Volume 10, Issue 4, Pages 173 – 232 (2011)

Selected Abstracts from the 5th International Meeting of the Society for Acute Medicine

Research Audit and Clinical Practice, Volume 10, Issue 4, Pages 173 - 232 (2011)

29th -30th September 2011, Imperial College London

Delegates at the 5th International meeting of the Society for Acute Medicine enjoyed some unseasonal autumn sunshine at Imperial College London at the end of September. The number of submitted abstracts for this meeting was considerable and this year many were of exceptionally high standard. As well as a poster display of over 100, the reviewing panel selected six for oral presentation on the Friday morning. The abstracts from these presentations are published below.

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Lumbar Puncture

Research Audit and Clinical Practice, Volume 10, Issue 4, Pages 173 - 232 (2011)

Abstract

Most junior doctors learn common practical procedures, like lumbar puncture, on the job. This usually involves unstructured observation, demonstration and then supervised practice. Thus, most doctors have learned to perform a lumbar puncture without studying the theory of the procedure in any detail. The result is that patients experience less than optimal care, and more complications than necessary. This article first outlines some educational principles with regard to teaching and learning practical procedures and then describes the theory of diagnostic lumbar puncture.

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The increased mortality associated with a weekend emergency admission is due to increased illness severity and altered case-mix

Research Audit and Clinical Practice, Volume 10, Issue 4, Pages 173 - 232 (2011)

Abstract

Background: A weekend emergency medical admission has been associated with a higher mortality. We have examined all weekend admissions to St James’ Hospital, Dublin between 2002 and 2009.

Methods: We divided admissions by weekday or weekend (Saturday or Sunday) presentation. We utilised a multivariate logistic model, to determine whether a weekend admission was independently predictive of 30 day outcome.

Results: There were 49337 episodes recorded in 25883 patients; 30-day inhospital mortality at the weekend (9.9% vs. 9.0%) had an unadjusted Odds Ratio of 1.11 (95% CI 0.99, 1.23: p=0.057). In the full risk (unlike the univariate) model, a weekend admission was not independently predictive (OR 1.05; 95% CI: 0.88, 1.24). The case-mix for a weekend admission differed; with more neurological diagnoses (22.8% vs 20.4% : p = 0.001) and less gastrointestinal disease (18.3% vs 21.1% : p = 0.001). A biochemistry only illness severity score predicted a higher mortality for weekend admissions.

Conclusion: Patients admitted at the weekend had an approximate 11% increased 30-day in-hospital mortality, compared with a weekday admission. However, admission at the weekend was not independently predictive in a risk model that included Illness Severity (age and biochemical markers) and co-morbidity. Sicker patients, with a worse outcome, are admitted over the weekend; these considerations should inform the allocation of healthcare resources.

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Safe discharge of patients with low-risk upper gastrointestinal bleeding (UGIB): Can the use of Glasgow-Blatchford Bleeding Score be extended?

Research Audit and Clinical Practice, Volume 10, Issue 4, Pages 173 - 232 (2011)

Abstract

Introduction: Risk stratification of patients with suspected upper gastrointestinal bleeding (UGIB) using either Glasgow-Blatchford Bleeding Score (GBS) or preendoscopy Rockall score to facilitate early safe discharge (GBS=0, pre-Rockall=0) has been reported. This observational study compared score utility and considered the impact of extending the range of GBS or pre-Rockall scores permitting safe discharge.

Methods: Consecutive adult patients presenting to acute medical admissions or the emergency department from September 2008-March 2009 with suspected UGIB had clinical history, vital signs, laboratory and endoscopy results prospectively recorded using electronic databases. GBS, pre-Rockall scores and a composite endpoint (blood transfusion, endoscopic therapy, interventional radiology, surgery or 30-day mortality) were calculated.

Results: 388 patients with suspected UGIB were identified of which 92.3% were admitted (median (range) GBS=5 (0-19) and pre-Rockall=2 (0-11)) and 7.7% discharged (GBS=0 (0-4) and pre-Rockall=0 (0-4)). 186 (47.9%) underwent in-patient endoscopy. 151 (38.9%) were found to have the composite endpoint with 77.5% having transfusion, 45.7% endoscopic treatment and an 8.0% mortality within 30 days. AUROC (95% CI) for 30-day composite endpoint was 0.92 (0.89-0.94) using GBS and 0.75 (0.70-0.80) using pre-Rockall scores. Analysis using different GBS thresholds demonstrated that GBS=0, GBS ≤1 and GBS≤2 had superior utility in identifying freedom from an adverse clinical outcome at 30-days than pre-Rockall score 0.

Conclusions: GBS is superior to pre-Rockall score in identifying patients with suspected UGIB who have a low likelihood of an adverse clinical outcome and can be considered for early discharge. Diagnostic performance at different thresholds suggests that patients with GBS≤2 could be considered for early discharge, doubling the number of eligible patients (15.2 to 32.5%). This has important patient safety and resource implications.

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Acute Care Fellow: a brief introduction

Guest Editorial, Volume 10, Issue 4, Pages 173 - 232 (2011)

Chris Roseveare has kindly invited me to introduce myself through this ‘Guest Editorial’ page of Acute Medicine. I was appointed to the new post of Acute Care Fellow at the Royal College of Physicians of London in July of this year. This is a new post, created by the College in recognition of the immense pressures currently being experienced by acute medical services. The remit includes identifying the difficulties faced by physicians in delivering high quality care and seeking out and sharing examples of good practice. I will chair the new acute medical care committee at the College which will have wide representation from all medical specialties involved in the provision of acute medical care. Acute medical units are the hub of the acute medical take and acute medicine will be well represented on the new committee with SAM consultant, trainee and nursing representatives.

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Editorial

Editorials, Volume 10, Issue 4, Pages 173 - 232 (2011)

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.

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