To send home or not?

This is one of the hardest questions in healthcare.

The scene:

Patient is unwell, falls, vomits, experiences chest or abdominal pain; they either make their way to the GP who send them to the hospital or, as is most common these days, they take themselves to the A&E department or are brought by ambulance.

They arrive; tabula rasa. A constellation of signs and symptoms.

A nurse or doctor struggles to make sense of the information; drawing-in the story, the observations, examination and test results.

From here there are two outcomes – home, either reassured or perhaps take these antibiotics or pain-killers or, refer onwards.

For most emergency departments in the UK this means contacting the medical team either to route someone down the acute admission or if older, frailty route.

Before this stage is reached there are already a multitude of variable – thoughts, concerns and ideas passing-through the mind of the A&E doctors or nurses.

The symptoms are innocuous – are they really innocent?

Have I missed an important question?

Could the patient deteriorate rapidly?

Is hospital the safest place?

Yesterday in the hospital during the morning with my team I saw 22 patients, this is excluding relatives. I must have asked several hundred questions and made just as many decisions.

At what point is your bandwidth too full?

There was a moment when I was leaning against a wall, surrounded by people, when I felt that was probably it.

Bandwidth is an interesting phenomenon.

It compares human ability, particularly cognitive processing to a broadband or computer cable; you reach a certain volume of data and things can go no faster, indeed, because of congestion, the process slows-down, like rush-hour traffic.

When we were evolving on the African savannah, I doubt believe this was an issue – sure we needed to cope with lots of information, but, you would only be hunting one impala, not an entire herd.

So, the decision-making processes are difficult and the more information, the more interruptions and challenges, either the slower you get or the more you are likely to opt for a tried and tested heuristic.

In the case of the emergency department, you could sit and calculate the odds of a pain being a muscle tear or a clot, or you could assume clot, admit the patient and move-on.

Assuming clot and being wrong is never as bad as not and being wrong – in other words, you send person home and they collapse and die.

The balance or the challenge however is when allowing for more processing ability in your part of the system, the pressure is moved downstream to the mostly young doctors who are juggling themselves with multiple demands, assumptions and challenges.

The jam at Watford is relieved but the M25 overwhelmed to continue the motorway analogy.

When I see a patient, my first goal is to determine what is happening; or actually, for me at least, it is to do my best to gather the information, have a rough idea where things are heading, put the patient and often their family at ease and plan the next steps;

Again, here as with A&E the situation is similar – keep-in treat or investigate, or, send home, treat or investigate as an outpatient; not that difficult. Yet, here a second-wave of complexity begins.

By the time a patient has reached me they have passed through another layer; more symptoms have been elicited, more blood results, data and information accumulated. In some respects, this is useful, but equally it thickens the soup and makes any next steps more challenging.

And here I am at an advantage as having spent a proportion of my time working, engaging and talking with the services and care providers who operate outside the hospital system, I have a good understanding of who is safe to be at home, particularly if you are old, frail or vulnerable.

From my years examining complaints and incidents I have insight into the potential harmful aspects of hospitalisation often in older people; I therefore have a relatively high threshold for keeping people in.

This however adds inertia to my creaking cognitive processes; if we do this, and that, and that and Nora can do that and that and this, then… Lots of logic functions that result in avoidance of harm and maintenance of wellbeing.

It is not easy.

It is funny however when people consider the fevered hospital atmosphere where cries of ‘discharge!’ often ring-out on Monday afternoon as the system like the mind of the poor doctor or nurse is sludging-up, a fat-ball of actions and risk mitigation.

It might sound dull, yet, I revert to something I have been discussing for a long-long time.

Let’s put all our energy into supporting the decision-making processes up-front, augment the teams who can determine what is happening and how best to help (sometimes called doctors, nurses, therapists, pharmacists and in particularly special conditions, trusted assessors.)

Hospital admission is easy; you just have to worry or overwhelm the relevant doctor or practitioner with enough red-flag symptoms for their resolve to falter. If we can match this with an acknowledgment of the challenges of the work, we might get somewhere.

When I decide home or stay, the pressure can be significant. Nothing however is achieved by operating at a level of intensity beyond my ability.

I don’t have an answer to this; I think if there was more capacity (up front), perhaps more dignified time to slow-down a little, we might make better decisions that would lead to improved outcomes for patients and staff. (Thanks, four-hour wait).

I was talking with a wonderful young doctor yesterday about the pros and cons of sending people home; my mantra, now I am getting old, being, if you are going to be left in doubt, if you might not sleep that night because of worry, don’t do it.

The more experience I have gained, the more I have avoided these perilous situations which save me and likely my patients risk and grief. It is all to do with how confident you feel standing on the edge.

Perhaps my suggestion is to stand on the very brink, on tippy-toes, yet feel safe with whatever safety-net or harness is available.

Collective decision making (led by someone who is willing to take responsibility) is the ideal way forwards.

Stay or go?

‘Go and come back if you aren’t right or you are worried.’

Safety net.

‘I am human, I sometimes make fail, regard me thus and we will be OK.’

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