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.