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We carried out an audit to assess the impact on hospital admissions of patients being assessed by either middle grade trainees (residents) or consultants in a district general hospital (DGH). Our aims were to establish:
Number of children kept in hospital overnight and those discharged the same day
Number of readmissions of those discharged the same day
Any adverse events in those discharged home the same day.
We studied retrospectively all acute admissions to the children’s wards at Doncaster Royal Infirmary, a medium sized district general hospital, over the months of January and July 1998. We excluded all surgical and non-acute admissions. At the time of the study the Children’s Hospital did not have a day or acute assessment unit. Therefore the children were reviewed following admission to the wards. Whether trainees or consultants reviewed patients was an entirely random process, dependent on willingness and time to carry out ward rounds in late afternoon or early evening. The review could also be triggered by nursing staff or parents. The interval between the time of admission to the ward and the time the patients were reviewed varied from immediate review to a few hours. The decision to discharge children was usually taken jointly by medical and nursing staff, provided that parents were willing to look after their children at home. The parents of children discharged home on the same day as admission were given open access to the children’s ward—that is, they could either telephone the ward for advice or return with the child if concerned.
A total of 512 sets of case notes were reviewed by MMM and RAS. A pro forma was used to collect the data, which was stored on an Excel spreadsheet.
A total of 173 (34%) patients were under 1 year, 150 (29%) were 1–2 years, 53 (10%) were 3–4 years, 41 (8%) were 5–6 years, and 95 (18%) were over 6 years (fig 1). The source of referral was documented in 499 case notes. Of these, 287 (58%) were via a general practitioner, 178 (36%) were via the accident and emergency department, and 29 were from other sources. The commonest reason for admission was breathing difficulties followed by fever.
Of the 512 patients admitted, 260 (51%) were reviewed by middle grade trainees or consultants. Of those reviewed, 109 (42%) were discharged home the same day. The age group distribution (fig 1) and reason for admission (fig 2) of those reviewed was similar to that of the total sample. More children under 1 year were kept in overnight than were discharged home the same day; the reverse was true for those in the 1–2 year and 3–4 year age groups. The reason for admission of those discharged home the same day was also similar to that of the total sample. Slightly more patients were admitted in January than in July, but more patients were discharged home the same day in July than in January (26% v 15%; fig 3). This could well be due to the fact that there is more pressure on beds in the winter months. However, it could also be due to a different spectrum and severity of diseases.
Of those discharged home the same day, seven (6%) were readmitted within seven days, four because of the same complaint and three with a different complaint. There were no adverse events. Those who were reviewed but kept in overnight had a similar distribution of the reason for admission to that of the total sample and those who were reviewed but with an excess of vomiting and/or diarrhoea.
In conclusion, assessing the need for admission resulted in 20% of all admissions (40% of those reviewed) being discharged home the same day. Vomiting and/or diarrhoea were more likely to result in patients being kept in overnight. We believe the number of patients who can be discharged home the same day will be much higher if all acute admissions are reviewed and assessed in the way described. This policy seems safe and acceptable to parents.
With the planned reduction in the number of specialist registrars, it seems that expanding the number of consultants would achieve the dual benefit of moving closer towards a consultant provided service and will also lead to reduction in the number of children requiring an overnight hospital admission.