Ben Lovell

Acute Medicine is invested in patient care, and therefore multiple departments There is a myth that Acute Physicians only work in Acute Medical Units (AMUs). In fact, they tread a constant path between the AMU, the Emergency Department (ED), ambulatory care, Intensive Care Units (ITUs) and various specialty wards within the hospital. Just as our focus is not tied to a single organ or body system, is it not solely linked to a certain geographical place. As a result, those working in Acute Medicine are invested in the pathways, problems, processes and positive attributes of departments and units outside of the AMU, because they affect our patients. In this issue, our research papers draw attention to how our patients’ care is tied up with some of the structural physiology of two of our sister departments: the ED and the ITU. Dobbe et al describe the decline in ED patients with self-poisoning requiring organ support in ITU. Compared to the 1990s, the number of patients moving into ITU with drug or alcohol intoxication has more than halved in their hospital, which the authors attribute to a stronger consultant presence in the ED and changing departmental processes, rather that a decrease in the prevalence of self-poisoning amongst patients. The introduction of frailty metrics have improved our recognition of vulnerable older people in Acute Medicine. However, the wide and sometimes bewildering array of these screening tools causes confusion and concerns about consistency in scoring outcomes. In their paper, Van Dam et al examine the agreement between four commonly used frailty screening instruments in the ED and found ‘fair to moderate’ agreement between them, but a startling variation in the diagnosis of vulnerability. How can we achieve consistency in this important undertaking? In their paper Byrne et al focus on the correlation between long ED waiting times patient outcome. They report their paradoxical finding that those waiting the shortest time in ED have poorer 30-day outcomes that those with longer waits; although those with longer ED waits have significantly longer in-patient lengths of stay. The authors discuss the role of healthcare funding, patient flow, and triage systems to investigate this paradox. Patel and King highlight an issue many of us already suspect: doctors on the AMU are not terribly good at documenting and diagnosing dermatological pathology. Their simple educational QI project shows that with the engagement of motivated medical trainees, positive patient and process outcomes are truly achievable. In our previous issue, Denny et al discussed the identification and management of proximal DVT and the issue of post-thrombotic syndrome, using a patient case vignette. In this issue, they extend the patient narrative to explore the diagnostic challenge in differentiating between chronic DVT and recurrent acute DVT. This differentiation is crucial, as the treatment options for each condition are rather different, and mismanagement results in the over or underuse of anticoagulant agents. As Acute Physicians continue to work seamlessly across many parts of the acute care pathway, it is important that we remain focussed on how we improve clinical standards and patient safety. High quality Acute Medicine research is fundamental to this work.