Hospital admissions from nursing homes: a qualitative study of GP decision making

Abstract

BackgroundDecisions regarding the hospitalisation of nursing home residents may present a difficult dilemma for GPs. There are pressures to admit very frail patients with exacerbations of illness even though such frailty may limit the possible health gains. As 'gatekeepers' to NHS, GPs are expected to make best use of resources and may be criticised for 'inappropriate' admissions. Little is understood about the influences on GPs as they make such decisions AimTo explore GPs views on factors influencing decisions on admitting frail nursing home residents to hospital. Design and settingA purposive sample of 21 GPs from two counties in the South of England. MethodData from semi-structured, one-to-one interviews with GPs were analysed using thematic analysis following principles of the constant comparative method. ResultsThis study suggests that while clinical assessment, perceived benefits and risks of admission, and patients' and relatives' preferences are key factors in determining admissions, other important factors influencing decision making include medico-legal concerns, communications, capability of nursing homes and GP workload. These factors were also perceived by GPs as influencing the feasibility of keeping patients in the nursing home when this was clinically appropriate. Key areas suggested by GPs to improve practice were improving communication (particularly informational continuity), training and support for nursing staff, and peer support for GPs. Local initiatives to address these issues were very variable. ConclusionDeveloping a systematic palliative care approach to address poor documentation and communication, the capability of nursing homes, and medico-legal concerns has the potential to improve decision-making regarding hospital admissions.

Appropriateness of unscheduled hospital admissions from care homes

“…Care-home residents are vulnerable to unanticipated changes in health, either as a result of decompensation of chronic disease or new pathologies. Decision-making processes about hospitalisation have to balance patient and carer preferences, clinical and medicolegal risk and the perception of this risk (which might be a particular issue for those with less clinical experience), 10 and differing models of care. 11 Various reports suggest that healthcare staff do not always make the right decision, 7 and there is wide variation in GPs' perceptions about the management of carehome residents in the emergency department setting.…”

The Family Physician's Perceived Role in Preventing and Guiding Hospital Admissions at the End of Life: A Focus Group Study

“…[26][27][28] Moreover, family physicians might sometimes feel unable to provide up-to-date and adequate end-oflife care, 26,27,29 and decisions about a transfer to a hospital at the end of life can be complex and multifaceted. 30 In Belgium there is a strong emphasis on primary care, with almost 95% of the population having a family physician whom they consult regularly (78% at least once a year). 31 Moreover, as end-of-life care is integrated into the regular care system, family physicians usually coordinate and provide out-of-hospital end-of-life care.…”

Variation in ambulance call rates for care homes in Torbay, UK

“…A number of commentaries have expressed the view that admissions to hospitals from care homes are the direct result of poor patient care or poor staff training (Partridge , McDermott et al . ). Our findings are consistent with previous research that has shown that having dementia increases the risk of admission to hospital for ACS conditions (Carter & Porell ).…”