Interface Medicine
Dr Dan Mitchener MBBS MRCP MRCGP DGM
Senior interface GP/ Physician
Oxford University Hospitals Geratology/ Medicine
Medical lead of Abingdon EMU
What is “the interface”
 Patients presenting to ED, GP streams, 111, NHS Direct
 Interface between primary and secondary/ tertiary care- wide
gap?
 Other agencies- Physio/ OT/ SW?- access not timely
 Other generalist interface- eg trauma, orthopaedics,
perioperative care
 DDUs, RACs- day clinics and treatment centres- review.
 1957- Lionel Cosin recognised this need of early discharge,
day units
 Outside hospital- outreach clinics- CHs, GP surgeries, EMUs
Central ideas of EMUs
 Alternative place of treatment
 Interface between: GP, hospital- IP, OP, daily treatments, advice
 Diagnostic unit- fuller assessment than GP and prompt senior
decision to determine pathway- eg pleural effusion
 Treatment focussed- IV fluids, Abs, furosemide early in day
 Allows patients’ adjustment to diagnoses- psychological,
pharmacological, social, functional, future planning
 Make management adjustments, talk to relevant agencies,
deliver treatments, many benefits of IP stay- close observation,
Further investigations- clinic or GP/ none?
 Does not necessitate staying in overnight, unless specific needs
Figures- 2014
 60% purely ambulatory episode
 20% have a CH inpatient stay during their episode- reflects
acuity of patients, logistical stresses and best path- some SPA
(Single Point of Access)- planned admissions to CH
 15% initial escalation to JR- some lack of EMU/CH beds. Some
patients better in acute hospital- complex O2 requirements,
multiple medical questions- short admission to drop down to
CH/ ambulatory
 3% escalation to bed-based care from ambulatory pathwaygone home against our recommendation, external decision to
escalate- NH, OOH
 Now- Improved selection? Less acute? Using available beds
Inpatient bedsLowest beds per 1000 in the EU. Oxfordshire- one of lowest
counties (especially with tertiary bed factor)
 Access to beds- needed
 6 available on site- 72 hours stay.
 Acute beds- direct admission to geratology/ EAU if sick
 Local community beds- generic, rehab
 Social worker- prompt carers/ placement/ respite/ DTA
Other interfaces
 Hospital at home:
-Preassessment- ? Safe overnight- bloods, support- sc fluids
-Post discharge (mostly)- IVs, nebs and support
 Therapists: Physiotherapist/ OT- overlap to cover- safe MDT
fit discharge. Close preemptive liason and input with
 Social worker
 ****Transport- man and van (double handed crew last winter)
 Consider logistics- can we get patient home if comes in lateesp if needs fluids, analgesia, therapy. A chance if they are in
early to discharge. Stairs to property?
Written Interface
 Need for a well written, concise but inclusive discharge summary
to allow further care from GP
 Peg patient at a level to indicate if improving or not to
subsequent care setting
 “GP to do resus status/ check bloods”- really? after a 2 week
stay
 What investigations have been/ not been done. Follow up- ?
Arrange for patient- eg blood test
 What other things have been done?........
 Allow greater appreciation of others’ roles- how GPs can access
hospital functions- sometimes a learning curve for registrars
Time consuming activities need
to be conveyed…..
 Discussions with relatives
 Future plans- home, care, prognosis
 Resus status
 Ceilings of care-Transfer- community to main hospital?
 Advanced planning
 GP IT systems- direct access
Relatives- First contact
May start off as angry, aggressive, emotional- ploys to get
what they (think that) they want
May go home before decision-makers are around- nooo!
Walk them down path- drawbacks of admission; logistics“I would so like to help mum- yes, I would stay with her”
just tonight/ weekend?
Don’t push the “no beds” early on- not helpful to
negotiation to care gap and progression to plan
Relatives
Personal advice- “I would….” but appreciate the task in hand
Home? “What can I expect?” “What do I do if?”
Pre-emptive drugs- nausea, agitation, pain- in hand, not FP10
ideally
Other considerations- Frame/walker, commode, dressings, pads
Supportive visit from hospital at home/ phone/ attend following
day
Early input of social care, plan
Pitfalls of community EMU
 Patient obviously needs acute admission/ investigations. Avoid
extra journey limb- eg head injury, Posterior stroke
 (2nd) Opinion- GP function duplication? (but can raise quality)
 Palliative- stay at home to die? “Compromise assessment”
 At risk of dying in transit (but assessment can be useful)
 “Favours”- expected? Eg trop, bloods, catheters- “why not?”
 As capacity stressed, more tendency for GPs to “sell”
patients- we WANT to accept- accurate info is key
Successes
 Avoidance of unnecessary admission days-
-One stop shop, ambulatory episodes
-Short prompt incisive admissions to determine pathways-Support to discharges from acute sector- planned and
unplanned- treat and explain
 Rule out reasonable concerns, not investigate past necessary;
Focus on important, effective therapy; Setting appropriate
ceiling to the treatment which is delivered;
 Avoid sending out for multiple (conflicting?) opinions- moves
pathway forward and early focus.
Interface complexities
 We are medically employed by OUH (Nursing, pharmacists and
therapists employed by OH), Commissioned by commissioners,
Referred to by GPs, OOH, ambulance and ENPs
 Pressure to accept patients by OUH, commissioners, GPs,
ambulances- SCAS paramedics
 Pressure to decline- nursing (safety)/ physical space/
ambulances- PTS transport/ logistics (NICE/local guidance)
 Conflicting messages from standard operating procedures in
place/ pathways- eg CURB, PE score
 “Try us first” is reasonable- not strokes, fractures, STEMIs…….
 Practice good faith- strive to accept patients- GP relations
General practice
 “Parents”- great variations in capabilities
 Longest term frequent contacts
 Unappreciated by many
 Most important facilitators of keeping well
 Can tell them how to parent- one size fits all but…..
 More personal relationship than the more theatrical
detached hospital relationship
 Simple step wise adjustments in own environment
Hospital practitioners
 “Teachers” Increased knowledge base, esp in one
specialty- ? Too much?? More siloed behaviour
 Decline patients- and able to do so; Redirect patients
 Advise on phone- “just do this”- perhaps different to
advice if they are seeing patients- “scan to make sure”
etc….
 Some, often more senior clinicians- more helpful
dialogue to agree pathway of care with us/ GP
(some )Myths, dogmas and plain
stupidity in medicine
 Head injury advice- eyes, limbs don’t work, intractible
vomiting, awful headache develops……………
 If you want to leave hospital you have to self discharge- no
rights for discharge meds etc- Hospital or a prison?
 Contract with hospital needed but patients can balance risk
 “Health is top priority”- Is it?- family, business, friends?
 One of the things said to patients after often mild
abnormalities found
 Often after “why have you come with this?” Why didn’t you
go to your GP?
 “Anyone can do a capacity assessment”- yes, badly
Give people what they want, esp if others all in
agreement. Direct patients/ relatives to correct choices
 More governance=less freedom- wards/ NHs- unable to
omit drug BUT can at home with sensible relative……
 Safety of targeted antibiotic- yes, but infective delirium
unclear source- stamp on it with IV first dose????
 People get worse before getting better- lag/ fluctuant
course frequent- crux time
Interface
 Integrating all opinions on appropriate background of
timely necessary tests, services
 Making plan to go forwards and boundary setting
 Delivering treatments and inputs compatible with home
living.
 Support discharges, esp when things go wrong
 Delivering what patients, families, staff, GPs,
commissioners want
 Beneficial to patients’ wellbeing and understanding