Unsafe admission

Yes, we all know the NHS is in crisis.

I don’t get the sense that people fully understand the enormity of the problem, but, there you go… Boiling frogs.

I have been reading recently about a concept I hadn’t heard of before – potentially unsafe discharge.

This is all an extension of ‘medically fit’ – the half-arsed notion the NHS uses to guide patients’ return home after a hospital stay.

It is a continuum – the patient moves from being medically fit to undergoing a safe discharge. The latter means you send the person home with the belief that they are not as unwell or sick as when they first attended – arrive with broken hip, go home with crutches, arrive breathless with pneumonia, home with antibiotics, this sort of thing.

All of this is also part of the idea that can result, when it goes wrong in failed discharge – this is when a patient is unexpectedly readmitted to hospital – officially, in the UK, within 30 days of them going home. Although, as with everything in healthcare there is more to it than that and, perhaps for another day, as I want to get back to the discharge process.

Going back to the crisis I mentioned at the start, the corollary of this is people going home who are less and less fit; I think back to the 70’s and one of my favourite sitcoms – ‘Only when I laugh*’ – the idea being, the wound/stitches/injury only hurts when I laugh, and, the joke, you shouldn’t be laughing in hospital, with the irony that none of the patients are that unwell and the further twist being the concept that in hospital people are sick and shouldn’t be too happy – which of course we know is wrong; just because you are old/ill/frail/infected/whatever doesn’t mean you lose your sense of humour.

(please excuse any double negatives in that last paragraph :-))

Anyway –

Most hospital inpatients these days fit into three broad categories –

Those who are very sick – who, without 21st Century care might die prematurely

Those recovering from being very sick

And, all the rest, most of whom are older, with multiple co-morbid conditions.

This latter group are usually the ones in the category of medically fit who are stuck waiting for physiotherapy, rehabilitation and most painfully social care – home care, care home, that sort of thing.

Again, I am going off-piste;

It is mostly accepted that we should aim for medically fit people who receive safe discharges. In this age of austerity, what is medically fit has been mutated into what might have been considered medically-unfit and unsafe discharge ten years ago.

And this too is not my point.

Where I am trying to get, is the start of the whole process, which relates to the other side, of the end-game – discharge; it is the concept of hospital admission – the notion that it is far easier to be admitted to hospital than it is to see your GP (although, I concede admission these days is harder than it was five years ago, with significant national variation).

It is relatively easy to enter hospital because most frequently the services at the front-door i.e. A&E, aren’t strong enough owing to inadequate links with community services or the pressure of less concrete concepts such as social isolation, loneliness, frailty being so great.

The example being:

89-year-old woman, lives alone, dementia, diabetes, COPD, has fallen, bruised face – best admit.

And this is the thing. This is the nub.

This is the polar opposite of an unsafe discharge, it is an unsafe admission. It is where the pressures, the demands – our friend the four-hour wait, influences decisions and instead of stepping back and looking at the situation as a whole, we focus on the tiny elevation in blood pressure or white cell count and translate this into, too unsafe to go home, not taking into account the potential harms that this can cause –

Loss of identity, disorientation, hospital acquired infection, falls, immobility, incontinence, pressure sores, dehydration, malnutrition, drug errors – the list of possibles is long.

Some hospitals have this sussed; creating frailty services that try to intercept the older people at the front door and reverse the unsafe admission; this is a growing movement and not embedded in all hospitals, nor is it the universal experience of all patients who might benefit – the current, dominant model of care being high-tech, acute medical, single-organ based, CT scan, take pictures and ask questions later practice. Nationally we have invested in acute services rather than services for older people, this latter effectively being what acute services are, but not everyone has woken-up to.

So –

The challenge.

Consider both unsafe discharges, don’t send people home too soon because of the pressure of beds, only to have them deteriorate and return in a worse condition five days later, equally, do everything you can to avoid one of the worst things that can happen to an older person – unnecessary hospital admission.