Hospital admissions from nursing homes: A qualitative study of GP decision making

Abstract

Background: Decisions regarding the hospitalisation of nursing home residentsmay present a difficult dilemma for GPs. There are pressures to admit very frail patients with exacerbations of illness even though such frailtymay limit the possible health gains. As 'gatekeepers' to NHS, GPs are expected tomake best use of resources and may be criticised for 'inappropriate' admissions. Little is understood about the influences on GPs as theymake such decisions Aim: To explore GPs views on factors influencing decisions on admitting frail nursing home residents to hospital. Design and setting: A purposive sample of 21 GPs fromtwo counties in the South of England. Method: Data fromsemi-structured, one-to-one interviews with GPs were analysed using thematic analysis following principles of the constant comparativemethod. Results: This study suggests that while clinical assessment, perceived benefits and risks of admission, and patients' and relatives' preferences are key factors in determining admissions, other important factors influencing decisionmaking includemedico-legal concerns, communications, capability of nursing homes and GP workload. These factors were also perceived by GPs as influencing the feasibility of keeping patients in the nursing home when this was clinically appropriate. Key areas suggested by GPs to improve practice were improving communication (particularly informational continuity), training and support for nursing staff, and peer support for GPs. Local initiatives to address these issues were very variable. Conclusion: Developing a systematic palliative care approach to address poor documentation and communication, the capability of nursing homes, andmedico-legal concerns has the potential to improve decision-making regarding hospital admissions. ©British Journal of General Practice.