Editorials

The role of consultants in the referral process for acute medicine has been a subject of discussion for as long as I have been involved with the speciality. This journal has previously published data from individual sites which demonstrated benefits on a local level when consultants were directly involved in taking referral phone calls from general practitioners. This was further evaluated as part of the Society for Acute Medicine’s 2016 Benchmarking Audit, (SAMBA16), which generated some National data around outcomes according to the seniority of clinician receiving the referral. This is presented in the current edition. The authors acknowledge the limitations of the data, particularly the difficulty in comparing units with different facilities for assessment, treatment and follow-up, which may have influenced the options available for consultants when taking referrals. As with previous research in this area, the paper focuses on the quantitative benefits in terms of the admissions ‘avoided’ as a result of telephone advice given; the data collection does not allow any analysis of what subsequently happened to these patients, and it is possible that some were subsequently admitted to hospital. It is important also to remember the qualitative benefits of direct communication with GPs: the ability to glean important nuggets of information which may be omitted from a referral letter, as well as the value of regular conversations in building relationships between primary and secondary care. My own experiences over the past 2 decades suggest that these benefits are often at least as great, albeit more difficult to measure, than ‘admission avoidance’.

Infections represent a large proportion of the acute medical intake, and this is reflected in many of the case reports we receive for consideration of publication. Three such cases are included in this edition. When the case history includes ‘visiting sewage-contaminated land’, many clinicians would be thinking along the lines of leptospirosis while awaiting serological testing. However in the case presented by Sarah Lawrence and colleagues from the Manchester area, it turned out to be the family pet which was responsible for their patient’s disseminated intravascular coagulation. Captocytophaga carnimorsis is not an organism with which I was previously familiar, but this case has reinforced my view that allowing your dog to lick your mucus membranes is something to be avoided. Lemierr’s syndrome is another condition which I have not previously encountered; however the authors of our third case report suggest this may be worth considering when a patient’s ‘simple sore throat’ fails to improve. In this case, it was the finding of another unusual bacterium – fusebacterium necrophorum – in the blood culture which led to the further investigation and diagnosis of this condition. Early recognition and initiation of appropriate antibiotic therapy is associated with an improved outcome, so this represents an important reminder of a condition which might otherwise be forgotten.

Although this is technically the ‘autumn edition’, I suspect that Winter may already have arrived with a vengeance by the time it has been printed and mailed, so I hope that readers working in the NHS’ busy Acute Medical Units are managing to keep their spirits up, and have battened down the necessary hatches for whatever the months ahead choose to throw at us.

The ability to predict the future would be a useful skill for anyone working in the acute medical unit. While crystal balls have not yet become standard issue for acute medicine trainees, a variety of tools now exist to help identify the likely outcome for patients referred for hospital admission – and enable their management to be planned. Two articles in this summer edition of Acute Medicine highlight this important issue. The team from Athens led by Sotirios Kakavas have investigated the prognostic value of beta-2 microglobulin in patients admitted to hospital with pulmonary embolism. Higher levels of this inflammatory protein were associated with a worse outcome, suggesting that it may have a role in identifying those patients who would benefit from management in a higher dependency setting. All patients in their cohort were admitted to hospital, which is clearly different to the established practice in many UK acute medical units where significant proportions of patients are now managed via ambulatory care. Identification of the low-risk patient who can safely be managed without in-patient monitoring will still require a different approach. However, the results of this study suggest that there may be a role for beta-2 microglobulin, either alone or in combination with other markers, in future prognostic modelling.

The ALICE score, developed by the acute medicine team in Plymouth, appears to perform well in a variety of hospitals in predicting length of stay for patients admitted to hospital. The paper by Dan Wilding and Kate Evans indicates that a lower score predicts a shorter hospital stay, which could have
significant implications. It is well established that unnecessary in-patient transfers can result in delays in care which may extend a patient’s time in hospital. Accurate, early identification of those patients who are most likely to be able to go home within 48-72hours may help to reduce transfers and improve the efficiency of the service. Of course, this will still be dependent on there being sufficient capacity to enable patients to remain on the acute medical unit for this time pending discharge, as well as good communication with bed management teams. The overnight transfer of patients whose discharge from hospital the next day was predicted and planned is a common source of frustration, when hospital capacity is under duress – as now seems to the case in most hospitals throughout the year.

This edition includes just a single case report, although we have several lined up for future editions later in the year. Although liver abscess is not an uncommon problem, the case highlights the important issue of ‘source control’ in the management of sepsis. The patient described was clearly unwell at the time of admission, and deteriorated further, despite rapid initiation of antibiotics and other ‘sepsis 6’ measures. The clinical and radiological evidence of pneumonia was compelling, but recognition, and early drainage of the abscess resulted in a rapid improvement, as well as confirmation of the causative organism. Clues to the cause included a past history of complicated diverticular disease and mild derangement of liver function, but relatively little in the way of abdominal findings such that this would have been an easy diagnosis to miss, if the acute medicine team had not been alert to this possibility. We must never be afraid to challenge out initial presumptions, particularly when a patient’s condition fails to improve.

I am delighted that Mark Holland has provided a ‘Viewpoint’ article for this edition, reflecting on his tenure as President of the Society for Acute Medicine. Mark hands over to Nick Scriven in the Autumn – no doubt, he will be feeling a sense of relief tinged with a little sadness, which I remember well when my time in the role came to an end in 2013. Mark has been a great asset to the Society and should be very proud of his achievements in raising the profile of the Speciality of Acute Medicine.
I hope you enjoy whatever remains of summer, and that you can all manage some respite before the start of the ‘predictable’ pressures of the months which follow.

Resilience is a quality that acute physicians require in abundance. The ability to ‘bounce back’ from hardships, along with the attributes of ‘faith, hope, optimism and a sense of purpose’, described in the introduction to the article on p10, are particularly important to those working at the hospital’s front door during the early weeks of January. This year was no exception, with downstream pressures resulting from social care cuts adding to the perennial problems of winter illness. Thankfully the arrival of this Spring edition means that these weeks are behind us; the risk of tripping over a TV news cameraman in the emergency department corridor has fallen dramatically, and hospital communications teams can park the term ‘unprecedented demand’ for another year. The challenges, of course, continue, but ‘normal service pressure’ has now resumed – for a few months, at least.

The article by Elen Bradley-Roberts and Chris Subbe from Bangor provides an interesting perspective on resilience and its influence on patients with acute illness. Their literature review identified that this was an under-researched area in relation to acute medicine, with much of the data relating to patients admitted to critical care units. However, there are clearly parallels with the AMU, and a better understanding of the impact of an acute hospital admission on patients may help us to provide appropriate support following their discharge. This links with Rachel Kidney’s article on readmissions, which are frequently used as an indicator of the quality of hospital care provided to patients. After analysing a large database from St James’ Hospital in Dublin, the authors conclude that the factors most strongly associated with 30 day readmission are unlikely to be influenced by the care received during the hospital stay. The lack of variation from year to year, despite major changes in health services funding in Ireland over this period adds weight to their contention that 30 day readmissions are likely to be unhelpful as a quality indicator. The Society for Acute Medicine currently recommends use of 7 day readmission figures as a more appropriate marker of AMU quality – aiming to reassure us that the pressure to shorten length of stay does not result in early readmission to hospital. However, the data from this paper may enable us to target interventions to reduce 30 day readmission amongst those patients at the highest risk. Many hospitals have already established community COPD services, which have been used to provide early supported discharge following admission with an exacerbation. Emergency Departments commonly have well developed links with community alcohol teams, although such services are often stretched too thinly. It may be that a combination of physical and psychological support, targeted at the groups of patients at highest risk of readmission to hospital, would be a costeffective model to reduce pressure on our services.

Enjoy what is left of Spring and early summer, and hopefully I will catch up with some of you at the SAM meeting in Cardiff in early May.

‘Where’s the evidence?’ It’s a question that most clinicians will ask themselves – or their team – every day. Good evidence requires good research, but it is often challenging to find high quality data pertaining to the AMU setting. It is encouraging that this journal has started to receive more research-orientated submissions over the past year, but the increase continues to be more of a trickle than a flood. The article by Louella Vaughan, published in this edition, highlights some of the difficulties which may arise when trying to undertake research in the AMU – along with some solutions. Engagement of the multidisciplinary team on the acute medical unit is a key part of this. Many of us will be familiar with the daily pressures to maintain patient flow through the unit, so anything which is perceived to increase workload will probably be met with resistance. A clear explanation of the local benefits which will arise from research is critical. Things are unlikely to change on a large scale until we have dedicated acute medicine research nurses, senior academics and junior doctors with protected time to write research proposals, organise ethics submissions and conduct studies. We have to be realistic in the context of the current financial pressures in our NHS; however, encouraging more acute medicine trainees to undertake research as their ‘special skill’ during higher speciality training would represent a step in the right direction.

I am delighted to have been able to include, in this edition, two papers from our acute medicine colleagues in the Netherlands. The Dutch Acute Medicine society has collaborated closely with the Society for Acute Medicine in recent years, and many members will recall the highly successful joint SAM / DAM conference in Amsterdam few years ago. The papers on sepsis management in the pre-hospital setting are highly topical, given the recent publication of NICE guidance in this area, proposed new definitions of sepsis and the current political drive to improve treatment of this condition. Although it is not particularly surprising that earlier recognition and documentation of sepsis reduced time to antibiotic administration following hospital arrival, this finding adds weight to the NICE proposals with regard to pre-hospital assessment. Early warning scores are already being used by some UK ambulance trusts as part of their initial patient assessment protocols. It was encouraging to note that the proportion of patients in whom sepsis was documented by paramedic crews was higher than had been noted in previous studies – the authors hypothesise that this may related to the educational benefits arising from their ongoing PHANTASi trial, the protocol for which is also included in this edition. The results of this study, investigating the impact of pre-hospital antibiotic administration for patients with severe sepsis, will hopefully be published in 2017.

I suspect that by the time this edition is published, Christmas and New Year will have passed, so I wish you all well for whatever Winter has left in store, and look forward to the warmer (and hopefully calmer) months which will follow.

Acute Medicine is full of ‘C-words’ – the Nursing and Midwifery Council’s ‘Six Cs’ (Care, Compassion, Competence, Commitment, Courage and Competence) are as relevant on the AMU as anywhere else in the Health Service; acute physicians would probably also include co-ordination, collaboration and crisis management, as winter looms before us. Dan Beckett’s paper from Forth Valley in Scotland, suggests another word that should be added to the list. As we strive to design sustainable rotas which span 7 days and comply with European work-time directives it is understandable that continuity often falls by the wayside, particularly in smaller Units. The transition from the acute medicine team to an in-patient specialist ward will usually, and appropriately, require hand-over of care. However, as described in this paper, patients who remain within the AMU may find that they see a different consultant each day. Moving to a model whereby patients in the AMU remained under the care of the admitting consultant was shown to shorten their AMU length of stay, facilitating transfer to the appropriate in-patient team, although not increasing the proportion of patients discharged directly from the unit. The authors proposed that this latter finding related to changes in the skill mix of the consultant team covering the AMU, demonstrating the complexity of the challenges we face. It would have been interesting to study the impact on patient satisfaction – as well as consultant job satisfaction – from this new model; my own, purely anecdotal data, suggests both may be considerably improved.

This month’s case report selection illustrates some interesting clinical conundrums. Lower limb cellulitis is a common reason for presentation to the acute medical, or ambulatory care unit; however, when the rash or erythema is bilateral, there is often an alternative diagnosis. In the case described by Cranga and colleagues, antibiotics turned out be the cause (rather than the solution) to the problem. Early liaison with the dermatology team enabled the diagnosis of acute generalized erythematous pustulosis to be made, and resolution of the condition followed discontinuation of antibiotics. The authors include a useful table to support clinicians in making this (albeit rare) diagnosis. Emily McNicholas reminds us of the importance of a collateral history – it is not hard to see how a patient with fever, confusion and incontinence might be labelled as having a urinary tract infection; the retrospective story of a cocktail stick in the throat prior to onset of the symptoms might have pointed to the correct diagnosis is this had been obtained at the time of admission. This case also shows the dangers of separation of Emergency Department notes from those of hospital in-patients, even within the same organization – a problem which will be familiar to many UK readers of this journal.

Patients with frailty represent a significant proportion of admissions to the acute medical take and often provide considerable management challenges. Natalie Offord and colleagues from the British Geriatric Society have described the development of the Frailsafe collaborative which
clearly provides a major step forward. At the other end of the age spectrum, adolescents and young adults (AYAs) may represent a different kind of challenge for the acute medicine team. Some of the key messages from the recent Royal College of Physicians’ Acute Care Toolkit for AYAs are summarized in the article on p157. Anyone who is involved in managing this group of patients is recommended to read this article, and please look out for the link to a survey about this at the end of the article.

Hospital mortality has been a hot topic in the medical and popular Press over recent years. Many readers will recall ‘scandals’ around hospitals whose mortality rates appeared higher than that which would be expected. The so-called ‘weekend effect’ whereby patients admitted to hospital between Friday and Monday appear more likely to die during their hospital stay has been regularly quoted in Parliament by the Secretary of State as justification for the Government’s manifesto pledge to create a ‘7 day NHS’. A number of recent publications have illustrated the complexity of this statistic, which – at least in part – is likely to reflect illness severity as much as organizational factors. The paper by Emma Mason in this edition further supports the concept that hospital mortality statistics may be hard to influence through structural or staffing changes. Those working in the acute medicine setting will not be surprised to read that almost half of those patients who die within 48 hours of arrival in hospital had solely palliative care needs at the time of admission. Many of these patients were elderly, frail and resident in a care home environment, but many also had undergone previous admissions within the months leading up to their death; the authors comment that this could have provided an opportunity to discuss end of life care plans, potentially enabling their final admission to hospital to have been avoided. Preventing ‘avoidable’ deaths in hospital from conditions such as sepsis and acute pulmonary embolism is a key component of the job of an acute physician. However, even when death in unavoidable we must do what we can to ensure patients die in the environment of their choice. Reducing deaths in hospital should not simply focus on those whose death can be prevented.

Although mortality statistics may be misleading when interpreted in isolation, good quality data can be a powerful tool to influence changes in the acute medicine setting. By the time this edition is published, the 2016 Society for Acute Medicine Benchmarking Audit (SAMBA16) will already have take n place; previous years’ data were published in this journal and we hope to see a continued rise in the numbers of participating units this year. Tom Brougham and colleagues from Bristol have illustrated how an electronic system for data collection on their AMU enabled reorganization of their junior doctor rota, reducing waiting time for patients. Their data illustrate the problem which will be familiar to many acute physicians, whereby the surge in afternoon arrivals on the AMU often coincides with shift changeovers and reductions in junior doctor and other numbers. Matching staffing to workload can have significant benefits for patient care and may enable a reduced strain on the night shift team if patients are seen in a more timely fashion. Whether this can be linked to improved patient outcomes in the future will be interesting.

Finally, I would like to welcome one more addition to the editorial board. Dr Nick Murch is an acute physician in the Royal Free hospital, with an interest in medical education and simulation skills training. With an increasing number of acute medicine trainees undertaking medical education as their specialist skill, I am keen to develop the training and education section of the journal over the coming years, and look forward to Nick’s input in this regard. We will continue to welcome submissions of research relating to acute medicine education and training, which we will consider for future publication in this section of the journal.

Quality in health care is difficult to measure. Detailed retrospective reviews of patients’ admission records often reveal areas where quality can be improved, but are time consuming and subjective. In our search for simple, reliable and reproducible measures, we end up using surrogate markers; things which we can collect easily, rather true markers of quality in what we achieve. The Society for Acute Medicine quality standards, which have formed the basis of the SAMBA audits over recent years, are no exception to this. The standards stipulate that patients should be assessed using an early warning score on arrival in the AMU, be seen by a clinical decision maker within 4 hours and a consultant within 14 hours, while quality indicators include the proportion of patients being discharged directly from the AMU and 7 day readmission rates. While these can provide a useful benchmark for comparison between units or evidence of improvement over time, they clearly cannot provide a complete picture of the quality of care delivered on the AMU. Timely assessment is important, but undertaking an early warning score does not necessarily mean that an abnormal score was acted upon promptly; rapid review by a ‘clinical decision maker’ is only valuable if an appropriate clinical decision is taken. Consideration for the patient’s experience on the AMU is also a key element in delivering a high quality service. This year’s SAMBA audit included a modified version of the ‘Friends and Family’ questionnaire in an attempt to provide a snapshot of patient experience of acute medical care. The results of this are presented here in the first instalment of the data analysis from SAMBA15. The usual ‘health warnings’ apply to these data – a single day in June is not necessarily representative of the remainder of the year, while not all participating organisations submitted patient experience data, introducing the possibility of selection bias. However some interesting themes emerge, many of which will be familiar to those who have worked (or been patients) on acute medical units. It is encouraging that positive comments outnumbered negative by 3:1, while positive comments about staff attitude were over 40 times more numerous than criticisms, despite recognition of the workload faced by staff on the AMU. Concerns about noise levels and catering were common themes, but the importance of timely assessment and care emerges in both categories; patients clearly appreciate being seen and treated rapidly and are frustrated by delays. Our pursuit of better measures of quality should not lose sight of the importance of measuring, and improving the speed with which we deliver care.

Many readers will be familiar with the challenges associated with the measurement of quality in acute medicine. The annual Society for Acute Medicine Benchmarking Audit (SAMBA) has attempted to map performance of acute medical units (AMUs) against quality standards established by SAM in 2011. The data presented in this autumn’s edition need to be interpreted with some caution – a single weekday in June is not necessarily representative of practice at other times of the year, and the figures are more than one year old, with the 2015 audit data currently being analysed. However the paper contains some interesting points which are worthy of comment. Overall, around 20% of patients waited more than 4 hours from arrival on the AMU before being seen by a ‘competent decision maker’, while more than a third of patients waited longer than the defined standard (8 hours during daytime and 14 hours after 5pm) to see a consultant. It should be noted, however that almost 70% of these patients passed through the Emergency Department (ED) prior to their arrival on the AMU, and many will therefore have already seen a senior ED clinician with a management plan being initiated. It is clearly important that Units who admit significant numbers of patients directly from General Practitioners are recording time delays for this group of patients, who should be subject to the same degree of rigorous prioritisation afforded to patients in the ED. It is also of interest that those patients least likely to fulfil all three of the defined standards were those who arrived on the AMU in the early evening period (5pm-10pm), while patients who arrive after 10pm were most likely to be seen within the appropriate time period. This is not surprising when one considers the way in which arrangements for consultant review are often designed, with morning ‘post take’ ward rounds enabling review of those patients who were admitted overnight. This needs to be addressed – 25% of patients arrived on the AMU during the evening period, and local experience suggests that many of these are patients referred directly by general practitioners. Many units now have a consultant presence on AMU until 8pm and some have extended this further to enable real-time consultant review of this cohort of patients later into the evening.