The use of early warning scores to monitor the condition of patients has been one of the biggest changes in hospital practice over the past decade. This journal has featured many papers evaluating different scoring systems for medical patients admitted to hospital in an emergency; as the mechanisms for measuring, recording and calculating these scores become more refined our ability to predict which patients will deteriorate and require higher dependency care has continued to improve. In this edition, a paper from Canada has highlighted the key importance of one component of most scoring systems. Using a weighted scoring system, the authors have identified respiratory rate as the most valuable independent predictor of patient outcome. For a large cohort of patients in Thunder Bay hospital, Ontario, respiratory rate provided a true ‘early warning’ sign of imminent deterioration – rising several days before a patient’s death, and falling for patients who survived. The authors comment that respiratory rate is often inaccurately recorded – perhaps a result of the lack of an electronic measurement device or time pressures on nursing staff combined with the need to count breaths over a one minute period. This may explain why a fall in blood pressure or rise in pulse is often perceived to be more important when reviewing the observation chart at the foot of a patient’s bed. However this paper provides strong evidence to demonstrate why variations in this this clinical sign should not be overlooked.

Bed pressures in UK hospitals have regularly featured in news reports over recent months. The challenge of facilitating discharge for those patients who require increased social service support after they leave hospital has had a significant impact on our emergency departments and acute medical units. However, providing a safe and effective system of triage at the hospital ‘front door’ is also key element in improving patient flow on the AMU. Acute medicine consultants are increasingly becoming involved in identifying patients whose problem can be managed without hospital admission; the evaluation of consultant-led phone triage of medical referrals to Ipswich hospital over a 12 month period indicates that this is a cost-effective solution to reduce hospital admission. The benefit was greatest for referrals from general practitioners, for whom the authors comment that sharing of the burden of risk and uncertainty is a key component of the effectiveness of the consultant-led approach. Having provided a similar service in my own hospital over the past 15 years, I would share this view; the regular phone contact also enables building of relationships between senior primary and secondary care clinicians, which is crucial if we are going to improve integration of services in the future.

Finally, hospital acquired pneumonia is generally something to be avoided – but may have proved to be serendipitous for the patient in one of this edition’s case reports. During the course of his prolonged hospital stay with back pain, an MRI scan of his brachial plexus revealed incidental consolidation in his left upper zone, prompting treatment with intravenous antibiotics. Surprisingly, this treatment resulted in a reduction in his analgesic requirements; this improvement, along with the development of a lower motor neurone 7th nerve palsy led the team to investigate the possibility of Lyme neuroborreliosis, which was confirmed by serological testing. Radicular back pain and cranial neuropathies are recognised complications of Lyme disease; acute physicians reading this article should remember this when faced with this unusual combination in the future.


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Trends in weighted vital signs and the clinical course of 44,531 acutely ill medical patients while in hospital

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