Patient profile/social data
BC is a 66-year-old white British woman, retired, who is being treated for bowel cancer with chemotherapy elsewhere. She was brought in by her husband, with whom she lives independently, and who is
profoundly deaf.
Medical history
Bowel cancer, left hemicolectomy (bowel section removed), liver metastases (cancer spread to liver) and osteoarthritis.
Reason for attending the emergency department
BC was referred to the medical team with chest pain that she had been experiencing for the past 2 days by her GP who queried a PE (blood clot to lung).
Pathway into emergency department
BC had experienced retro-sternal pain and had rung her chemotherapy nurse, who had advised that she see her GP, who assessed her, completed an ECG, measured her blood pressure and then referred her to the medical team. She was driven to the hospital by her husband.
Diagnostic tests
Bloods, urinalysis, two ECGs and a chest X-ray.
Diagnosis
Query a PE (a clot on the lung).
Admit/discharge decision
Initial decision was to admit but following a discussion with the patient the consultant was persuaded to discharge her with an appointment to return the next day for a CT scan and review in ambulatory care.
Time in the department
BC arrived at 15.52 on a Monday afternoon and was seen by the medical SHO at 17.30. Reviewed by the medical consultant at 18.19. Time of departure not recorded.
Treatment
Pain relief (paracetamol) and anticoagulant injection (prevention of clots).
Stages of deciding on discharge
1: The role of other health professionals in the decision
BC had been experiencing increasing pain for the last 2 days and was unsure how to manage the pain so she sought advice from her current health care providers: the oncology nurse, the oncologist and her GP.
Yes, well, I phoned, um, I phoned the [name of clinic] where I was, where I’m having the chemo to say I was having the chest pains and they were quite uncomfortable. There was nobody in the clinic so I phoned the senior oncology nurse, I had got her mobile number, and, um, she was working at the [name of hospital], she wasn’t there, so, um, then she phoned my consultant’s secretary, who said that all in all, the, the, um, resident medical officer at the [name of hospital] said it wasn’t suitable for me to go in, um, if I had chest pains and to go down to my GP. So I got an appointment at the GP for ECG and blood pressure and the doctor said it was all fine but, but it was all fast, it was too high, um, and hence he phoned here.
Interview with patient [P022_020913]
The medical consultant was unhappy to discharge BC without discussing her case with her oncologist, which he did, and they both agreed that she could be discharged on the proviso she returned the next day for further investigations:
He [the medical consultant] agreed that if the cardiac blood test was normal then he would begin anti-coagulant treatment overnight and arrange for her to return to the ambulatory care unit the next day for her scan if her oncologist was happy. He spoke to the oncologist who agreed the plan.
Fieldnotes [FN_13_020913]
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2: Role of patient in decision-making
BC had made it abundantly clear to the health professionals that she did not like being in hospital and did not feel that her current condition warranted admission:
The medical SHO was told by the patient that she did not want to stay. The SHO decided to keep the patient in ED as he was hoping that she may be suitable to discharge. The patient was reviewed by the medical consultant [. . .]. The patient responded by saying that she did not want to come into hospital. As a result the consultant offered a compromise that if the cardiac blood test was normal then he would begin anti-coagulant treatment overnight and arrange for her to return to the ambulatory care unit the next day for her scan if her oncologist was happy [. . .] The patient was very happy to be going home, as was her husband.
Fieldnotes [FN_13_020913]
3: Admitting reduces risk and helps to speed process up
One of the primary reasons behind choosing to admit a patient is to weigh up the risks associated with not admitting. In the case of BC the medical consultant initially thought that admission was the safest option:
The patient was reviewed by the medical consultant who said that he was confident that this was not a cardiac event but would like to see the blood results to exclude this. He was more concerned however by a blood result that is raised and this can be due to her having a clot but also as a result of her cancer treatment which makes her more vulnerable and as a result she would require a scan to exclude a clot and wanted to admit her.
Fieldnotes [FN_13_020913]
When the medical SHO was asked why he would have preferred to admit BC he replied: ‘Admitting patients can help ‘speed things up’ (fieldnotes; FN_13_020913).
4: The availability of an alternative to admission
Having a service such as the ACU allowed the consultant to offer the patient an alternative pathway to admission while being reassured that the same level of care and access to investigations could
be guaranteed.
Key elements of patient experience
BC and her husband shared an acute dislike of hospitals and desire to not be admitted:
They told me that they ‘hated being in hospital’ and would ‘rather not be here’, because of recent events and time spent as a patient . . . Her husband also felt that hospitals were not run well and were dirty and there was a lot of hanging around.
Fieldnotes [FN_13_020913]
Interviewer:So what did you feel when you heard you were coming in here?
Patient:Oh, disappointed. I mean, last time I came in . . . I wanted to go home, but it was about, I don’t know, obviously at night, and they wouldn’t let me go home, and I felt absolutely fine, and I stayed overnight and I didn’t have anything with me, and it was a complete, you know, it was horrid, because I wanted to get home, because the consultant didn’t come round until quarter past twelve the next morning, and, um, I just didn’t know what to do with myself, so not a good experience.
One to be avoided.
Interview with patient [P0_22_020913]
However, there was also a sense of disappointment that her primary reason for attending, her pain, had been overlooked and not addressed:
BC complained to the medical consultant that her reason for attending was to address her pain which had not been resolved and that she was disappointed that she was till in pain despite telling everyone that was what she was experiencing.
Fieldnotes [FN_13_020913]
Key elements of health professionals’ experience The nurse practitioner from the ACU felt that:
Patients were given unrealistic expectations by the referring practitioner and then it is up to the NP to unpick these expectations and is left to explain that yes they had been told one thing but they had been misled . . . and of course the patients and their families get cross.
Fieldnotes [FN_14_020913]
Data sources
Fieldnotes transcript (FN_13_020913 and FN_14_030913), incorporating notes on observation, informal conversations, and unrecorded interview with medical SHO and MNP, transcript of recorded interview with patient (P022_020913) and field jottings (2 and 3 September 2013).
Summary of clinical panel review of case 11 (BC)
At stage 1 of the clinical panel the clinician reviewers both judged this to be an appropriate decision (1 on the Likert scale), although one reviewer commented that from the patient’s viewpoint BC’s primary symptom, her pain, had not been addressed. PPI review suggested that from a patient experience perspective this case was worthy of fuller discussion at stage 2.
During stage 2 discussion, the reviewers suggested a number of ways in which, while it was an appropriate decision to discharge the patient with an outpatient appointment for the next day in ambulatory care, the patient experience could have been better.
The clinician discussion centred around the risk stratification protocols for diagnosis of chest pain and whether this process serves the patient well in such a case as BC’s, where the presence of low levels of cardiac enzyme in the blood and presentation of pain may indicate an admission, but where her medical history and preference for discharge are mediating factors:
CP1 (GP AGPS):We can risk-stratify them [. . .] to whether it’s safe for a patient to go home with a query pulmonary embolism, but a lot of the time it comes down to patient choice. Some patients just don’t want to stay in hospital, and they’re willing, when given the risks and benefits of waiting an investigation or going home, they choose to go home.
CP2 (consultant ED):But occasionally there’s a patient who does have a raised troponin who you say,
‘Hang on a minute, I was going to send you home, but you’ve got a raised troponin and the pathway says that I should admit you to hospital.’ And sometimes the patient says, ‘I don’t want to come in’, in which case I say, ‘Well . . .’ [indicates that he would go with patient wishes].
The medical physicians discuss that this comes down to the doctor’s individual levels of risk aversion.
CP4 (medical registrar) commented: ‘it’s a high-cost strategy for a relatively low risk, but I think because in our patient population [hard to hear] tend to be young, the adverse outcome is massive, so I tend to be relatively risk averse.’
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The panel were in agreement that an ambulatory pathway was beneficial for BC, but believed that her route to this decision could have been more direct had a different service been available at the hospital:
CP4:I just wondered what CP1 [AGPS] thought about the pathway of this poor patient ringing the oncology nurse [. . .] round the whole hospital and then told to go to your GP?
CP1:I mean we would probably get the oncology nurse ringing us actually [. . .] we would never say,
‘Go and see your GP’ for a pulmonary embolism. But I guess if that pathway doesn’t exist in this establishment [. . .] the best way to get them into hospital was probably through their GP.
The panel also pointed out there was an element to BC’s care which was suboptimal and which is commonly experienced by patients in ED:
CP2 (consultant ED):I think that’s something we’re really bad at, because we . . . admit people to ambulatory care or to our clinical decision unit and it’s normally us that go round and review all the investigations and say to the patient at the end of their, er . . . their visit, ‘So, all good news, everything’s normal, you can go home, it’s all fine,’ and they go ‘Can you give me some painkillers?
No one gave me any painkillers, I’ve been here 6 hours.’ ‘Oh, well we were ruling out heart attack.’
‘Well I haven’t had a heart attack, [hard to hear] some painkillers!’
There was reflection from a PPI member that failure to address patient comfort could have been due to handover between different professionals, a fact that was acknowledged as something that ‘we still can’t get 100% right at the moment’ (CP3, senior nurse ambulatory care) given the strain on the system from numbers coming through ED: ‘I think mistakes happen and things get, don’t get communicated as well as they should be’ (CP3).