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 […]
Let’s be honest – the past few months have been tough for anyone working at the hospital coalface. Even the most optimistic masters of NHS spin will have had difficulty denying some of the harsh realities which have faced staff, and patients; often on a daily basis. The Royal College of Physicians’ report Hospitals on the Edge, published last September, presented a gloomy picture of a system on the brink of collapse, becoming overwhelmed by year-round demands which continue to grow inexorably. Then came winter, Norovirus – and Robert Francis. His much anticipated, and long-delayed, report with its 293 recommendations, should be seen as a wake-up call to those in the position to effect change. The political, and media focus so far has been on the failures to recognise what went wrong – target culture, whistleblowing and regulation, as well as individual failings. All of these need to change, but the root causes of the problem should also not be forgotten. I have no doubt that many healthcare workers and patients reading the report from across the UK will have had days, and experiences which were not dissimilar to many of those described in Mid Staffs. The demands on our service, and the expectations of its users is rising; and yet we cannot expand our capacity to meet these demands. The past decade has seen countless efforts to improve efficiency and flow at the hospital front door: admission prevention schemes, ambulatory care, community geriatric services, chest pain pathways and rapid access clinics, to name but a few, have squeezed down the length of hospital stay for many patients. Undoubtedly there is more that can be done; systems can still be improved, but the hamster wheel needs to turn faster and faster each year – and the hamster is getting tired.
This time last year, I was contemplating the predictions of Nostradamus, the possibility of a ‘barbeque summer’, and the hope that an Olympic ‘feel good factor’ would find its way onto the AMU. Longterm predictions are as tough for clinicians as they are for weathermen and 14th century apothecaries, but even looking a few days into the future can be difficult. In some ways it is the unpredictability of acute medicine which provides our biggest challenges: risk scores, early warning scores, and discharge prediction tools attempt to add some science to the subjectivity of clinical assessment. Every scientific meeting seems to feature a new biomarker, promising to eliminate uncertainty and improve accuracy, but probably opening a few cans of worms in the process. None of us has a crystal ball; recognising uncertainty – and communicating this to our patients – is a key skill which we all need to develop.
The challenge of delivering a high quality acute medicine service, 7 days a week, has been a major theme for 2012. Many readers will already have read the ‘Toolkit’ for delivery of a 7 day consultant service on the AMU, produced by the Royal College of Physicians (RCP) in association with SAM. This can be downloaded from the SAM website (www.acutemedicine.org.uk) along with the AMU Quality Standards which were released earlier in the summer. The article by Hannah Skene and David Ward on p205 complements these two documents, highlighting some of the practicalities in implementing quality standards across the 7 day week. This paper also comments on best ward round practice, a topic which has been the subject of some combined work by the RCP and Royal College of Nursing this year, and which provided the subject of the ‘best poster’, awarded to John Soon at this year’s SAM Autumn conference. The abstract from this presentation is included in the ‘selected abstracts’ article on p217.
During the summer I had the privilege to represent SAM at a reception organised by SepsisUK to co-incide with World Sepsis Day. The event featured some powerful, and moving talks from patients and relatives affected by sepsis, portraying the importance of early diagnosis and treatment for this devastating condition. Case reports in this journal over the past 10 years have demonstrated how often acute physicians are faced with atypical presentations of infection; this is particularly true for older patients as demonstrated in the cases on p 226. Ron Daniels’ ‘viewpoint’ article emphasises the important role which acute physicians have in recognising the signs of sepsis, ensuring early treatment and escalation to higher dependency areas where necessary. For patients who do not fall into any other clear cut speciality category during the first 48 hours of their hospital stay, acute physicians must provide the leadership and continuity of care which are essential in ensuring a good outcome.
January is a busy time on the AMU, so wishing you all a ‘Happy New Year’ may seem inappropriate to some readers. As I mentioned at the top of this editorial, my track record in prediction has not been good lately; however I hope it’s a fairly safe bet to suggest that – no matter how hard these next few weeks may get – the months which follow will probably be a whole lot easier!
This summer the UK has been privileged to witness some really special achievements. The Diamond Jubilee celebrations, followed by Olympics and Para-Olympics, proved to even the most hardened sceptics that Britain can pull off global events to be proud of. Danny Boyle’s tribute to the NHS provided a timely reminder that – whatever its shortcomings – our largest employer remains a key part of our Heritage.Hopefully the performances of our athletes will inspire us to become a fitter, and healthier Nation and end the much-feared obesity epidemic….there’s no harm in hoping.
But amidst all the Olympicand Para-Olympic euphoria, many acute physicians willhave found themselves battling against the familiar challenges of bed crises in our acute hospitals -even in August. When we can achieve so much, why is it that we seem to struggle to resolve this problem after so many years of trying? The Foundation Year doctors, arriving on 1st August, might be forgiven for assuming that this is a new problem – of course it isn’t. The last decade has been filled with attempts to find solutions – length of hospital stay has reduced dramatically for many conditions, ambulatory care pathways have been developed along with widespread schemes to avoid ‘inappropriate’ hospital admissions. According to Gordon Caldwell’s article in this edition, will still need to become ‘leaner’ – in his words to ‘Cut the Crap’ from our systems. He cites many examples of what could – and should – be cut out; I am sure many of his suggestions will ring true with readers of this journal. The inefficiency of ‘waiting’ is highlighted in his article; certainly this wastes many precious hours of our time – and the day never seems quite long enough as it is. But such delays are trivial in comparison to the waits which our patients endure on a daily basis; this is a fundamental problem which we have to resolve before we can move forward.
I met an American patient recently – visiting for the Olympics and admitted to hospital with diarrhoea and rectal bleeding.This was likely to be a new presentation of inflammatory bowel disease – she was not in imminent danger, but not really well enough for outpatient management.The plan to start some treatment and arrange flexible sigmoidoscopy ‘in the next day or two’ was greeted with the response ‘So what the Heck is wrong with today?’ Americans sometimes have a refreshingly direct approach – but of course she had a point: what the Heck was wrong with today? OK – I could rationalise it: even if the test were done we would probably have had to wait to see how she responded to treatment, and she had no-one to ‘keep an eye on her’ if she left hospital. However it made me realise how, in NHS hospitals we have become so used to waiting that UK patients – and their doctors – often perceive it as inevitable. Patients wait for assessment, wait for a test to be done and then wait for the result, they then wait for someone to review and act upon the result and then wait again for something, or someone else.
It is true that some patients get better while waiting – time can be a healer, and can reveal the ‘real’ diagnosis. However it is hard to make the case that delays ever improve outcome; if something is deemed to be necessary, and is only going to be done once, then why not do it as soon as the decision has been made? Is there ever a justification for a patient waiting in a hospital bed for additional nights for a test or assessment which is scheduled on a future date? I suspect that every reader of this journal will have patients under their care who fall into that group; across the UK, on a daily basis, this figure will amount to thousands.
My American patient suggested this must be a British thing: ‘Nobody back home would accept this’, she said. If queuing was an Olympic discipline, the GB team would be nailed-on for gold, and NHS patients would be first on the team sheet. But perhaps the time has come to challenge these assumptions; to ask ourselves, and our colleagues the same question: ‘What the Heck is wrong with today?’If we don’t ask it, sooner or later our patients will.
The ability to identify and discharge the low-risk patient, and to predict those cases where deterioration is likely is already a key element of the practice of acute medicine . This is an area which has been extensively examined in the past, but two articles in this edition add an interesting dimension to the literature. The use of physiological variables to calculate risk enables fluctuations in a patient’s condition over time can be monitored, allowing appropriate escalation measures to be instituted. The National Early Warning Score has already been implemented in Wales and roll-out across England is expected imminently. Austen and colleagues have highlighted some of the advantages that a standardised system will provide in comparison to their locally-developed Early Warning Score; however the problem of under-scoring due to incomplete or inaccurate recording remains and will continue until electronic solutions are more widespread.
The snow and freezing temperatures will hopefully have passed by the time this edition reaches you; the sight of daffodils may be asignal that the relief of spring is not far off. Winter frequently stretches AMU resources to the limit – in recent years we have had epidemics of seasonal and swine f lu, but this year Norovirus seems to have been the bigger challenge. Ward closures from diarrhoea outbreaks have traditionally been more of a ‘downstream’ problem (no pun intended), but the impact of closure of the AMU would be substantial.At the time of writing this has still, thankfully, been avoided in my own hospital; however it remains a circumstance for which we have to be prepared. This edition’s ‘Viewpoint’ article describes how temporary closure of the AMU was managed in a London hospital. The use of an empty ‘winter pressures ward’ eased the burden in this case, enabling the AMU service to be maintained. Even with the luxury of this spare capacity, there was clearly significant disruption, requiring close collaboration between a variety of departments, which is well described by the authors. Many hospitals have become highly dependent on a functioning AMU to provide timely, safe and effective care for medical emergencies. Major incident plans are in place to deal with mass casualty incidents; we need to consider similar contingencies to deal with AMU closure if patient safety is going to be maintained. This article is a timely reminder of the need for forward planning.
Once again, 12 months seem to have f lown by and we find ourselves at the end of this journal’s 10th Anniversary year. So what will 2012 have in store for us? Will financial chaos send us spiralling into the abyss or will the Olympics and Diamond Jubilee bring back the long-awaited ‘feel good factor’? Maybe the England football team will finally win a trophy, and surely we are due for some decent weather. I prefer to stay optimistic, and believe predictions of ‘barbeque summers’, rather than those of Nostradamus! One thing we can certainly look forward to in 2012 is a ‘silver’ anniversary for SAM – as well as the first to be held overseas, the spring meeting in Dublin will be the 25th held by the Society. I hope that many UK readers will be able to make the short trip across the Irish Sea to attend this special event.
Summer has been a busy time for the British media – phone hacking, atrocities in Norway, famine in Africa, riots, financial crises….hardly the usual ‘silly season’. The lack of health stories on the front pages might suggest that all is calm on the hospital front line. I suspect that most readers will disagree. Certainly in my hospital summer has f lown past with little respite from the pressures of emergency admissions, which now seem to continue all year round. However the wide variety of different conditions presenting on the acute medical take helps maintain our sanity and keeps the grey cells ticking over. The three case reports in this edition highlight this variety. Tanuj Lad reminds us that type 2 respiratory failure does not always mean COPD, while Desai and Sivaramakrishnan present an important differential diagnosis for a patient with diarrhoea. Haemophagocytic syndrome might not be a common cause of fever and rash, but the importance of maintaining a broad differential diagnosis in patients with HIV should noted, even when the CD4 count is not particularly low. These cases also illustrate the excellent learning opportunities for junior doctors on the AMU. Although it is often hard to find the time to teach on our ward rounds, such opportunities must not be missed. Nicola Cooper’s article provides some useful advice on how to maximise these opportunities amidst the continued work pressures.
Welcome to the first summer edition of Acute Medicine which became a ‘quarterly’ journal this year. Some readers may be relieved to have survived the passing of spring, with Bank Holidays and a Royal wedding bringing the challenges of 7 day working into sharp focus. There have been times in the past when it felt
Welcome to this special 10th anniversary edition of the Acute Medicine journal. Yes – there really have been 30 editions since Vol 1 issue 1, then the ‘CPD Journal of Acute Medicine’ rolled off the press. The journal has clearly evolved and expanded since then – both in terms of circulation and page count; submissions