For those unfamiliar to Acute Medicine, the decision whether a patient requires hospital admission sometimes can be a confusing and vexing one.
There are obvious situations. We tend to think of an Emergency when there is an imminent threat to the ABCs e.g. Airway Obstruction, Severe Respiratory Distress, Lethal arrhythmias, Catastrophic bleeding, Coma or Seizures.
Naturally all potentially life-threatening conditions if unmanaged could eventually result in these handful of pre-terminal events. However, they may also present less dramatically. Four additional considerations should be made.
No greater emphasis can be placed on physiologcal abnormalities (and more importantly, trends). Whether on the ward, in the operating room or in ICU, vital signs are the most frequently recorded assessments that are taken. They are important markers of serious disease. Although they may lack sensitivity or specificity (particularly if only considering one parameter in isolation or at one point in time), taken collectively and in combination with other clinical data they provide useful information about a patient’s condition. You need to think twice before discharging anybody with abnormal vitals.
A common mistake is to assume that because the patient ‘looks well’ or that their problems have been protracted that they are not acutely deteriorating. For unscheduled presentations, the important question to ask is ‘why are they here today’. It is critical that one not only gets a feel for the nature of the the problem and when it first started but what has happened in the last few minutes, hours or days prior to presentation. Have there been a change in the symptoms? Are they worse? More frequent? More protracted? Unresponsive to usual treatment? Has a new issue or symptom arisen? Has the patient reached a point where they can no longer function safely at home? Simply asking a patient ‘At what point do you think you got worse and in what way?‘ and ‘What has happened since then’ often yields important information about trajectory. Part of this assessment is also to identify a triggering or precipitating event that needs to be managed or eliminated. Not infrequently this will require hospitalisation.