All Journals from Mark Holland
Background: Education, research, and Quality Improvement (QI) are key enablers for high quality care. We aimed to map the capability of Acute Medical Units (AMUs) to facilitate excellence in these areas.
Methods: AMUs were surveyed in an organisational questionnaire within the Society for Acute Medicine Benchmarking Audit 2021.
Results: 143 units participated. 80 units had a QI lead, 24 had a research lead and 99 had a medical education lead. 15 units had all three leadership roles. Most QI work considered service structure rather than changes in processes or care outcomes.
Conclusion: The organisational capability of AMUs in the strategic areas considered is variable. Improving leadership and disseminating learning could help build a strategic foundation for acute medicine to grow.
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Cardio-Renal-Metabolic (CaReMe) diseases, in the form of heart failure, chronic kidney disease and diabetes mellitus, justify prescription of multiple prognostically beneficial medications, specifically renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter-2 inhibitors. Use of these medications is complicated by association with adverse effects, particularly acute kidney injury and hyperkalaemia. Balancing risk and benefit is a common dilemma in acute medicine, with increasingly frequent and complex treatment decisions. Physicians should contemplate adjustments to medications within the context of not just acute illness but also long-term benefit. In the setting of hyperkalaemia, potassium-binding medications can be utilised. At hospital discharge optimisation of therapy can be achieved through clear safety netting advice, scheduled biochemical follow-up, and planned clinical review.
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Background: The relationship between diagnosis, illness severity, and mortality risk for unselected emergency admissions is poorly defined.
Aim: To define primary ICD-10 diagnostic chapters at discharge, admission illness severity by the National Early Warning Score, and in-hospital mortality for all unselected emergency admissions.
Method: Retrospective, observational, cohort study of 122,259 unselected, adult emergency admissions to Salford Royal Hospital between 2014 and 2022.
Results: In-hospital mortality was 4.3% but most patients had an ICD-10 chapter associated with a lower risk of death. 60% of in-hospital deaths were in four chapters, infections, circulatory and respiratory diseases, or neoplasms. An admission NEWS ≥3 was associated with earlier mortality and an eight-fold increased risk of in-hospital mortality. 45% of all in-hospital deaths occurred in patients with an admission NEWS <3.
Conclusion: Mortality in emergency hospital admissions is associated with illness severity and four diagnostic chapters. NEWS should not be the only arbiter of hospital admission, as for certain diagnostic chapters the risk of death is high even if vital signs on presentation are normal.
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Aim: To determine the in-hospital mortality of eight physiological categories based on shock index, pulse pressure and ROX index, and to compare each category according to admission level of consciousness and National Early Warning Score.
Method: A non-interventional observational study of 122,262, unselected, adult emergency admissions between 2014 and 2022.
Results: In-hospital mortality increases according to physiological category and whether the admission NEWS was<3 or ≥3. For NEWS ≥3, patients were more likely to die when not alert. Irrespective of total NEWS, patients with a low ROX index <22 are more likely to die.
Conclusion: Patients with the same NEWS value can have different physiological derangements. Level of consciousness also provides greater insight than NEWS alone regarding the risk of in-patient mortality.
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Introduction: Readmission after hospital discharge is an ongoing challenge that healthcare systems face worldwide, with multimorbidity increasing the readmission risk significantly. Identifying higher risk groups of patients allows for safety netting at discharge to be implemented to prevent harm. The aim of this study was to compare readmission rates and reasons across common diagnostic groups presenting to the acute medical unit.
Method: A retrospective analysis was performed on an anonymous dataset extracted from Salford Royal Hospital from 2014 – 2022 covering all non-elective inpatient admissions to AMU or medical same day emergency care where the patient survived to discharge. Episodes were grouped according to ICD-10 diagnostic codes, with readmission rates and reasons at 30 and 90 day calculated and compared using descriptive statistics. Further subgroups were evaluated according to demographic and co-morbid features.
Results: There were 89,897 admissions to AMU and SDEC where patients survived to discharge: age 68±19 years, 53% female. 5,880 episodes were excluded due to inpatient death.
The most common first admission reasons were pneumonia (n=9,121), COPD (4,800) and sepsis (3,440). The overall 30 day readmission rate was 12.3%, with the highest rates being found where first admission episode was due to liver disease (21.9%), chronic obstructive pulmonary disease (COPD, 21.1%), and falls (17.9%). 6% of all patients were readmitted within 30 days due to recurrence of the primary presenting illness, representing 49% of all readmissions. After primary illness recurrence, pneumonia was the second most common readmission reason in 17 of 22 diagnostic groups and accounted for 25% of all readmissions excluding primary illness recurrence.
Overall 90 day readmission rate was 24.2% with the same 3 most common diagnostic groups (liver disease 44%, COPD 39% and falls 34%). For 90 day readmission reasons according to specified comorbidities, the highest rates were seen in heart failures (34.1%) and COPD (33.1%). The highest readmission reason in the diagnostic groups was 41.4% of heart failure patients being readmitted with respiratory causes.
Heart failure was the most impactful co-morbid factor associated with higher likelihood of 90 day readmission in other disease presentations (34.4% with heart failure, 22.8% without).
Discussion: Readmission rates vary significantly between diagnostic and co-morbid groups meaning that targeting high risk groups for safety netting may be possible using only simple admission details.
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