General practitioners' attitudes and decision making regarding admission for older adults with infection: a UK qualitative interview study

Support in acute situations when a community health nurse is called: experiences of older patients, their significant others, and involved healthcare professionals- a qualitative interview study

BACKGROUND

Care decisions for older patients in acute situations are challenging to make, and there is limited knowledge of support in home healthcare settings, where older patients receive ongoing health care from, for example, community health nurses. Therefore, this study aimed to describe the support for all involved in acute situations when a community health nurse was called, as experienced by older patients, their significant others and healthcare professionals involved.

METHODS

The study was conducted using a phenomenological reflective lifeworld research approach, in which meanings of the study phenomenon were analyzed. The included participants were those who had been involved in acute situations. Twelve participants from four acute situations were interviewed. The participant included three older patients, one significant other, four community health nurses, one registered nurse student, one specialist in general practice, and two ambulance personnel, with one being a registered nurse and the other a specialist ambulance nurse.

RESULTS

Support in decision-making was received from the knowledge of temporality, which provided a comprehensive understanding based on past and present knowledge of the older patient. The knowledge of temporality allowed for the early detection of new symptoms and facilitated care decisions tailored to the older patient. There was a dependency on pre-existing mutual interpersonal support, and confidence developed through relational, caring, and medical competence.

CONCLUSIONS

The advantages of temporality, confidence and mutual interpersonal support in acute situations highlight the importance of enhancing relational continuity in home healthcare settings and establishing a structural collaboration among community health nurses, specialists in general practice, and ambulance personnel. This collaboration aims to provide support for making decisions regarding tailored care.

Physicians' experiences and actions in making complex level-of-care decisions during acute situations within older patients' homes: a critical incident study

BACKGROUND

Complex level-of-care decisions involve uncertainty in which decisions are beneficial for older patients. Knowledge of physicians' decision-making during acute situations in older patients' homes is limited. Therefore, this study aimed to describe physicians' experiences and actions in making complex level-of-care decisions during the assessment of older patients in acute situations within their own homes.

METHODS

Individual interviews and analyses were performed according to the critical incident technique (CIT). In total, 14 physicians from Sweden were included.

RESULTS

In making complex level-of-care decisions, physicians experienced collaborating with and including older patients, significant others and health care professionals to be essential for making individualized decisions regarding the patients' and their significant others' needs. During decision-making, physicians experienced difficulties when doubt or collaborative obstructions occurred. Physicians' actions involved searching for an understanding of older patients' and their significant others' wishes and needs, considering their unique conditions, guiding them, and adjusting care according to their wishes. Actions further involved promoting collaboration and reaching a consensus with all persons involved.

CONCLUSION

Physicians strive to individualize complex level-of-care decisions based on older patients' and their significant others' wishes and needs. Furthermore, individualized decisions depend on successful collaboration and consensus among older patients, their significant others and other health care professionals. Therefore, to facilitate individualized level-of-care decisions, the health care organizations need to support physicians when they are making individualized decisions, provide sufficient resources and promote 24 - 7 collaboration between organizations and health care professionals.

Making complex decisions in uncertain times: experiences of Dutch GPs as gatekeepers regarding hospital referrals during COVID-19-a qualitative study

BACKGROUND

General practitioners often act as gatekeeper, authorizing patients' access to hospital care. This gatekeeping role became even more important during the current COVID-19 crisis as uncertainties regarding COVID-19 made estimating the desirability of hospital referrals (for outpatient or inpatient hospitalization) complex, both for COVID and non-COVID suspected patients. This study explored Dutch general practitioners' experiences and ethical dilemmas faced in decision making about hospital referrals in times of the COVID-19 pandemic.

METHODS

Semi-structured interviews with Dutch general practitioners working in the Netherlands were conducted. Participants were recruited via purposive sampling. Thematic analysis was conducted using content coding.

RESULTS

Fifteen interviews were conducted, identifying four themes: one overarching regarding (1) COVID-19 uncertainties, and three themes about experienced ethical dilemmas: (2) the patients' self-determination vs. the general practitioners' paternalism, (3) the general practitioners' duty of care vs. the general practitioners' autonomy rights, (4) the general practitioners' duty of care vs. adequate care provision.

CONCLUSIONS

Lack of knowledge about COVID-19, risks to infect loved ones, scarcity of hospital beds and loneliness of patients during hospital admission were central in dilemmas experienced. When developing guidelines for future crises, this should be taken into account.

What if something happens tonight? A qualitative study of primary care physicians' perspectives on an alternative to hospital admittance

BACKGROUND

Due to demographic changes, hospital emergency departments in many countries are overcrowded. Internationally, several primary healthcare models have been introduced as alternatives to hospitalisation. In Norway, municipal acute wards (MAWs) have been implemented as primary care wards that provide observation and medical treatment for 24 h. The intention is to replace hospitalisation for patients who require acute admission but not specialist healthcare services. The aim of this study was to explore primary care physicians' (PCPs') perspectives on admission to a MAW as an alternative to hospitalisation.

METHODS

The study had a qualitative design, including interviews with 21 PCPs in a county in southeastern Norway. Data were analysed with a thematic approach.

RESULTS

The PCPs described uncertainty when referring patients to the MAW because of the fewer diagnostic opportunities there than in the hospital. Admission of patients to the MAW was assumed to be unsafe for both PCPs, MAW nurses and physicians. The PCPs assumed that medical competence was lower at the MAW than in the hospital, which led to scepticism about whether their tentative diagnoses would be reconsidered if needed and whether a deterioration of the patients' condition would be detected. When referring patients to a MAW, the PCPs experienced disagreements with MAW personnel about the suitability of the patient. The PCPs emphasised the importance of patients' and relatives' participation in decisions about the level of treatment. Nevertheless, such participation was not always possible, especially when patients' wishes conflicted with what PCPs considered professionally sound.

CONCLUSIONS

The PCPs reported concerns regarding the use of MAWs as an alternative to hospitalisation. These concerns were related to fewer diagnostic opportunities, lower medical expertise throughout the day, uncertainty about the selection of patients and challenges with user participation. Consequently, these concerns had an impact on how the PCPs utilised MAW services.

Urgent assessment and ongoing care for infection in community-dwelling older people: a qualitative study of patient experience

OBJECTIVES

To explore the experience of infection from the perspective of community-dwelling older people, including access and preferences for place of care.

DESIGN

Qualitative interview study, carried out between March 2017 and August 2018.

SETTING

Ambulatory care units in Oxfordshire, UK.

PARTICIPANTS

Adults >70 years with a clinical diagnosis of infection.

METHODS

Semistructured interviews based on a flexible topic guide. Participants were given the option to be interviewed with their caregiver. Thematic analysis was facilitated by NVivo V.11.

RESULTS

Participants described encountering several barriers when accessing an urgent healthcare assessment which were hard to negotiate when they felt unwell. They valued home comforts and independence if they received care for their infection at home, though were worried about burdening their family. Most talked about hospital admission being a necessity in the context of more severe illness. Perceived advantages included monitoring, availability of treatments and investigations. However, some recognised that admission put them at risk of a hospital-acquired infection. Ambulatory care was felt to be convenient if local, but daily transport was challenging.

CONCLUSIONS

Providers may need to think about protocols and targeted advice that could improve access for older people to urgent healthcare when they feel unwell. General practitioners making decisions about place of care may need to better communicate risks associated with the available options and think about balancing convenience with facilities for care.

Infection in older adults: a qualitative study of patient experience

BACKGROUND

Infection is common in older adults. Serious infection has a high mortality rate and is associated with unplanned hospital admissions. Little is known about the factors that prompt older patients to seek medical advice when they may have an infection.

AIM

To explore the symptoms of infection from the perspective of older adults, and when and why older patients seek healthcare advice for a possible infection.

DESIGN AND SETTING

A qualitative interview study among adults aged ≥70 years with a clinical diagnosis of infection recruited from ambulatory care units in Oxford, UK.

METHOD

Interviews were semi-structured and based on a flexible topic guide. Participants were given the option to be interviewed with their carer. Thematic analysis was facilitated using NVivo (version 11).

RESULTS

A total of 28 participants (22 patients and six carers) took part. Patients (aged 70-92 years) had experienced a range of different infections. Several early non-specific symptoms were described (fever, feeling unwell, lethargy, vomiting, pain, and confusion/delirium). Internally minimising symptoms was common and participants with historical experience of infection tended to be better able to interpret their symptoms. Factors influencing seeking healthcare advice included prompts from family, specific or intolerable symptoms, symptom duration, and being unable to manage with self-care. For some, not wanting to be a burden affected their desire to seek help.

CONCLUSION

Tailored advice to older adults highlighting early symptoms of infection may be beneficial. Knowing whether patients have had previous experience of infection may help healthcare professionals in assessing older patients with possible infection.

Challenges and strategies for general practitioners diagnosing serious infections in older adults: a UK qualitative interview study

BACKGROUND

Serious infections in older people are associated with unplanned hospital admissions and high mortality. Recognising the presence of a serious infection and making an accurate diagnosis are important challenges for General Practice. This study aimed to explore the issues UK GPs face when diagnosing serious infections in older patients.

METHODS

Qualitative study using semi-structured interviews. 28 GPs from 27 practices were purposively sampled from across the UK to achieve maximum variation in terms of GP role, experience and practice population. Interviews began by asking participants to describe recent or memorable cases where they had assessed older patients with suspected serious infections. Additional questions from the topic guide were used to explore the challenges further. Interview transcripts were coded and analysed using a modified framework approach.

RESULTS

Diagnosing serious infection in older adults was perceived to be challenging by participating GPs and the diagnosis was often uncertain. Contributing factors included patient complexity, atypical presentations, as well as a lack of knowledge of patients due to a loss in continuity. Diagnostic challenges were present at each stage of the patient assessment. Scoring systems were mainly used as communication tools. Investigations were sometimes used to resolve diagnostic uncertainty, but availability and speed of result limited their practical use. Clear safety-net plans shared with patients and their families helped GPs manage ongoing uncertainty.

CONCLUSIONS

Diagnostic challenges are present throughout the assessment of an older adult with a serious infection in primary care. Supporting GPs to provide continuity of care may improve the recognition and developing point of care testing for use in community settings may reduce diagnostic uncertainty.