Modes of Admission to Hospital: A Survey of Emergency Admissions to a General Medical Unit

In a survey of the modes of referral and disposal of “acute patients” to a general medical unit during the period 1 February 1968 to 31 July 1970 only 1,432 out of 3,455 were referred by general practitioners. There was a high incidence of self-referral to hospital, and this trend was on the increase. A large percentage of self-referred patients came from their homes, and 65-77% of these arrived by ambulance ordered by themselves.     

Access to Primary Care and Visits to Emergency Departments in England: A Cross-Sectional,Population-Based Study

Background

The number of visits to hospital emergency departments (EDs) in England has increased by 20% since 2007-08, placing unsustainable pressure on the National Health Service (NHS). Some patients attend EDs because they are unable to access primary care services. This study examined the association between access to primary care and ED visits in England.

Methods

A cross-sectional, population-based analysis of patients registered with 7,856 general practices in England was conducted, for the time period April 2010 to March 2011. The outcome measure was the number of self-referred discharged ED visits by the registered population of a general practice. The predictor variables were measures of patient-reported access to general practice services; these were entered into a negative binomial regression model with variables to control for the characteristics of patient populations, supply of general practitioners and travel times to health services.

Main Result and Conclusion

General practices providing more timely access to primary care had fewer self-referred discharged ED visits per registered patient (for the most accessible quintile of practices, RR = 0.898; P<0.001). Policy makers should consider improving timely access to primary care when developing plans to reduce ED utilisation.     

Open access to orthopaedic appliances for general practitioners.

A clinic to which general practitioners can refer patients for some types of orthopaedic appliances was opened in North Clwyd in 1983. During 1985, 956 patients were referred by 82 general practitioners; 860 patients received an appliance, and the average waiting time was less than five weeks. Most referrals were for soft collars (44%), lumbar sacral supports (30%), and dorsilumbar supports (7%). Thirty eight patients failed to attend, 54 declined an appliance, and four referrals were considered to be inappropriate. A few patients were subsequently referred to consultant outpatient clinics, 22 for physiotherapy and 34 were referred simultaneously to the open access clinic. The referral rates for general practitioners with access to community hospitals were low. Such an arrangement merits wider consideration.     

The Hospital Bed and the General Practitioner: A Pilot Study of Two Practices with Respect to Hospital Bed Usage and Patient Management

Fourteen hundred randomized patient records of two urban practitioners covering a one-year period were studied. The two practitioners represented two very different types of general practice. Dr. A was an active staff member of a teaching hospital; Dr. B confined his work to office and home visits.The age, marital status, occupation, diagnoses, and patient management were coded on IBM cards, and the data analyzed with the aid of a computer program.The findings indicate that over 90% of patients seen by both practitioners were managed entirely from their offices. Dr. A admitted 41 (5.9%) of the 700 patients seen and referred 24 (3.4%); Dr. B admitted no patients and referred 44 (6.3%). These and other findings suggest that the role and function of the urban general practitioner is changing rapidly in this era of specialization.     

Self referral to an accident and emergency department for another opinion.

OBJECTIVE--To determine whether patients referring themselves to an accident and emergency department for another opinion after consulting their general practitioner present with serious illness, show any risk factors for being admitted, or are more likely to be patients of particular practitioners. DESIGN--Six month prospective survey. SETTING--District general hospital''s accident and emergency department, receiving 42,000 new patients a year. PATIENTS--180 Patients identified as attending for another opinion having already consulted a general practitioner. INTERVENTIONS--Classified as admission, referral to specialist clinic, follow up in accident and emergency department, or referral back to general practitioner. END POINT--Admission, with an analysis of admitted patients. MEASUREMENTS AND MAIN RESULTS--General outcome, diagnostic category, age, time of attendance, time since seen by general practitioner, and name of general practitioner were recorded. Forty seven patients were admitted, 99 were discharged back to the general practitioner (62 without a letter), and two died. Patients were most likely to be admitted if they attended within 24 hours after seeing a general practitioner, were aged under 5, or presented with respiratory or gastrointestinal complaints. Some general practitioners were overrepresented. CONCLUSIONS--Important disorders present in this way, and therefore these patients should be seen by a doctor. Information about these attendances could be useful to general practitioners in reviewing their performance.     

Sources and patterns of referrals of oral cancer: role of general practitioners.

Referrals of patients with oral squamous cell carcinomas to an oral medicine clinic were assessed with regard to the sources, delays, and pattern of referrals from general medical practitioners and general dental practitioners. Slightly more patients were referred by dental practitioners than by medical practitioners, but general medical practitioners were far more likely to see advanced tumours and to request an urgent second opinion or suggest a diagnosis of malignant disease. The greatest delay overall was caused by the patients in seeking advice from their practitioner, particularly those who attended a general medical practitioner. Both groups of practitioners requested a hospital opinion within roughly a month--a reasonable interval. Subsequent delays were minimal. Delays occur mainly because the patients are slow in seeking professional advice and, in general, do not appear to have been reduced over the decade since a previous British study on referral patterns was carried out. This study emphasises the importance of educating patients about oral cancer since it is they who appear to be mainly responsible for the delays in diagnosis. The results also help to dispel the myth that general medical practitioners might be less competent at diagnosis and referral of patients with oral cancer than are dental practitioners, though we are aware of misdiagnoses from both groups.     

Medical patients aged 65 and over admitted to an accident and emergency department.

A study of 100 consecutive emergency medical admissions to Oldchurch Hospital was made to establish if the mode of referral--either by the general practitioner or self referral--influenced the presentation and severity of illness and the eventual outcome. Of the 94 cases analysed, 55 were self referred and 39 were sent in by their general practitioners. No significant differences were found between the two groups of patients, which suggests that the patient (or the patient''s family or companion) is as discriminating as the general practitioner in deciding when emergency referral to hospital is necessary.     

Coronary Care Unit in a General Medical Ward

A five-bedded coronary care unit has been set up within a general medical ward without the provision of extra medical or nursing staff. During 30 months 1,000 patients were admitted. Sixty-three developed cardiac arrest; 28 were resuscitated successfully initially; and 18 were eventually discharged. The corresponding figures for the 28 patients with ventricular fibrillation treated by direct current defibrillation were 20 and 12 respectively. The mortality rate during the first three days (the usual length of stay in the unit) was 8·9% compared with 9·7% after transfer to the general ward. It is suggested that these results are comparable with those from more highly staffed purpose-built units.     

Cost effectiveness of treating primary care patients in accident and emergency: a comparison between general practitioners,senior house officers,and registrars.

OBJECTIVES--To compare outcome and costs of general practitioners, senior house officers, and registrars treating patients who attended accident and emergency department with problems assessed at triage as being of primary care type. DESIGN--Prospective intervention study which was later costed. SETTING--Inner city accident and emergency department in south east London. SUBJECTS--4641 patients presenting with primary care problems: 1702 were seen by general practitioners, 2382 by senior house officers, and 557 by registrars. MAIN OUTCOME MEASURES--Satisfaction and outcome assessed in subsample of 565 patients 7-10 days after hospital attendance and aggregate costs of hospital care provided. RESULTS--Most patients expressed high levels of satisfaction with clinical assessment (430/562 (77%)), treatment (418/557 (75%)), and consulting doctor''s manner (434/492 (88%)). Patients'' reported outcome and use of general practice in 7-10 days after attendance were similar: 206/241 (85%), 224/263 (85%), and 52/59 (88%) of those seen by general practitioners, senior house officers, and registrars respectively were fully recovered or improving (chi2 = 0.35, P = 0.840), while 48/240 (20%), 48/268 (18%), and 12/57 (21%) respectively consulted a general practitioner or practice nurse (chi2 = 0.51, P = 0.774). Excluding costs of admissions, the average costs per case were 19.30 pounds, 17.97 pounds, and 11.70 pounds for senior house officers, registrars, and general practitioners respectively. With cost of admissions included, these costs were 58.25 pounds, 44.68 pounds, and 32.30 pounds respectively. CONCLUSION--Management of patients with primary care needs in accident and emergency department by general practitioners reduced costs with no apparent detrimental effect on outcome. These results support new role for general practitioners.     

The role of deputizing agencies in the delivery of primary health care services.

When not available to their patients, family practitioners in large cities can "sign out" to deputizing agencies, which coordinate the activities of part-time physicians on call. The physicians making use of one such agency in Toronto appeared to be representative of family practitioners in the region. One thousand of their patients seen consecutively by one physician were asked a series of questions. The majority of the 811 evaluable patients were considered to have problems justifying an after-hours call, although 16% of the problems were of a trivial nature. However, almost half of the patients with trivial problems would have gone to the local emergency room, as would 85% of all the patients. Although virtually all (94%) of the visits with the elderly were justified, 34% of the patients in this age group said they probably or definitely would not have sought emergency room care if a physician had not been available. The use of deputizing agencies should reduce the overuse of emergency room facilities and provide optimal after-hours primary medical care.     

Nurse practitioners in accident and emergency departments: what do they do?

OBJECTIVE--To determine the distribution and scope of nurse practitioner schemes in accident and emergency departments in England and Wales; to describe the caseloads of doctors and nurse practitioners on two representative days; and to estimate the number of patients managed by nurse practitioners in the year to 31 March 1991. DESIGN--A postal survey of accident and emergency departments and a content analysis of case notes of new patients attending a representative sample of accident and emergency departments on two days. SETTING--All accident and emergency departments in England and Wales. PARTICIPANTS--Survey: 560 nurses in charge of accident and emergency departments. Census: case notes of 5814 patients in 37 accident and emergency departments. MAIN OUTCOME MEASURES--Survey: number of accident and emergency departments with nurse practitioner schemes. Census: demographic and clinical characteristics of new patients attending and whether nurse practitioner or doctor made diagnoses and ordered investigations, treatments, referrals, discharges. RESULTS--513 replies (92%) from 465 surveyed functioning accident and emergency departments and 48 departments recently closed. 27 (6%) departments used designated nurse practitioners and 159 (34%) "unofficial" nurse practitioners. Only 530 (9%) of the 5814 patients in the census were managed entirely or mainly by nurse practitioners, with higher proportions in ophthalmic departments (nearly 30%) and minor casualty departments (over 40%) than in major departments (3%). Most patients managed by nurse practitioners (86%) had minor trauma. In the year ending 31 March 1991 an estimated 390,000 (95% confidence interval 260,000 to 520,000) patients out of a total of 12.5 million (3.1%, 2.1% to 4.1%) were clinically managed by a nurse practitioner. CONCLUSIONS--Designated nurse practitioner schemes are rare. The volume and range of nurse practitioner work in major general accident and emergency departments is small compared with those in specialised and minor accident and emergency departments.     

Evaluation of the efficacy and acceptability to patients of a physiotherapist working in a health centre.

The records of the first 805 patients who had been referred by general practitioners at this health centre to the attached physiotherapist were examined in November 1985, three years after the physiotherapy department was opened. Seventy per cent (549) of the patients had been treated within one week, treatment having started on the same day for 8.5% (67) of the patients. This compares with a mean of six weeks for direct access to a district general hospital that is eight miles away and between six and 13 months for the three nearest orthopaedic consultants who are 13 miles away. The most common conditions treated were knee injuries (16.5%), followed by cervical (15.5%) and shoulder (13.8%) injuries. Surprisingly, only 9% were back injuries. The non-attendance rate was 2.2% and only 7% of patients failed to complete treatment. Nearly all the patients were able to attend the clinic, only 4% requiring home treatment. By March 1986, 90 treatments a week were being carried out at a cost of 6.11 pounds per patient. Compared with official hospital figures, this represents a savings of 21,500 pounds a year for a practice of 12,000 patients.     

Management of labour in an isolated rural maternity hospital.

OBJECTIVES--To evaluate the use of a maternity unit run by general practitioners and midwives, describing the outcome of labour in an unselected group of women and quantifying the contribution made by general practitioners. DESIGN--Retrospective population based review of obstetric patients who had access to an isolated rural maternity unit. SETTING--Rural area 120 km from a consultant maternity unit. SUBJECTS--997 consecutive women delivered between January 1987 and May 1991. MAIN OUTCOME MEASURES--Mode of delivery and complications by place of booking and place of delivery; need for medical intervention and transfer. RESULTS--530 women (53%) were booked for delivery in the rural unit; this group had a caesarean section rate of 3.8% and an unplanned transfer rate of 12.8% to the consultant unit in labour. Of the 462 who delivered in the low risk unit, 25 (5%) required a forceps delivery; postnatal complications requiring emergency medical support occurred in a further 33 (7%). CONCLUSIONS--Risk characterisation is possible, but medical support from general practitioners and obstetricians is required in almost a third of women at low risk for complications of delivery. Results of this study support the team approach to obstetric management but not the move towards isolated units without organised medical support.     

Newly registered elderly patients: who are they and why such delay in the transfer of their medical records?

The time taken to transfer the records of elderly patients registering with a new general practice was investigated. Thirty five (5%) of a total of 671 patients aged 75 and over were entered as new patients on to the age-sex register of an urban group practice during one year. Twenty nine had moved into the area and six had changed their general practitioner for personal and other reasons. An average of 141 (range 71-296) days elapsed before dispatch of their medical records to the new practice. During this period an average of 3·5 (range 0-15) consultations with a general practitioner were recorded, indicating the need of such patients for medical care. The long delays were caused by the processing of medical records at the central register and the transfer of records between family practitioner committees and general practitioners. Delays were most apparent in the time taken for general practitioners to dispatch the necessary documents to the family practitioner committees, and these should be minimised.The use of a summary card written and updated by the general practitioner and retained by the patient would facilitate continuing care should patients change to a new practice. Meanwhile, assessment of elderly patients after registration with a new practice by a member of the primary health care team may identify problems before the records have been transferred and may help the resettlement of these high risk elderly patients.     

Use of Radiological Facilities by General Practitioners

The 11,360 direct referrals to diagnostic radiological facilities by general practitioners in the Aberdeen area during 1973 were studied. These represented about 12% of the adult radiology performed in the main x-ray departments of the city, and barium meal examinations amounted to half of all such outpatient contrast examinations. Chest x-ray and barium meal examinations were the most frequently used procedures.Some abnormality was detected at 34% of all examinations, and the barium meal examinations requested by general practitioners showed a similar percentage of abnormal findings to those requested by Aberdeen hospital doctors.The average referral rate for all practices was 24·6 per 1,000 practice population per year. Singlehanded general practitioners referred fewer patients for diagnostic radiology than those working in group practices, and rural practitioners referred fewer than urban general practitioners. This trend was emphasized at a distance greater than 15 miles from the city.     

Referral patterns to an ophthalmic outpatient clinic by general practitioners and ophthalmic opticians and the role of these professionals in screening for ocular disease.

Case notes of 1113 consecutive new patients referred to a consultant ophthalmologist at a district general hospital were reviewed to determine the source and efficacy of referrals and the current screening practices of general practitioners and ophthalmic opticians. General practitioners initiated referral in 546 cases (49%) and ophthalmic opticians referral in 439 (39%). Visual loss or visual disturbance was the most important single reason for referral (345 cases; 31%), followed by suspected glaucoma (145 cases; 13%), abnormalities of binocular vision (140; 12.5%), disorders of eyelids or ocular adnexa (127; 11%), and red eye (86; 8%). General practitioners referred many more patients with disorders of the eyelids and adnexa and ophthalmic opticians many more patients with suspected glaucoma. Ophthalmic opticians were far more likely than general practitioners to refer patients with suspected glaucoma correctly. A total of 180 patients (16%) were referred from ocular screening, in 149 cases by ophthalmic opticians and in 10 by general practitioners. Seventy patients had glaucoma or incomplete features of glaucoma, all of them referred by ophthalmic opticians. Of eight diabetic patients referred by ophthalmic opticians, three had asymptomatic disease and in two diabetes was diagnosed as a result of ocular screening. No patient was referred for asymptomatic diabetic retinopathy from screening by general practitioners. Ophthalmic opticians were more likely than general practitioners to diagnose retinopathy requiring photocoagulation. Use of a community based service to screen for glaucoma could save unnecessary consultant outpatient appointments. A similar service could facilitate detection of diabetic retinopathy at a stage when treatment is most effective.     

Home care for patients with suspected myocardial infarction: use made by general practitioners of a hospital team for initial management.

Two hundred and sixty three general practitioners were offered the use of a hospital based service consisting of a medical senior house officer, a nurse attached to a coronary care unit, and a specially equipped ambulance estate car to help with the initial management of patients with suspected myocardial infarction who might be suitable for home care. One hundred and sixty nine general practitioners registered as potential users of this service; during 22 months they called the hospital team to see 271 patients, 235 of whom the team suspected had indeed suffered a myocardial infarction. During the same period, however, these general practitioners also admitted 317 patients with suspected myocardial infarction directly to hospital. Other general practitioners admitted 323 patients and deputising doctors 258. A further 529 patients with suspected infarction were admitted without the intervention of a general practitioner. Of the patients seen by the team, 54 required immediate admission to hospital; 17 of the remaining patients who initially appeared suitable for home care later required admission to hospital. In a large city such as Nottingham the provision of hospital based facilities to help general practitioners with home management is unlikely to make an appreciable impact on the overall pattern of care of patients with suspected myocardial infarction.     

Census of single homeless people in Sheffield.

OBJECTIVE--To determine the number of single homeless people in Sheffield and to examine their demography and social and medical details. DESIGN--Census carried out between 8 am and 8 pm on one day. Participants completed a questionnaire designed to provide data relating to employment history, contact with welfare and health services, social state, prison history, medical history, and health state. SETTING--Sites in Sheffield identified by local workers as being places of residence of homeless people. SUBJECTS--340 single homeless people. MAIN OUTCOME MEASURES--Self reported history of alcohol or drug misuse, existence of a chronic medical condition, and use of general practitioner and hospital services. RESULTS--The mean age of the population was 42.5 years and a quarter of the population were aged less than 30; there were 48 women. Significant differences were noted between men and women with respect to self reported psychiatric illness (77/266 men v 27/42 women), self reported alcoholism (83/273 v 4/44), prison history (152/255 v 8/41), and registration with a general practitioner (73/275 v 38/46). Various chronic medical conditions were reported, and the perceived health state of the population was low; 129 claimed to have been admitted to a psychiatric hospital. 220 people were registered with a general practitioner, and 179 claimed to see their doctor. Sixty five had attended or been admitted to a general hospital in the month preceding the study, 45 for accident and emergency services. CONCLUSIONS--The homeless in this population were younger than those found in previous studies. The prevalence of psychiatric illness was high in the population, and the overall health state was poor. Most subjects obtained health services from general practitioners.     

Out of hours workload of a suburban general practice: deprivation or expectation.

The out of hours workload of a training practice in a suburban and semirural area on the south coast of England was studied for one year. An overall rate of contact of 273/1000 patients was found, which indicated a workload greater than that reported in most other studies. The duty doctor received over 35 telephone calls from patients during some Saturdays (1200 Saturday to 0800 Sunday) and Sundays (0800 to 0800 Monday), up to five being between 2300 and 0700. Of the patients who contacted a general practitioner, 44% were given advice by telephone and 4.9% were admitted to hospital. The admission rate was lower than that given in other studies. A considerable proportion of the workload arose from doctors covering the casualty department of a cottage hospital. Patients having a high expectation of 24 hour care by general practitioners in an area of comparative affluence (Jarman indices -13.8 to 1.7) may account for this aspect of the workload.