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Dr Chris Johns: What I’ve learned triaging admissions

A GP for 23 years, Dr Chris Johns also triages acute cases at his local hospital part-time. Here he offers practical tips on how GPs can prevent admissions

Profile Dr Chris Johns

Age 50

Title Clinical lead, GP acute unit

Location Singleton Hospital, Swansea

I’ve been a full-time GP for 23 years. I’m still a partner, but around two and a half years ago I was appointed to triage acute cases at our local hospital, Singleton in Swansea.

GP acute units are relatively new and there are only a handful. We operate a free service to GPs in Swansea, Neath and Port Talbot, taking medical admission calls and offering alternatives, quicker access to a higher level of investigation, advice and a second opinion.

If patients are too ill for us they get admitted. Alternatively, we’ll work with GPs to manage the patient in community resource teams, or see them ourselves. We try to get the diagnostics such as X-rays and CT scans done, then discharge the patient and keep them ambulatory. We also give advice to GPs. It’s almost counselling and mentoring – GPs often have a plan or bounce ideas off us. Nine out of 10 times we agree with them.

Also, if a patient needs to see a consultant we can book them into a clinic the next day. GPs know that’s available, so we get the odd call when someone wants to circumvent the waiting list. At the moment, we’re stopping around 37% of cases from requiring admission – more than one in three.

Five lessons I’ve learned

• The most common advice we give is to get to know local pathways – they should be readily available online. They’re based on local guidelines and evidence-based medicine, so they recommend what’s best for the patient in a given circumstance, and they’re also the guide that all NHS staff will use for your patient’s care. Most of the calls we get are related to chest pains or breathing problems, such as suspected pulmonary embolisms, exacerbations in COPD/COAD or community-acquired pneumonia, and often we find that if a GP has their patient on the relevant ambulatory care pathway they can avoid hospital input or admission. 

Lack of experience is probably a major factor in GPs making unnecessary referrals, but for younger GPs this is natural and will improve with time. I would encourage GPs to do as much clinical work as they can, particularly home visits. It’s also useful to develop a special interest, which can help colleagues to cross-refer tricky cases. If you don’t work in a big practice you could form a network with other practices in your area. At my practice, for example, we have 10 GPSIs covering specialties including dermatology, minor surgery, diabetes, chronic heart disease and asthma. All orthopaedic patients are first referred to a GPSI, whatever the problem.

• GPs can also improve their diagnostic confidence by using a risk score. There are lots of evidence-based scoring tools, and they’re a helpful supplement to clinical knowledge. Some require extra investigations such as blood tests, but if you have the time and you’re keen to improve your experience in an area of medicine, familiarise yourself with reliable assessment scores. If your practice has a young high-referring doctor, it might benefit them to have more 15-minute appointments to build their risk management skills.

Care plans can prevent unnecessary admissions, but they’re not a major contribution to keeping patients out of hospital in my experience. The only exception to this is the use of rescue packs, with, for example, antibiotics in case the patient has an exacerbation out of hours and wants to self-treat.

• My top tip for GPs would be to develop a good relationship with secondary care doctors. We should try to be more empathetic towards one another if we want different professions to work closely together.

Readers' comments (4)

  • The more one knows, the more one is aware of important differential diagnosis to rule out, and the more on should and perhaps must refer on that basis.
    Surely part of the theme of Good Medical Care is considering those important other possibilities and ruling them out- ruling them out often means we have to call on the expertise of the “wider team” who have all the "toys" made available acutely to them i.e. secondary care.

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  • Excellent and sensible advice from Dr Johns. His own confidence is now developing from his current experience. I would agree that over a third do not need admission & can either be discharged or managed as an Outpatient. The key here is to have Acute Physicians with at least 3 times/week urgent access/early discharge clinics available, working closely with these GP's

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  • Sensible advice. There's an area between "obviously ill- needs hospital bed for e.g. pneumonia', and many cases that need rapid CXR/ecg/scan or bloods to allow risk of possible serious illness to be ruled in or out quickly and safely- so both doctor and patient can sleep soundly. Fortunately our local MAU seems to understand most requests of this latter nature from GPs.

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  • No doubt a good case for your service. Which you give freely. I would charge for time

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