7.3 Validación mediante pruebas con usuarios
7.3.1 Focus group (Despegar)
The problems described in the previous section reflect several dilemmas that may be deemed applicable to other NHS services:
l whether to invest in triage to onward pathways or to carry out most care at the first contact
l whether to ‘step up’ care when needed or involve senior input at the start
l whether to have protocolised pathways or empower practitioners to respond creatively to patient need
l whether to facilitate patient choice or make decisions based on objective need
l whether to take an individual or population/system view.
The heterogeneity of patient need and resource constraints means that it is important to consider how each need/resource may be reconciled or balanced in different situations. The following types of patient illustrate the variety of need:
l individuals requiring time-consuming diagnostic skill and investigations to rule out – or diagnose and provide immediate treatment for – life-threatening illness (Porthaven case 10, see Appendix 12)
l individuals with functional impairment or social difficulties who have new care needs resulting from their illness or living situation (Porthaven case 7, see Appendix 12)
l individuals (or carers) with anxieties about their health or care (Underbridge case 5, see Appendix 12)
l individuals with an undifferentiated and uncertain diagnosis (Churchtown case 1, see Appendix 12).
Many individuals with multimorbidity may present with all four types of need, and an ideal acute care system will be able to manage expectations, provide diagnosis, treatment and care, and involve patients in the decisions.
Principles for optimum practice were identified from the problems described in the first part of the synthesis. These principles are summarised in Figure 17, which depicts how they are relevant to the wider system (hospital and community), the internal design of the acute care settings and the interactions between patients, carers and practitioners. This second part of the synthesis presents a series of positive statements which indicate how the principles for avoiding inappropriate admissions and unsafe discharges in acute care settings might have an effect. The statements have been generated by combining analytic statements that relate to best practice as observed, reversing negative statements and drawing on inferences related to silences in the data (these last indicated by *).
Practitioner interactions
The experience and engagement of patients and carers/families may be optimised by:
l demonstrating understanding about the patient’s discomfort, distress and predicament
l eliciting his/her goals and preferences as well as information about the patient’s condition and valuing patient and carer knowledge
l making the decision-making process explicit and giving viable choices
l ensuring they feel they can ask questions and make suggestions
l providing information about progress through the system even if it is only to inform people about uncertainty
l practitioners taking over decision-making for those who are the most confused or unwell
l establishing a routine practice of attending to care needs while in acute care – communication, allaying fears and concerns, provision of food and drink, attending to toileting needs, etc.
Patient expectations about being admitted may be managed by:
l GPs and paramedics stressing the possibility or likelihood that patients will go home, when making referrals
l making initial assessments at a desk with patients clothed (more like a GP or outpatient clinic)
l providing an ‘ambulatory space’ when patients are waiting for results or being observed, which allows individuals to be seated and clothed and access food and drinks themselves.
Patients’ and carers’ (sometimes different) anxieties about illness being managed at home may be addressed by:
l eliciting and giving value to concerns
l talking through the risks to create understanding about drawbacks and benefits of care in hospital versus the community
l negotiating compromises
l providing safety net advice about what to do if discharged
l involving senior practitioners when needed to check and support decisions.
WIDER SYSTEM
Adequate resourcing throughout health and social care to ensure timely
availability of alternative care pathways
INTERNAL ACUTE CARE SYSTEM
Differentiation of patients according to physical, emotional and social care needs
Tolerance of risk by the system to prevent risk-averse practice
Timely access to senior medical input and/or support to optimise decision-making
Time for seniors to teach and train staff in decision-making, assessment and triage
Timely availability and judicious use of diagnostics and other pathways
Flexible use of spaces for waiting, watching, caring and treating
Clarity about practitioner and team roles Knowledge about and trust in
alternatives to acute care
Information-sharing between hospital, community and general practice
Standards that relate to patient outcomes and system performance, rather than isolated process measures
PRACTITIONERS’ INTERACTIONS WITH PATIENTS AND CARERS Identifying and addressing patients’ and carers’ concerns
Consistency of information and advice given by practitioners
Communication between practitioners that supports decision-making Collaborative decision-making between patients, carers and practitioners
Sensitivity and tact in balancing priorities and communicating rationale for complex decisions to patients and carers
FIGURE 17 Principles of decision-making for avoiding inappropriate admissions and unsafe discharges in acute care settings.
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The ability of junior doctors to make good decisions may be enhanced by:
l pathways to specialist teams and diagnostics being clear, known, easy and reliable, but sufficiently focused so that all patients are not routinely referred
l ensuring availability of senior doctors
l encouraging senior nurses to provide supportive advice
l being respected by doctors from specialty teams.
Junior doctors’ learning may be enhanced by:
l seniors expecting that juniors may seek advice about a preferred plan rather than wait to be told what to do
l receiving ‘micro’ training in relation to difficult cases.
Seniors may deploy their clinical expertise regarding individual patients in a variety of ways, by:
l selecting cases they may discharge or admit much more rapidly than juniors
l selecting cases with clinical complexity and uncertainty, or anxiety
l advising juniors on decisions without seeing the patient
l advising juniors on decisions by reviewing the patient briefly and advising on tests and referral pathways.
System factors: using resources to manage flow within and out of acute care settings
During the pre-hospital phase, patients may be directed to the appropriate place/team by:
l GPs making themselves available and trusted by patients at risk of admission
l GPs referring patients to specialist teams, where clinically appropriate, rather than signposting to the ED
l hospitals providing referral systems involving clinician–clinician conversations (such as Porthaven AGPS) to differentiate and direct GP referrals to the correct hospital or community team
l ambulance staff liaising with GPs or the admission avoidance team prior to the decision to transfer to the ED.
Overall flow and capacity within EDs may be managed by:
l having a senior doctor and nurse oversee all patients within a unit while others care for individuals
l having information systems in place that allow capacity and flow in the ED and the whole hospital to be visible
l having patient areas visible from central positions, while also guarding privacy
l having easy access to the AMU, radiology and other acute care spaces
l having easy access to past clinical records from hospital and primary care systems.
Relations between specialty teams and practitioners in EDs may be enhanced by:
l ensuring an understanding of each team’s remit and contact details
l making space to work together collaboratively.
Rushed decisions to admit as the 4-hour deadline approaches may be avoided by:
l identifying and managing patients who are likely to need a more prolonged decision-making time period soon after arrival
involving teams specialising in discharge at an early stage in the pathway
Discharges may be made more safely by:
l liaising with GPs about concerns and plans*
l arranging for GPs to follow up patients the next day*
l having specialist ‘hot’ clinics or diagnostics (plus follow-up) available within days
l support from community teams able to provide social care and/or treatment at home*
l transfers to nursing homes with the facility to monitor and provide rehabilitation*
l encouraging juniors to consider the discharge option, though also checking with a middle-grade or senior doctor
l involving hospital teams specialising in discharge
l providing clear information to patient, family and community teams on safety netting.
The specific components above are more likely to be successful when incorporated into systems where:
l the culture is positive, engendering learning and flexibility
l risk is ‘named’ but managed positively
l teams are stable with minimal use of locums (optimising local knowledge of context and how to get things done efficiently).
Although the ED environment may be stressful, we have indicated several measures that may be employed to mitigate this pressure, and specific features of the clinical environment and communication with
patients that could enhance the safety of patients and optimise their experience. The different elements of the acute care system, both in the community and in secondary care, need to collaborate more closely and generate joined-up pathways though a blend of flexibility and management of flow.
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Chapter 8 Discussion
Introduction
The 3A study has investigated emergency medical admission decision-making in four diverse sites and revealed similar interactional but diverse organisational responses to common pressures on time, space and practitioners. Time pressure limits the extent to which patients and carers are enabled to share in decision-making, and gives little opportunity for full information to be obtained, or alternatives to admission identified and arranged. The complexity of medical and social issues, the importance of patient safety, practitioners’ risk aversion and the need to maintain flow through busy departments are all factors that contribute to admission by default. Each organisation responded with contrasting spatial and
organisational infrastructures, different staffing models, and a variety of innovations.