of serious bleed|
|86 year old female patient in nursing home very confused and shouting out (2 am)||Pressure from nurse in charge as disturbing other residents||N||N/A||Seemed like toxic confusional state of acute onset. The patient was not previously known to this nurse but it was obvious from the records that this lady had previous episodes which responded to antibiotics – prescription given|
|45 year old man with acute severe r flank pain IM diclofenac administered and advice for recall in 1 hour if no better||Renal colic||N||N/A||I could have admitted this patient and probably would have a few years ago. These days however the ability to recall is much improved and indeed this chap had settled considerably – advised to see own GP the next day|
|3 year old child with D+V for 3 days not keeping fluids down and lifeless (11pm)||Child unwell and dehydrated||Y||No||Had been seen earlier in day by own GP – advised to try small amounts of fluid – child unable to tolerate even sips – Needed admission|
|18 month child with abdominal pain and diarrhoea||Extreme pressure from father (? Alcohol)||Y||No||Child did not require admission but social circumstances poor, father very aggressive and I had no real choice – letter to own GP highlights this|
|74 year old man living with wife. Cough and high temp for 3 days on Amoxicillin no better difficulty sleeping (11.30pm)||Chap was quite unwell||Y||No||I don’t think admission was appropriate here on reflection. There were no physical signs in chest and although feverish he was quite lucid and able to walk around – last patient on my shift – I wonder?|
|67 year old diabetic lady symptoms of UTI and high sugars. Type 2 DM on insulin – capillary sugars 19, 21 and 17 over last 3 hours||Loss of diabetic control with infection||Y||No||I really was not sure what to advise this lady regarding her insulin and I could not check her urine for ketones so I admitted her|
|52 year old man with 3 episodes of short lived chest pain over last 48 hours||Possible angina episodes||Y||No||Younger man with possible new angina I felt more comfortable in admitting him despite the fact that he was fine and there were no physical signs|
|14 year old boy with 12 hour history of r sided abdominal pain||Possible appendix||Y||No||Gave a story of progressive colicky abdominal pain with tenderness in RIF|
Learning points identified from these cases
The 10 cases took me 3 sessions to collect (18 hours). I feel that the vast majority of these cases demonstrate appropriate clinical care. There are however four cases that I would have perhaps treated differently had they been my own patients In-Hours.
I remember the consultation with the 18month old child and the aggressive father vividly. I felt intimidated and took the easy option to extricate myself from a sticky situation. I did highlight the issue with the aggressive father to his own GP and indeed once I had left the house I phoned the Paeds SHO and warned her. The child did not need admission from a medical point of view but I believe I had very little option. I don’t often get problems with aggressive patients OOH but this case reminded me that every so often there are personal safety issues. There is an event planned for next year dealing with the aggressive patient and I will make every effort to attend.
The 74 year old man with the cough that I admitted was probably not the best choice. I was at the end of my shift and tired, it was easier to admit. I have reflected on that decision and will make an effort not to do that again.
The 67 year old diabetic lady with the UTI and loss of diabetic control raises two issues for me. Firstly I did not have the correct equipment available (ketostix) – I have since addressed this with OOH medical director and they are now part of the standard equipment (oddly enough they would have been available at base). The second issue is a personal learning point – I really did not feel confident in adjusting this lady’s insulin dose (the real reason for admission). I have had similar issues In-Hours and have identified diabetes in general as a learning need but now with more and more Type-2 diabetic patients converting to insulin I need an update in management.
The 52 year old man with 3 episodes of short lived chest pain threw me a bit and as they sounded cardiac in nature my instinct was to admit. On reflection these episodes were all related to rushing up a certain hill near his home and lasted less than 3 minutes each – I should probably have given a GTN spray, advice to take it easy and referred him to his own GP the next day. I am a little confused with the acute investigation of possible new angina and as such probably need to read local protocols.
From the above I would like to make the following changes:-
- Attend an event on dealing with the aggressive patient
- Learn more about diabetes – specifically issues around insulin use in type-2 DM
- Examine my referral pattern again to pick out patients I may admit as “an easy option”
- Find local or national protocols regarding management of new onset angina
- Explore ways to follow up admitted cases out of hours for my personal learning feedback.