Gonna ask for my admission, gonna speak to the man in charge…

The Admissions Myth

When is an admission an admission?

24 hours a day, 7 days a week, 365 days a year, people come to emergency departments. They come by car, by foot, by ambulance, by helicopter looking for care in the hospital. Yet they are not “admissions”, they are “attendances”.

The majority of these patients have all their care done in the ED and are sent home. A minority, let’s say a third, need to be referred and seen by a second specialist team who will decide invariably to keep the patient in hospital. At this point they become an admission.

It’s the same patient, the same person, but by a simple decision they cross the Rubicon from attendance to admission. This is weighted with significance, and I think it’s wrong.

The work of the philosopher Wittgenstein covered the philosophy of language, and how words can have a meaning which is reflective of the culture in which they are used.* I believe that when it comes to hospital work, a greater seriousness is given to someone who is an “admission” versus someone who is an “attendance”.

Admission is weighted with significance: They were so sick, they had to be admitted. (And note that the word “admission” also means “a statement of truth.”) An attendance is a different thing all together. It carries with it the notion of something much more casual, someone just visiting or passing through.

Admissions get discharged. Attendances just… go home.

I now feel that using these two words are counter-productive to emergency medicine. Emergency department attendances should be called emergency department admissions. Actually, they should just be called admissions.

Think for a moment about that cohort of patients that we see in the ED and send home. Headaches and head injuries who have needed CT investigation. Acute asthmatics that responded to treatment. The fractures and dislocations we treat. These are not insignificant pathologies. These are not just attendances that went home.

An acutely unwell patient who came to hospital for treatment they needed? Sounds like an admission to me.

The attendance-admission differential creates an artificial separation between our work as emergency medicine specialists and that of our inpatient-based, on call colleagues. By having that differential, that switch, it becomes a thing to be avoided. “Admission avoidance” is a goal in hospitals throughout the land. Shouldn’t we replace this notion of “admission avoidance” with “appropriate, timely care”?

By sticking with the nomenclature of “attendance” we are deminishing the clinical acuity of our patients; both the ones we send home and the ones who end up staying in hospital. Having the single nomenclature of “admission” from the moment a patient books in, allows for the patient journey to be seen as a continuum from the ED doors to their eventual discharge, and should remove some of the hurdle attached to the current referral/admission dynamic.

* I’m no philosophy scholar. If I’m grasping the wrong end of the stick here, let me know.

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2 thoughts on “Gonna ask for my admission, gonna speak to the man in charge…

  1. Great article, and it raises this issue of ownership. Who owns the patient? Who owns the problem? Classically inpatient teams won’t have a bar of a patient if they’re not “admitted” under their unit. Or they’ll “see the patient but they’re not getting admitted under my unit”. In ED we don’t have the luxury of refusal, we own every patient and every problem that comes through the door. Perhaps changing the word attendance to admission for ED patients could change the psychology of ownership, to a situation where inpatient teams realise that the hospital owns the patient, and we are all obliged to help solve the patients problem. Maybe it will help break down the “us and them” mentality of ED vs the wards, to one where people realise, we’re all on the same side?

    • Yup, that’s exactly it. They’re all hospital patients, no different. The culture of the emergency department being some kind of work-generating inconvenience for everyone else in the hospital might be broken down a little if we bang the drum for the (majority) of patients who don’t get referred/admitted.

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