Approximately 900 000 patients are admitted to somatic hospital wards in Norway each year (1), and approximately three-quarters of them are admitted to an internal medicine unit (2). The 98 beds at the medical department of Drammen Hospital account for approximately one per cent of the total number of somatic beds in Norway. The department has a little more than 10 000 admissions per year, and the majority of the patients are in need of emergency treatment. The number of admissions is increasing at a regular pace – by 7.9 % in total from 2010 to 2014 (Einar Husebye, personal communication).
The admissions come from GPs in the area and the out-of-hours services, as well as from specialists in private practice and various outpatient units at the hospital. It is a policy goal to involve GPs to a greater extent in the assessment of emergency admissions (3, 4), but few studies have been undertaken in Norway to identify those who admit patients (5).
Assessing which patients to hospitalise is one of the key tasks of doctors in the primary health service. A GP has an estimated 3 000 consultations per year, and somewhat less than 300 of these concern acute conditions (6). On average, 2–3 % of those who come for a consultation are hospitalised, i.e. approximately 75 patients per year. The sorting undertaken by the primary doctors must be sufficient to identify conditions that might develop in a serious direction. The price of high safety, however, is that some patients are admitted with conditions that later turn out to be of a less serious nature.
Some diseases and conditions indicate that the patient is in clear need of hospitalisation, such as suspicion of acute myocardial infarction, pulmonary embolism and sepsis. For certain conditions there are general guidelines regarding who should be admitted, for example serious COPD with exacerbation (7) and a high Wells score for deep-vein thrombosis (8). Most often no specific criteria will be available, and validated rating forms for degree of seriousness are not normally applied in the referral notes.
The decision to hospitalise thus tends to be based on professional discretionary judgement and an assessment of what would be in the patient’s best interests. The referring doctor will assess the medical condition and possible risk of exacerbation, the wishes and expectations of the patient and next of kin, and psychosocial issues.
A study conducted in Tromsø found that 24 % of those who were admitted for emergency treatment at the medical department did not derive any health benefit from their hospitalisation (9). A later mapping study from Trondheim found that approximately 20 % of those who were admitted for emergency treatment were eligible for alternative measures, whereof admission to an observation ward constituted the largest group (5). Both studies concluded, however, that at the time of admission it was difficult to distinguish between those who would benefit from hospitalisation and those who would not.
A mapping study of admissions from Værnes casualty clinic found that approximately one in every five could have been avoided, either through a consultation with a specialist the next day or admission to a municipal intermediate care unit/nursing home (10). These studies are based on retrospective analyses, and there are no prospective studies that show how patients who might benefit from hospitalisation can be identified at the time of admission.
Triage tools are used in most emergency receptions in Norway to assess the degree of urgency. Many use systems they have developed themselves, whereas others use validated tools (11). Few studies have been made to assess whether these tools can be used to identify admissions for which other alternatives are available.
A study from Cape Town undertaken in 2008 used the Modified Early Warning Scale (MEWS) in an emergency reception. The need for admission increased with rising scores, as did the risk of death during the hospitalisation period (12). Triage tools have primarily been developed to identify degrees of urgency in emergency receptions, and we have little knowledge of the applicability of these tools in the primary health service.
In this study we registered data on admissions to a medical department with a large catchment area. We investigated whether there were alternatives to admission available prior to the hospitalisation period by reviewing the referral notes, and in its aftermath by studying the hospital records and discharge reports. In addition, we investigated possible correlations between the result of triage in the reception and alternatives to hospitalisation.
Material and method
All admissions to the medical department were registered over a randomly chosen full week from Monday through Sunday in the autumn of 2014.
Epidemiological data
From the hospital’s patient records we registered sex, age, the distribution between emergency and elective admissions, admissions to an inpatient ward/treatment provided in the reception, hospitalisation time, the referring doctor and from where the patients were admitted. In addition, we registered the 25 most frequently occurring diagnoses at admission and discharge.
Prospective analysis
The referral notes from primary doctors were assessed by a medical council consisting of two GPs and a specialty registrar from the medical department. We used a structured consensus method (Delphi) which has previously been used in similar studies (13). We assessed whether the referrals contained a defined medical issue and whether any alternatives to hospitalisation were available in light of the referral note.
The alternatives were categorised as admission to a municipal intermediate care unit, an appointment with a GP or outpatient clinic within three days, and discharge to the home (with supervision if relevant), or as a pending admission and conference between the GP and the hospital doctor.
The medical council emphasised the presence of a need for diagnostic clarification, the degree of seriousness and the risk of health loss, in addition to psychosocial factors. These criteria are in line with those for admission to a municipal intermediate care unit, which state that either the condition should be diagnostically clear, or the risk of exacerbation should be minor (14). This discretionary assessment was made in light of the resources and premises that primary doctors normally need to take into account in their decisions, and with no knowledge of the further course of events.
Retrospective analysis
The records from the hospitalisation periods were reviewed retrospectively. We compared the group for which possible alternatives to admission had been described with an identical number of patients randomly drawn from the rest of the group.
This review was undertaken by two GPs and two specialty registrars at the medical department. These doctors had not participated in the assessment of the referral notes and had no information as to whether or not these patients had been assigned to the group with alternatives to hospitalisation.
Triage
The patients were triaged by a nurse upon arrival in the emergency reception. The MEWS tool and the Manchester Triage Scale (MTS) were both used. Both are validated for triage in emergency receptions and are in use at Drammen Hospital (15–17).
The MEWS tool is based on vital variables – respiration frequency, pulse, systolic blood pressure, temperature and consciousness. The MTS scale is based on 52 flowcharts for various presentations in which different symptoms are rated and compiled into a total assessment of the degree of urgency.
Results from the triage were collated with the analyses of availability of alternatives to admission. We tested a possible correlation between the triage and alternatives to admission with the aid of the statistics software package SPSS.
Totalled results are reported as averages with measures of dispersion, unless stated otherwise.
Clinical information and figures have been anonymised, and no personal registrations were made. The project was approved by the data protection officer at Oslo University Hospital, who is also responsible for Vestre Viken Hospital Trust. The study has also been submitted to a regional committee for medical and health research ethics, which concluded that it was not subject to approval.
Results
A total of 255 patients were admitted during the week studied, whereof 132 were women (51.8 %) (Table 1). Approximately one-half of all admissions involved patients in the age group 16–65 years. This group accounts for approximately 80 % of the total population. Close to 11 % of the admissions involved patients older than 85 years; this group accounts for approximately 3 % of the total population. However, the highest admission rate was found in the age group 76–85 years.
Table 1
Sex and age distribution of patients admitted to the medical department of Drammen Hospital over one week in 2014
|
Sex and age (years)
|
16–25
|
26–35
|
36–45
|
46–55
|
56–65
|
66–75
|
76–85
|
86+
|
Total
|
Average
|
|
Number
|
(%)
|
Number
|
(%)
|
Number
|
(%)
|
Number
|
(%)
|
Number
|
(%)
|
Number
|
(%)
|
Number
|
(%)
|
Number
|
(%)
|
Number
|
(%)
|
|
|
Women
|
15
|
(5.9)
|
9
|
(3.5)
|
10
|
(3.9)
|
12
|
(4.7)
|
26
|
(10.2)
|
20
|
(7.8)
|
28
|
(11.0)
|
12
|
(4.7)
|
132
|
(51.8)
|
60.7
|
|
Men
|
2
|
(0.8)
|
10
|
(3.9)
|
12
|
(4.7)
|
15
|
(5.9)
|
16
|
(6.3)
|
28
|
(11.0)
|
24
|
(9.4)
|
16
|
(6.3)
|
123
|
(48.2)
|
63.4
|
|
Total
|
17
|
(6.7)
|
19
|
(7.5)
|
22
|
(8.6)
|
27
|
(10.6)
|
42
|
(16.5)
|
48
|
(18.8)
|
52
|
(20.4)
|
28
|
(11.0)
|
255
|
(100)
|
62.1
|
|
Population Buskerud County
|
|
(14.9)
|
|
(14.8)
|
|
(17.6)
|
|
(17.2)
|
|
(14.8)
|
|
(11.8)
|
|
(6.0)
|
|
(2.8)
|
|
(100)
|
|
The patients were admitted from a regular dwelling (90 %), from another hospital department (5 %) or from another hospital (5 %). Those who were admitted from nursing homes or other municipal institutions were counted in the group admitted from regular dwellings.
Altogether 93 % of the patients were admitted for emergency treatment, while the rest (7 %) were elective admissions. More than one-half (57 %) were admitted from the primary health services – 26 % by referral from a GP and 31 % from municipal casualty clinics/out-of-hours services (Table 2).
Table 2
Referring doctor for admissions to the medical department of Drammen Hospital over a week in 2014
|
Referring doctor
|
Number
|
(%)
|
|
General practitioner
|
67
|
(26.3)
|
|
Casualty clinic/out-of-hours services
|
79
|
(31.0)
|
|
Direct admission
|
47
|
(18.4)
|
|
Outpatient clinic and open return
|
45
|
(17.6)
|
|
Other institution
|
16
|
(6.3)
|
|
Not stated
|
1
|
(0.4)
|
|
Total
|
255
|
(100)
|
Progression
The vast majority of the admitted patients (82 %) were placed in an inpatient ward, while the others were examined and treated as outpatients in the reception before discharge. The average time spent on examination and treatment in the emergency reception was two hours and 38 minutes.
The hospitalisation time for those who were admitted was 3.7 days, approximately the same as for those who came directly with no referral from a doctor (3.5 days). With the exception of two patients, these arrived by ambulance.
Diagnoses
The main diagnoses at admission and discharge are described in Table 3. The most common diagnostic groups upon admission included cardiovascular disease, 101 cases (40 %), pulmonary disorders, 28 cases (11 %) and infections, 22 cases (9 %).
Table 3
Diagnoses in patients admitted to the medical department at Drammen Hospital over one week in 2014
|
Diagnoses
|
Upon admission
|
Upon discharge
|
|
|
Number
|
(%)
|
Number
|
(%)
|
|
Chest pain
|
42
|
(16.5)
|
21
|
(8.2)
|
|
Cardiac arrhythmia
|
25
|
(9.8)
|
22
|
(8.6)
|
|
Angina pectoris, including unstable angina
|
15
|
(5.9)
|
16
|
(6.3)
|
|
Acute myocardial infarction
|
7
|
(2.7)
|
14
|
(5.5)
|
|
Cardiac failure, hypertension
|
7
|
(2.7)
|
12
|
(4.7)
|
|
Syncope/loss of consciousness
|
5
|
(2.0)
|
8
|
(3.1)
|
|
Cardiac valve failure, endocarditis, pericarditis
|
0
|
(0.0)
|
4
|
(1.6)
|
|
Total cardiovascular disorders
|
101
|
(39.6)
|
97
|
(38.0)
|
|
Pneumonia, all forms
|
12
|
(4.7)
|
16
|
(6.3)
|
|
Shortness of breath
|
8
|
(3.1)
|
1
|
(0.4)
|
|
Chronic obstructive pulmonary disease, including asthma
|
5
|
(2.0)
|
10
|
(3.9)
|
|
Pulmonary embolism
|
3
|
(1.2)
|
4
|
(1.6)
|
|
Total pulmonary disorders
|
28
|
(11.0)
|
31
|
(12.2)
|
|
Infections – erysipelas, sepsis, gastroenteritis, meningitis
|
19
|
(7.5)
|
28
|
(11.0)
|
|
Fever, unspecific infection
|
3
|
(1.2)
|
0
|
(0.0)
|
|
Total infections, excl. cardiovascular, pulmonary and renal disorders
|
22
|
(8.6)
|
28
|
(11.0)
|
|
Poisoning
|
12
|
(4.7)
|
15
|
(5.9)
|
|
Renal disorder
|
7
|
(2.7)
|
13
|
(5.1)
|
|
Diabetes mellitus
|
2
|
(0.8)
|
1
|
(0.4)
|
|
Total nephrological disorders/diabetes
|
21
|
(8.2)
|
29
|
(11.4)
|
|
Anaemia, haemorrhage, including gastrointestinal haemorrhage
|
14
|
(5.5)
|
12
|
(4.7)
|
|
Abdominal pain
|
2
|
(0.8)
|
0
|
(0.0)
|
|
Total gastroenterological disorders
|
16
|
(6.3)
|
12
|
(4.7)
|
|
Deep-vein thrombosis, phlebitis
|
13
|
(5.1)
|
2
|
(0.8)
|
|
Poor general condition, dizziness, somnolence, confusion, weight loss
|
13
|
(5.1)
|
4
|
(1.6)
|
|
Cancer, examination or exacerbation
|
7
|
(2.7)
|
11
|
(4.3)
|
|
Cerebrovascular disease
|
1
|
(0.4)
|
1
|
(0.4)
|
|
Other
|
24
|
(9.4)
|
38
|
(14.9)
|
|
Total various diagnoses
|
58
|
(22.7)
|
56
|
(22.0)
|
|
Diagnosis not stated
|
9
|
(3.5)
|
2
|
(0.8)
|
|
Total
|
255
|
(100)
|
255
|
(100)
|
Assessment of alternatives
Of the 255 patients, 146 were admitted by a primary doctor, and 135 referral notes were available. Based on these, alternatives to admission were registered in 18 patients, i.e. somewhat more than 13 % (Table 4). For two of every three patients (n = 12), a bed in a municipal intermediate care institution was the most relevant alternative.
Table 4
Alternatives to admission in patients admitted to the medical department of Drammen Hospital over one week in 2014
|
Admission or alternative
|
Number
|
(%)
|
|
To be admitted
|
116
|
|
|
Total alternatives
|
18
|
(13.3)
|
|
Not defined
|
1
|
(0.7)
|
|
Total
|
135
|
(100)
|
|
Distribution of alternatives
|
|
|
|
Municipal intermediate care/nursing home, observation ward
|
12
|
(8.9)
|
|
Appointment with GP/outpatient clinic within 3 days
|
3
|
(2.2)
|
|
Discharge to home, with supervision or temporary admission as needed
|
2
|
(1.5)
|
|
Conference between primary doctor and hospital doctor
|
1
|
(0.7)
|
|
Total
|
18
|
(13.3)
|
The doctors who retrospectively reviewed the outcome of the hospitalisation period agreed that an alternative to admission would have been equally appropriate or better for nine of the 18 patients. As regards the other nine, the admission was deemed necessary. In total, an alternative to admission was found for 7 % of those who had been admitted by a primary doctor.
Triage
Altogether 106 patients had both a referral note that was reviewed by the medical council and had been triaged. Among these, we found 13 of the 18 patients for whom relevant alternatives to admission had been identified.
Table 5 shows the alternatives to admission by degree of seriousness. The distribution proved to be random as well as unsystematic. This also applied to the nine patients for whom we found that alternatives were available upon admission as well as after a review of the hospital records.
Table 5
Comparison of triage and alternative in patients admitted to the medical department of Drammen Hospital over one week in 2014. MTS: Manchester Triage Scale. MEWS: Modified Early Warning Scale
|
Comparison triage and alternative
|
MTS
|
MEWS
|
|
Urgency groups
|
Total
|
Admitted
|
Alternative
|
Total
|
Admitted
|
Alternative
|
|
|
number
|
Number
|
(%)
|
Number
|
(%)
|
number
|
Number
|
(%)
|
Number
|
(%)
|
|
Immediately, 0 min., code red
|
0
|
0
|
|
0
|
|
4
|
4
|
(100.0)
|
0
|
(0.0)
|
|
Very urgent, 10 min., code orange
|
43
|
41
|
(95.3)
|
2
|
(4.7)
|
16
|
14
|
(87.5)
|
2
|
(12.5)
|
|
Urgent, 60 min., code yellow
|
41
|
33
|
(80.5)
|
8
|
(19.5)
|
18
|
17
|
(94.4)
|
1
|
(5.6)
|
|
Can wait, 120 min., code green
|
17
|
15
|
(88.2)
|
2
|
(11.8)
|
35
|
29
|
(82.9)
|
6
|
(17.1)
|
|
Not urgent, 240 min., code blue
|
3
|
2
|
(66.7)
|
1
|
(33.3)
|
32
|
28
|
(87.5)
|
4
|
(12.5)
|
|
Not stated
|
2
|
2
|
|
0
|
|
1
|
1
|
|
0
|
|
|
Total
|
106
|
93
|
|
13
|
|
106
|
93
|
|
13
|
|
A correlation analysis showed a low and non-significant correlation between alternatives to admission and the two triage methods. For the MEWS tool, Pearson’s r = 0.024 (p = 0.81), and for the MTS tool, the correlation was r = 0.122 (p = 0.22).
Discussion
We found that 57 % of the 255 admissions to the medical department had been made by primary doctors, distributed approximately equally between GPs and casualty clinics. Previous studies have shown a significantly smaller proportion of admissions from GPs. In a study conducted at St Olavs Hospital in week 23, summer 2003, Eikeland and collaborators found that only 12 % of the emergency admissions to the medical, surgical, orthopaedic and gynaecological departments had been made by a GP (5).
Our study was conducted during a regular working week and only included admissions to the medical department. As far as we are aware, no studies have yet investigated whether the proportion of admissions made by GPs has increased since the introduction of the Regular GP scheme in 2001.
Altogether 82 % of the patients were admitted to an inpatient ward; the others were assessed and treated in the reception and discharged the same day. In general, a complete assessment and treatment in the reception, with no use of an inpatient ward, may be an appropriate and effective treatment for many patients. Often, the patient is admitted because the primary doctor is concerned that an acute exacerbation may occur. Frequently these patients only need a clear diagnosis, a so-called diagnostic loop, and can be further followed up as outpatients or by the primary health service. However, establishing a full diagnosis in the emergency reception requires a high rate of staffing with skilled personnel, both in order to prioritise the patients correctly and to avoid excessive treatment time and general congestion in the emergency reception.
There is currently a debate unfolding over the organisation of the emergency receptions, widely recognising that increased resources may help achieve safer as well as more effective patient pathways (18–20). In our study, for example, we observed that some patients with deep-vein thrombosis completed their treatment in the reception according to an algorithm that has later become better defined. This has gradually become better known among the primary doctors in the hospital’s catchment area. It is assumed that similar algorithms, for example pertaining to chest pain, also can help achieve more effective and safe patient pathways in the emergency reception.
Average hospitalisation time was 3.7 days. The corresponding figure for the entire year was 4.0 days (Einar Husebye, personal communication). Hospitalisation times tend to be shorter in Norway than in other European countries; according to an OECD report from 2010, they amounted to 4.5 days for all hospitalisations in Norway and 6.9 days in Europe as a whole (21). In general, hospitalisations are tending to decrease in length, in Norway as well as in virtually all other countries. This is primarily due to medical developments and pressure on beds and available resources as the number of admissions increases. Furthermore, primary health services are now required to receive patients who are ready for discharge at an earlier stage.
The diagnoses at admission corresponded relatively well with those at discharge in our study; this concurs with two large registrations previously undertaken in Norway (22, 23).
A little more than 20 % of the patients were admitted with a symptomatic diagnosis, while this figure had been approximately halved upon discharge.
In our review of the referral notes we found possible alternatives to hospitalisation for a little more than 13 % of the patients. In a retrospective review, an alternative to hospitalisation was found to be appropriate for only one-half of those for whom this was relevant upon admission. If 7 % is a realistic estimate of alternatives to admission, a correct identification of these patients would nevertheless help relieve the department. The difference between the assessments made upon admission and those made retrospectively after the hospitalisation period shows the degree of difficulty involved in identifying these patients in advance. This has also been the conclusion in other studies that have investigated opportunities for reducing the number of unnecessary admissions (5, 9).
In many studies, the necessity of admission has been assessed post hoc, in light of the results of the examination and treatment provided in the hospital (5, 9, 10). In our study, we have analysed the information available in advance as well as post hoc. We believe that in order to develop rational criteria for admission, it is essential to use the medical assessment made prospectively as a basis, and then retrospectively evaluate whether the sorting of the admissions is safe and medically sound.
We found little correspondence between the assessment of degrees of seriousness made in the reception immediately after admission and possible alternatives to it. This shows that triage tools are unsuitable for this type of sorting. Traditional triage tools are primarily intended to assess the degree of urgency at the pre-hospital stage and in emergency receptions, yet it is still surprising to see such a weak correlation between the triage and alternatives to admission.
It seems evident that primary doctors who need to consider referral cannot use tools that have low sensitivity. For example, if a primary doctor each year assesses 300 patients with acute conditions and 50 of these have a real need of hospitalisation, even a sensitivity of 90 % would mean that five patients would not be granted the admission they need. To keep this number as low as possible, the primary doctors will to some extent need to refer a number of patients for whom the further progression cannot be foreseen with any certainty. It is reasonable to assume that this is the reason why many hospital doctors feel that the primary doctors refer patients unnecessarily. If we use the same figures and assume that the primary doctors’ decisions have a specificity of 90 %, the corresponding figure will be 70 admissions, whereof 25 will be unnecessary.
On the other hand, liberal referring practices on the part of the primary doctors will necessarily increase the burden on hospitals. It is a fact that an accumulation of patients, for example in the emergency reception, may give rise to an increased risk of medical error and increased mortality (24, 25).
We conclude that a minor proportion of the patients who are currently hospitalised (6–7 %) would have benefitted equally well from an alternative. However, these patients are difficult to identify at the time of admission. Since the number of admissions is steadily increasing, it seems decisively important to establish better routines and methods to identify those patients who ought to be hospitalised and those who could draw equal benefit from alternatives.
