Volume 5

Does a Post-take Ward Round Proforma Lead to Sustainable Improvements in Quality of Documentation for Patients Admitted to the Medical Assessment Unit?

Research Report, Volume 5, Issue 3, Pages 81 - 116 (2006)

Abstract

This study assessed the quality of post-take ward round (PTWR) documentation, specifically looking at twelve criteria, in the medical assessment unit (MAU) prior to, 3- months and 2-years after introducing a PTWR proforma. 216 case records were analysed; 40 prior to, 40 three-months and 146 two-years after introducing the PTWR proforma. There was a significant improvement in eight criteria threemonths after introducing the PTWR proforma. These improvements were sustained two-years later and significant improvements made in a further 3 criteria (1 at p < 0.05 and 2 at p < 0.01).

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Hospital Readmissions: Patient, Carer and Clinician Views

Research Report, Volume 5, Issue 3, Pages 81 - 116 (2006)

Abstract

Aim: To explore patients, carers, and clinician views and identify factors, which affect the likelihood of hospital readmission.

Methods: A cross sectional retrospective study of adult medical patients readmitted to hospital within 28 days of discharge. Medical and nursing records were reviewed and patients and their carers were interviewed regarding their views about their discharge and readmission. Data were collected regarding demographic, social and medical profiles.

Results: Seventy-seven patients were readmitted over a five-week period out of 1289 patients discharged during the previous five weeks, representing a 6% readmission rate. Mean (SD) age of readmitted patients was 71.3 (14.6) years. Forty patients (51.9%) were aged ≥75 and 39 (50.6%) were males. Mean (SD) number of comorbidities was 3.68 (1.82). Mean (SD) number of medications was 7.79 (4.14). Most common reasons for readmission were exacerbation of chronic obstructive pulmonary disease and acute coronary syndrome. Mean (SD) time to readmission was 11.6 (8.2) days. Fifty (64.9%) patients were readmitted within 14 days of discharge. Forty eight (62.3%) patients were readmitted with the same medical condition as their previous discharge. Fifty (64.9%) patients and 45 (66.2%) carers felt that discharge was appropriate. Forty five (58.0%) patients and 44 (57.0%) carers thought that readmission was unavoidable. Clinicians considered 56 (72.7%) discharges appropriate and 55 (71.5%) readmissions unavoidable. A trend towards higher readmission rate among patients ≥ 75 years was noted (7.2% vs 5.1%, p=0.1).

Conclusion: Although the majority of discharges are appropriate, up to a third of readmissions may be avoidable in the views of carers, patients and clinicians. Patients and carers should be consulted regarding readiness for discharge before leaving hospital.

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Addison’s Disease Presenting with Abdominal Pain

Case Reports, Volume 5, Issue 3, Pages 81 - 116 (2006)

Abstract

Primary Adrenal Insufficiency is due to bilateral destruction of the adrenal cortex and has a prevalence of approximately 40-60 per million adults. 1 The commonest cause is autoimmune. 1 Prompt treatment not only restores quality of life but also a normal life expectancy. 2 Here we present an unusual case of primary adrenal insufficiency, which illustrates how such an important disease often provides a diagnostic conundrum.

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Metformin Associated Lactic Acidosis Not As Rare As We Think?

Case Reports, Volume 5, Issue 3, Pages 81 - 116 (2006)

Abstract

Metformin Associated Lactic Acidoisis (MALA) has been reported to be a very rare but serious side effect of metformin treatment with a fatality rate of 50%. However, with the number of patients on metformin increasing the incidence of MALA is likely to increase. We aim to raise the awareness of MALA and prompt acute physicians to consider this diagnosis in the acutely unwell diabetic patient on metformin. We present 3 cases that presented with MALA in the course of 6 months, all of whom survived. We discuss metformin, its effects and lactic acidosis. We encourage effective prompt resuscitation of these individuals to increase survival.

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Intra-Pericardial Rupture of Bacterial Hepatic Abscess: An Unusual Cause of ‘Cardiac’ Chest Pain

Case Reports, Volume 5, Issue 3, Pages 81 - 116 (2006)

Abstract

We report a rare case of bacterial pericarditis secondary to rupture of liver abscess into the pericardium. The patient presented with cardiac-sounding chest pain and with normal ECG, CXR and Troponin-I assay. The initial echocardiogram showed minimal pericardial fluid but, when he later developed overt clinical signs of cardiac tamponade, a CT scan of chest and abdomen revealed a pronounced pericardial effusion. It also revealed an abscess located in the left lobe of liver and this had apparently ruptured into the pericardial sac. Culture of the purulent pericardial aspirate grew Proteus and Enterococcus; these organisms have been reported only rarely as responsible for causing purulent pericarditis. The patient was treated initially by emergency ultrasound-guided pericardiocentesis; later he required thoracotomy and pericardiectomy in order to manage persistent re-accumulation of pus in the pericardium.

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Ecstasy: An Important Cause of Acute Liver Failure

Case Reports, Volume 5, Issue 3, Pages 81 - 116 (2006)

A twenty year old female was referred to hospital by her GP, after he received the results of blood tests taken earlier in the day. She had presented to him complaining of malaise, nausea and anorexia over a 3 day period. On the day of referral she had also become jaundiced with dark urine, but normal stool colour. There was no abdominal pain. She had no significant past medical history with no history of jaundice, liver disease or autoimmune conditions, and no apparent risk factors for blood-borne hepatitis infection. There was no relevant family history. She was taking no prescribed medication, had not taken any over the counter medication or herbal remedies. She denied excessive alcohol use or use of intravenous drugs in the past, although she was not specifically questioned on the use of other recreational drugs. She was a single mother and admitted to being under considerable stress recently. On examination she appeared well, apart from marked jaundice. There were no signs of hepatic encephalopathy or chronic liver disease. Abdominal examination revealed mild left upper quadrant tenderness, but no significant hepatomegaly. Liver function tests (LFTs) taken by her GP are shown in Table 1, revealing marked elevation of the Alanine Transaminase (ALT) (Table 1), with a relatively preserved albumin. Unfortunately her International Normalised Ratio (INR) had not been measured. An Ultrasound of the abdomen demonstrated a normal size liver with normal contour and texture with no other abnormality.

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An Unusual Case of Endocarditis

Case Reports, Volume 5, Issue 3, Pages 81 - 116 (2006)

A 74 year gentleman was admitted with a 6 month history of dizzy spells, malaise, generalised weakness and weight loss of over a stone. He attributed his weight loss to poor appetite due to persistent nausea. He had no significant past medical history apart from moderate mitral regurgitation and recent cholecystectomy. He felt some of these symptoms began after laparoscopic cholecystectomy 12 months before. The procedure had been complicated by a self-limiting biliary leak. He had been recently evaluated by chest physicians and gastroenterologists for clubbing and weight loss. Computerised tomography (CT) of the chest showed right basal fibrosis, CT of the abdomen and pelvis was normal, and upper endoscopy revealed a non-obstructive mild pyloric stenosis. Routine blood tests were unremarkable.

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The Role of Invasive Ventilation in Exacerbations of Chronic Obstructive Pulmonary Disease Causing Respiratory Failure.

Original Articles, Volume 5, Issue 3, Pages 81 - 116 (2006)

Abstract

Acute hypercapnic respiratory failure in chronic obstructive pulmonary disease can usually be managed initially with medical treatment and non- invasive ventilation. In circumstances where non- invasive ventilation cannot be used or has failed, intubation and invasive ventilation may be lifesaving. The outcome of patients with an exacerbation of COPD requiring invasive ventilation is better than often thought, with a hospital survival of 70-89%. Decisions regarding invasive ventilation made by physicians and patients with COPD are unpredictable and vary with the individual. This article reviews the role of invasive ventilation in exacerbations of COPD to assist decision making.

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How to Assess Patients Admitted with ‘Falls’

Original Articles, Volume 5, Issue 3, Pages 81 - 116 (2006)

Abstract

Many Medical Admission Units admit patients who have suffered a fall. Falls are incredibly common, yet often assessed and managed suboptimally in hospitals. Falls may be due to an acute illness, or due to a combination of factors which can be identified and managed in order to reduce the risk of falling in the future. A true ‘mechanical fall’ in an older person is rare.

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