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

BACKGROUND: Decisions regarding the hospitalisation of nursing home residents may present a difficult dilemma for GPs. There are pressures to admit very frail patients with exacerbations of illness even though such frailty may limit the possible health gains. As 'gatekeepers' to NHS, GPs are expected to make best use of resources and may be criticised for 'inappropriate' admissions. Little is understood about the influences on GPs as they make 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 from two counties in the South of England.

METHOD: Data from semi-structured, one-to-one interviews with GPs were analysed using thematic analysis following principles of the constant comparative method.

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 decision making include medico-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, and medico-legal concerns has the potential to improve decision-making regarding hospital admissions.