Volume 15

Editorial Volume 15 Issue 2

Editorials, Volume 15, Issue 2, Pages 49 - 108 (2016)

Hospital mortality has been a hot topic in the medical and popular Press over recent years. Many readers will recall ‘scandals’ around hospitals whose mortality rates appeared higher than that which would be expected. The so-called ‘weekend effect’ whereby patients admitted to hospital between Friday and Monday appear more likely to die during their hospital stay has been regularly quoted in Parliament by the Secretary of State as justification for the Government’s manifesto pledge to create a ‘7 day NHS’. A number of recent publications have illustrated the complexity of this statistic, which – at least in part – is likely to reflect illness severity as much as organizational factors. The paper by Emma Mason in this edition further supports the concept that hospital mortality statistics may be hard to influence through structural or staffing changes. Those working in the acute medicine setting will not be surprised to read that almost half of those patients who die within 48 hours of arrival in hospital had solely palliative care needs at the time of admission. Many of these patients were elderly, frail and resident in a care home environment, but many also had undergone previous admissions within the months leading up to their death; the authors comment that this could have provided an opportunity to discuss end of life care plans, potentially enabling their final admission to hospital to have been avoided. Preventing ‘avoidable’ deaths in hospital from conditions such as sepsis and acute pulmonary embolism is a key component of the job of an acute physician. However, even when death in unavoidable we must do what we can to ensure patients die in the environment of their choice. Reducing deaths in hospital should not simply focus on those whose death can be prevented.

Although mortality statistics may be misleading when interpreted in isolation, good quality data can be a powerful tool to influence changes in the acute medicine setting. By the time this edition is published, the 2016 Society for Acute Medicine Benchmarking Audit (SAMBA16) will already have take n place; previous years’ data were published in this journal and we hope to see a continued rise in the numbers of participating units this year. Tom Brougham and colleagues from Bristol have illustrated how an electronic system for data collection on their AMU enabled reorganization of their junior doctor rota, reducing waiting time for patients. Their data illustrate the problem which will be familiar to many acute physicians, whereby the surge in afternoon arrivals on the AMU often coincides with shift changeovers and reductions in junior doctor and other numbers. Matching staffing to workload can have significant benefits for patient care and may enable a reduced strain on the night shift team if patients are seen in a more timely fashion. Whether this can be linked to improved patient outcomes in the future will be interesting.

Finally, I would like to welcome one more addition to the editorial board. Dr Nick Murch is an acute physician in the Royal Free hospital, with an interest in medical education and simulation skills training. With an increasing number of acute medicine trainees undertaking medical education as their specialist skill, I am keen to develop the training and education section of the journal over the coming years, and look forward to Nick’s input in this regard. We will continue to welcome submissions of research relating to acute medicine education and training, which we will consider for future publication in this section of the journal.

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An Acute Severe Headache

Picture Quiz - Answers, Volume 15, Issue 2, Pages 49 - 108 (2016)

Discussion

Severe headaches are a frequent presentation to the Emergency Department, accounting for around 1% of presentations. Of these, 13-16% will have a sinister underlying pathology but accurate diagnosis of headaches on the medical take remain difficult for non-specialists. A retrospective study from the UK found that, of those presenting to Emergency Department with sudden onset severe headaches, only 60% were given a specific headache diagnosis, with one third of these given their diagnoses despite an inadequate history.

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Providing a navigable route for acute medicine nurses to advance their practice: a framework of ascending levels of practice

Training and Education, Volume 15, Issue 2, Pages 49 - 108 (2016)

This article conveys concerns raised by delegates at the International SAM Conference (Manchester, 2015) regarding how to advance nursing practice in acute medicine. It endeavours to capture the essence of ‘how to advance practice’ and ‘how to integrate advanced practice’ within the workforce structures of an acute medicine unit (AMU). It addresses the production of tacit knowledge and the recognition and integration of this to developing the nursing workforce. The current context of NHS efficiencies and recruitment issues emphasize the value of retaining tacit knowledge. Uniquely, this article offers an early conceptual framework through which levels of advancement and potential transition points to advance nursing practice in acute medicine are articulated. Determining how to advance requires identification of prior accomplishments such as, tacit knowledge, experiential learning, CPD, specialist courses and management experience. This requires nurses to make judicious decisions to advance their practice and the distinction between ‘amassing experience’ and ‘career progression’. It aims to stimulate thinking around the practicalities of advancement, the value of tacit knowledge and potential realization through the framework trajectory.

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Acute Internal Medicine Trainee Survey 2016

Training and Education, Volume 15, Issue 2, Pages 49 - 108 (2016)

Objectives: To ascertain the views of current Acute Internal Medicine (AIM) trainees on the strengths and weakness of the specialty, their training programmes, practical procedures and the provision of training days.

Methods: Online electronic survey circulated to all Higher Specialty Trainees (HST) in AIM. Participation was voluntary and all answers confidential. A total of 108 trainees responded.

Results: There were respondents from across the United Kingdom. The majority of respondents are happy or quite happy with their training (61%), with 11% unhappy or very unhappy. The variety of workload (68%), specialty exposure (69%) and practical procedures (67%) were strengths while lack of respect from other specialties (55%) and rota gaps (59%) remain significant problems. 53% of respondents feel they are expected to cover more rota gaps than their GIM colleagues, and 54% trainees feel they do not get a session a week allocated to them for specialist skill training/admin. Only 33% of trainees expect to get dedicated leadership and/or management training during their programme, and a large proportion of trainees (78%) feel that some form of ultrasound training should be a core part of the curriculum. Despite the difficulties, 85% of respondents would recommend AIM as a specialty.

Conclusions: This survey highlights some of the positives and negatives of training in AIM, and highlights areas where potential improvements to programmes could be made. Comparison of the data with 2015 shows small improvements in a number of areas, but still some significant concerns remain. The findings were fed back to the Training Committee in March.

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An unusual pathogen in ambulatory care: two cases of Scedosporium soft tissue infections presenting as “unresponsive cellulitis”

Case Reports, Volume 15, Issue 2, Pages 49 - 108 (2016)

Soft tissue infections with Scedosporium spp. are an uncommon but serious and emerging cause of infection in immunocompromised patients. Acute Medical Units (AMUs) in the UK are increasingly managing patients with cellulitis in an outpatient setting, therefore acute physicians should be aware of some of the more uncommon causes of soft tissue infection, particularly in patients not responding to initial antibiotic therapy. We present two cases of Scedosporium presenting to the AMU as cellulitis not responding to initial antibiotic therapy and outline the assessment and management of this important condition.

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HIV – lessons from a late diagnosis

Case Reports, Volume 15, Issue 2, Pages 49 - 108 (2016)

Late HIV diagnosis is the most important predictor of HIV-related morbidity and mortality in the UK and often results from missed testing opportunities during earlier contact with health services. The HPA now recommends routine HIV testing be commissioned as a priority for all general medical admissions in high prevalence areas, such as Milton Keynes. We present the case of a patient admitted to our Medical Admissions Unit (MAU) managed initially for presumed septic complications of metastatic disease who was later found to have terminal HIV disease. In keeping with UK-wide experience which we review, a local audit following this case found MAU HIV test coverage increased after routine testing but not after staff education alone, and resulted in implementation of routine HIV testing in our MAU.

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Editorial

Editorials, Volume 15, Issue 1, Pages 1 - 48 (2016)

Clinicians working in acute medicine will be familiar with change. The speciality and the environment we work in has changed continually over the past 15 years – I often reflect that no two years have been the same since I started working in the field back in 1999. Change is important, in order to achieve best practice, but sustaining such improvements can be an enormous challenge. The regular turnover of medical staff, local management restructuring and the constantly shifting National goal posts often conspire against us. It is easy for ‘changefatigue’ to set in. Submissions to this journal often describe local audits and service improvement projects which have raised standards: a low baseline may result in a statistically significant improvement from a relatively small intervention – often an education programme or poster campaign to raise awareness of the problem. However, what happens next is far more important: can the improvement be sustained when the key driver behind the project – the enthusiast – moves on, after their 4 month block of acute medicine comes to an end? One year on, we are often back where we started. Two articles in this edition appear to have achieved the Holy Grail of sustainability. In the paper by Joanne Botten from Musgrove Park, door to antibiotic time was improved for patients with neutopaenic sepsis by introducing a system whereby the antibiotics could be administered without waiting for a prescription to be written. The combination of a neutropaenic sepsis alert card and a patient-specific direction empowered the nurses and patients to ensure administration within an hour of arrival in over 90% of cases, a figure which has been sustained for over a year. Sustainable change is often facilitated by modifications in paperwork, but crucially the project’s success was not reliant on a single individual. The value of engaging with the wider team is also shown in Gary Misselbook’s paper describing sustained improvement in the layout and utility of an AMU procedure room. The authors describe how repeated attempts by different registrars had failed to achieve more than temporary reorganisation; the change was only sustained when nursing, infection control and administrative staff became involved in the process. The multiprofessional nature of the AMU is one of its greatest assets – we would all do well to remember this when instigating change.

On a similar note, observant readers may have noticed some changes to the editorial board of this journal – I am delighted to welcome Dr Tim Cooksley, acute physician from Manchester and Dr Prabath Nanayakkara from the VUMC in the Netherlands. Tim came through the acute medicine training programme in the North West and his role in the acute oncology service at the Christie Hospital as well as his active involvement in the SAMBA project over recent years brings an important perspective to the editorial team. Prabath has been heavily involved with the development of acute medicine in the Netherlands and co-hosted the successful SAMSTERDAM meeting in 2014. His international perspective will be welcome as we attempt to extend the reach of Acute Medicine to our European neighbours over the coming years. I am very grateful to Nik Patel, Mark Jackson and Ashwin Pinto for their help and support during the past decade and wish them well for the future.

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A simple intervention to improve antibiotic treatment times for neutropenic sepsis

Research Audit and Clinical Practice, Volume 15, Issue 1, Pages 1 - 48 (2016)

Abstract

Objectives: Patients with suspected Neutropenic sepsis require rapid antibiotic administration, but despite extensive education, only 67% of patients received antibiotics within 60 minutes.

Methods: A Neutropenic Sepsis Alert Card was created, as a Patient Specific Directive - this allows nurses to administer antibiotics to specific patients without prior medical review.

Results: Since the intervention, 301 patients presented with suspected neutropenic sepsis. 277 patients (92%) received their first dose of intravenous antibiotics within 1 hour of arrival into hospital, compared to 95 out of 143 patients (67%) presenting between January and June of 2014 (p=0.036).

Conclusion: The Neutropenic Sepsis Alert Card can significantly improve door to antibiotic needle time for chemotherapy patients with suspected neutropenic sepsis. This intervention is inexpensive and easily replicable in other health care organisations.

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The Relationship between Resource Utilization, Clinical Risk and Hospital Costs for Emergency Medical Admissions

Research Audit and Clinical Practice, Volume 15, Issue 1, Pages 1 - 48 (2016)

Abstract

There has been little study of the relationship between resource utilisation, clinical risks and hospital costs in acute medicine with the question remaining as to whether current funding models reflect patient acuity. We examined the relationship between resource use for investigations/allied professional and patient episode costs in all emergency medical admissions admitted to our institution during 2008-2013. Univariate estimates were compared with a multivariate model adjusted for major cost predictors. Interestingly, the model adjusted cost estimates changed considerably when compared with univariate analysis. We used both linear and non-linear (quantile regression) methods due to the highly skewed nature of hospital costs.

The data suggested that hospital episode costs were predictable and driven by objective measures of clinical complexity. The use of expensive investigations and healthcare professional time was secondary to the clinical acuity. Thus, cost was heavily weighted towards higher complexity, and lower resource utilisation associated with lower risk patient groups. However, the non-linear nature of the costings would caution against simple predictor models and non-linear techniques such as quantile regression may, as we have demonstrated, prove superior in defining the underlying relationships.

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