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.
- Physiological derangement
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.
2. Trajectory
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.
For more appreciation of the importance of Chronology see Chronology of Disease
And how to assess Function
Or evaluate Severity
And the usual list of Acute Pathologies presenting to the Emergency Department
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3. Failed community treatment
Contrary to popular belief, a lot of acute medicine is managed quite capably by GPs and specialists in an ambulatory setting without ever reaching the hospital. But sometimes after a suitable trial of appropriate treatment, the patient still does not respond or continues to deteriorate. Examples include minor infections, COPD exacerbations, worsening heart failure or troublesome glycaemic control. One may feel frustrated that seemingly well patients are referred to the hospital for admission but further enquiry reveals that only escalating therapy and frequent monitoring can stabilise these patients and accelerate their recovery. If after 10 minutes explaining to an inpatient team the reason for admission, they advise you to discharge the patient, your natural answer should be ‘they already tried that but I am open to suggestions if you have a different strategy’
4. Inadequate resources to manage outside of the hospital
Apart from specialised procedures, inpatient care offers mainly two advantages. a) More frequent assessment for changes in condition. b) Minimal demands on independent functioning. The main difference is often nursing (rather than medical) care. Although senior medical support is more frequently present, it is by no means continuous and uninterrupted. Apart from the intensive care unit, treatment decisions are rarely altered once a day and often less. Therefore, a common reason for hospitalisation is where either the patient’s condition is deteriorating at a pace that requires close observation in case an immediate medical response needs to be triggered, or that the patient simply can’t manage at home due to the effects of their illness
5. Psychosocial contraints
Unfortunately, the perjorative terms ‘acopia’ or ‘acopic’ is used for patients with seemingly minor illness who are unable to function safely at home or manage their condition appropriately. But this ignores a huge psychosocial dimension to disease management. This includes cognitive capacity, mental well-being, physical ability, social supports, financial means and other household responsibilities. But with increasing hospital demand, there is also a strong impetus to increasing resources directed towards community health services such as domiciliary care, community mental health, district nursing, hospital-in-the-home and residential care outreach. These hospital avoidance strategies allow even quite intensive treatments e.g. twice daily IV medications and injections to be administered safely and effectively. Importantly, patients often prefer this. There are also indirect benefits of maintaining function and independence which might be lost by being largely confined to a hospital bed. Nevertheless, there are some circumstances where this is not practical or feasible. It is always worthwhile discussing options with ambulatory services about what is achievable. This is an evolving field and it is surprising what is possible nowadays. Failing this, the only option is for the patient to continue treatment in hospital. If this appears to be a long-term issue then the only realistic option is eventual transfer to a residential facility for indefinite care.