Background
The role of general practitioners and nursing home physicians in hospital readmissions
Case-based decision theory
Purpose of the study
Methods
Study design
Sample and recruitment of municipalities
Description | Municipality A | Municipality B |
---|---|---|
Distance from the hospital | 5–35 km | Hospital placed within the municipality |
Inhabitants | Approximately 40,000 (rounded down) | Approximately 40,000 (rounded up) |
Physician Full Time Equivalent (FTE) per 10,000 habitants | 8 | 9 |
Degree of nursing home coverage or coverage in institutions for persons 80 years and older as a percentage of the corresponding age group in the population | 11% | 15% |
Emergency room | 1 | 1 |
Municipal Emergency Bed Unit (MEBU)/ Hospitals Emergency Bed Unit (HEBU) short-term nursing home/rehabilitation/palliative care | 1 | 1 |
MEBU/HEBU distance to hospital | 5 km from the hospital | Less than 5 km from the |
Context
Data collection
Years of experience | Included physicians (municipality A) | Included physicians (municipality B) |
---|---|---|
0–5 | 5 | 1 |
5–10 | 2 | 3 |
10–15 | 2 | 2 |
< 15 | 1 | 4 |
Mean years of experience | 9,6 years | 15 years |
Analysis of interviews and observation data
Theme | Category | Sub-category | Codes |
---|---|---|---|
T2: Lack of coordination, access to and continuity in the patient information flow | Information exchange | Lack of coordination between primary and secondary healthcare services |
Communication between the municipal healthcare service and the hospital during hospital discharge, is not good enough
|
Inadequate access to patient information |
Lack of adequate information exchange within the municipal healthcare service, and between the hospital and the municipal healthcare service
| ||
Medication- lists which are not up-to-date leads to additional work for the receiving physician
| |||
Status on resuscitation is not always clarified
| |||
Physicians baser their decisions on clinical assessments, the patients general condition and results from available measurements
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Continuity | Lack of continuity in the patient treatment |
It is difficult to know about previous hospital admissions; if the patients’ medical problem is already known and how the patients coped after ended shift at the emergency room
| |
Hospital admissions can become necessary because the nursing home physician don’t have the opportunity to do follow-ups during weekends and evenings at MEBUs
|
Results
Theme 1: Transference of responsibility from the hospital to the municipal healthcare service
The problem is, they [the hospital doctors] exclude a bone fracture, but they don’t investigate any further why the patient had fallen in the first place. (GP, Municipality B).
We’ve received phone calls from the head physician at the hospital, explaining to us that the hospital is full and that we should re-hold all hospital admissions. But… this can be compared with them saying that we sometimes admit patients to the hospital for the fun of it… if you know what I mean. (GP, Municipality A).
Theme 2: Lack of coordination, access and continuity in the patient information flow
I do believe, that in the relay race, when you pass the baton to the next sprinter, it should be a smooth transfer, not “here comes the stick,” you know, “catch it if you can!” (GP, Municipality B).
We have to call the on-call physician (to get information) because the patients don’t have the hospital stay summary along with them, and they don’t remember what have been done and said at the hospital. And they’re like “I got one pink pill and two green pills” and then I have to call, and that is annoying, especially if it is busy. (GP, Municipality B).
She had a known heart condition and a GP would probably have handled it differently. But as an emergency room physician without information about the patient, a hospital admission was the only solution. (GP, Municipality A).
If they can’t get hold of me, and the emergency room doctor has to come, it can be an intern or a physician without nursing home experience. And he sees, you know, a blood pressure at 60 and a CRP counting over 100, and… they’ll admit the patient to the hospital. (GP, Municipality A).
Theme 3: High workload and time pressure increase chances of readmission
Theme 4: The importance of patient and the family preferences
Seventy to 80% of our diagnostics is based on a comprehensive medical history, an anamnesis, so we have to listen to the patients! (GP, Municipality A).
The family wanted the patient to be admitted to the hospital no matter what. I believed that the patient was dying and wanted to give him palliative care at the nursing home. But after extreme pressure from the patient’s family, and with me as a novice physician not being confident enough to say “no, he cannot go to the hospital,” the patient was placed in an ambulance and passed away during transportation. (GP, Municipality A).
If the patient’s family’s demands are unreasonable, and they wanted us to do unnecessary examinations which could be a burden for the patient, then I wouldn’t admit the patient to the hospital on those terms. (GP, Municipality B)
Theme 5: The nurses are the physicians’ extended ears and eyes
The nurses can do closer observations than the physicians can do. That is to say, they have a visual observational foundation and a symptomatic observational foundation which is better than ours maybe … or more detailed … (GP, municipality A).
They [the nurses] are not necessarily familiar with the normal function level of the patient (…) I get plenty of telephones at the emergency room where they are telling me that the patient is ill, but they haven’t measured the blood pressure, not pulse, they don’t know anything else”. (GP, Municipality B).
If the nurses are very insecure, and if the tasks are too difficult, it can be a reason for hospital readmissions in my opinion. (GP, municipality B).
It is a problem when the patient gets ill during an evening shift and you know he needs supervision during the night [when a nurse is not working]. Then it is tempting to admit the patient to the hospital, because I know there are no nurses on call. But this is not a reason for a hospital admission. I can’t tell the on-call hospital physician I am admitting because there is no nurse here. But I believe it is dangerous, it is a dangerous practice to not have a nurse working at all times. (Physician, Municipality A).