Volume 15

Measurement of generic patient reported outcome measures (PROMs) in an acute admission unit: A feasibility study

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

Objective: Measuring patient-reported outcome measures (PROMs) is a challenge in Acute Admission Units (AAUs), where patients present with a variety of pathologies. Generic PROMs may be used to measure the quality of care in this population. The main objective of this study was to assess the feasibility of measuring generic PROMs in a Dutch AAU.

Design: Longitudinal cohort study

Setting: An AAU of a tertiary hospital in Amsterdam, the Netherlands

Participants: 123 patients admitted to the AAU during 5 weeks in May and June 2015

Methods: Patients admitted to the AAU were asked to fill out a questionnaire relating to three time points: 7 days before, during, and within 2 weeks after admission. Additionally, patients were asked to report on their experienced level of safety on the AAU and the contribution of the AAU to their recovery.

Results: There were significant trends in generic PROMs for all three domains. Physical functioning decreased during hospital admission and almost fully returned to the previous level after discharge. Satisfaction with social role and anxiety significantly decreased over time.

Conclusions: Measuring generic PROMs in the AAU is feasible. The analysis of the PROMs took little effort and results could be reported back to the healthcare workers on the AAU quickly. Patients appreciated being asked about their own perceived health and the quality of care. Given that this is the first study focusing on PROMs in AAU patients in the Netherlands, future studies with larger sample sizes, and from other nations are needed to further investigate PROMs in this patient group to establish International reference values.

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A simple intervention to improve patient safety, save time and improve staff experience in the AMU procedure room

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

Abstract

Over the last decade, operating theatres and Intensive Care Units (ICUs) have established systematic methods for performing procedures on patients that have been shown to reduce complications and improve patient safety. Whilst the use of procedure rooms on Acute Medicine Units (AMUs) is highly recommended by patient safety groups and Royal College publications, they are not universally available or appropriately utilised. In this article we discuss a quality improvement project that was undertaken on an AMU at a large university teaching hospital in the United Kingdom, highlighting its successes and challenges.

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Implementation of NICE recommendations on abdominopelvic CT, following unprovoked venous thromboembolism, in a UK teaching hospital: no additional detection of occult malignancy and high numbers of incidental findings

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

Abstract

Introduction: NICE Clinical Guideline 144 recommends that patients with an unprovoked VTE, who do not have signs or symptoms of cancer on initial investigation, be considered for further investigation with an abdomino-pelvic CT to exclude occult malignancy. This study aimed to evaluate numbers of scans performed in a UK teaching hospital and outcomes, following this recommendation.

Methods: Retrospective review of CT scans performed before and after publication of the NICE guidance in 2012. CT reports and case notes were analysed. Type and stage of malignancy, treatment and other relevant findings were documented. For the 2014 data set, all incidental radiological findings and follow-up recommendations were reviewed.

Results: The annual number of CT scans requested for “unprovoked VTE”, rose by 142% following publication of NICE Clinical Guideline 144. In the 2011 - 2012 data set, 21 patients were included, one of which was found to have a malignancy, which was clinically overt at the time of diagnosis i.e. not occult. Five patients (23.8%) had incidental findings requiring further investigation. In the 2014 –2015 data set, 51 patients were included, five (9.8%) of which were found to have malignancy. In retrospect, all showed signs/symptoms of potential malignancy on initial investigation. No occult malignancies were detected in the patients correctly referred. Incidental findings warranting further investigation were reported in ten cases (19.6%). On review, follow-up advice was deemed incorrect in four of these.

Conclusion: Addition of an abdomino-pelvic CT scan in patients with a first unprovoked VTE and no signs or symptoms of cancer on initial investigation, significantly increased the number of scans and incidental findings, but did not pick up any additional occult malignancies.

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Acute Mitral Regurgitation: an important cause of respiratory distress

Case Reports, Volume 15, Issue 1, Pages 1 - 48 (2016)

Abstract

Acute mitral regurgitation (acute MR) is a rare cause of acute respiratory distress, which can present diagnostic challenges. We present the case of a 57 year old man who developed acute shortness of breath subsequently associated with fever, raised white cells and elevated CRP. Chest x-ray revealed unilateral shadowing and he was treated for pneumonia, despite the finding of severe mitral regurgitation on echo. Failure to respond to antibiotic treatment following 3 weeks on ITU led to the consideration of acute MR as the cause of his symptoms and he responded well to diuretics. He subsequently underwent mitral valve repair. The causes and clinical presentations of this condition are discussed.

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When is a stroke not a stroke? An unusual mimic presenting to AMU

Case Reports, Volume 15, Issue 1, Pages 1 - 48 (2016)

Abstract

Introduction: Creutzfeldt-Jakob disease (CJD) is a rare prion disease classically manifesting with rapidly progressive dementia, abnormal movements and typical electroencephalographic (EEG) changes.

Case Report: A 74 year-old Caucasian man was recently discharged from another centre diagnosed with a stroke. He re-presented to our acute medical unit with worsening symptoms, and stroke remained the working diagnosis. Collateral history revealed a progressive cognitive decline and unilateral myoclonus. Further investigations supported the diagnosis of probable CJD, confirmed by the national CJD surveillance centre.

Discussion: Signs and symptoms atypical of stroke should raise the possibility of alternative diagnoses, including prion disease. CJD can present with unilateral symptoms, EEG and MRI changes. Early diagnosis prevents unnecessary investigations and treatments, allowing early palliative care input, where appropriate.

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Persistent dysphagia and drowisness following collapse in an alcohol-dependent patient

Picture Quiz, Volume 15, Issue 1, Pages 1 - 48 (2016)

The case:

A 58 year old man was brought to the emergency department with acute confusion after being found unconscious on his floor at home. He had a background of alcohol misuse with alcoholic liver disease. He was not taking any regular medications. On examination he smelt of alcohol and was tachycardic at 96 bpm with BP 110/70. The patient’s Glasgow Coma Score was 14, being drowsy but responsive with bilateral lower zone crepitations on auscultation of the chest. Neurological examination revealed generalized reduced muscle bulk but no focal deficits.

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On increasing the power of presentations (p cubed)

Education and Training, Volume 15, Issue 1, Pages 1 - 48 (2016)

In Medicine we believe our practice is evidence based and effectual. We review our results, keep abreast of the literature and make changes as knowledge evolves. Most presenters believe the same for their presentations. The majority of presentations directly contradict well established psychological principles, aspire to a level around them only of mediocrity and are almost uniformly ineffectual. Worse than this, we instruct our colleagues to present in the same way.

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So you want to talk about sex? – a brief guide to taking a sexual history for Acute Physicians

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

Introduction

It’s a Monday morning; the week-end has seen the re-admission of a retired teacher with a dry cough, increasing dyspnoea and no physical signs. His chest X-ray ten days previously didn’t show any abnormalities. The course of amoxicillin given by his GP has not helped. He has an oxygen saturation of 89% at rest. Something doesn’t add up?

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Trainee Report, Spring 2016

Trainee Section, Volume 15, Issue 1, Pages 1 - 48 (2016)

takeAIM update

Acute Medical registrars across the country have continued to drive the enthusiasm to Take AIM! Following the success of the first national takeAIM conference in Manchester in November, the takeAIM fellows are organising regional conferences to drum up interest. The first of these conferences was held in London on February 25th, followed by conferences in Bristol, Bradford, Birmingham, Durham and Newcastle. We are looking forward to an exciting program of clinical updates from specialists followed by break out groups where interested trainees can engage with current AIM trainees to talk about AIM as a career and the opportunities to broaden their clinical practice through specialist skills. Further details on the different projects under development can be found on the takeAIM website (takeaim.org.uk). If you would like to run a session in your area or have any careers events, please contact the takeAIM team and they can help you with materials and assistance!

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Persistent dysphagia and drowisness following collapse in an alcohol-dependent patient (Answers)

Picture Quiz, Volume 15, Issue 1, Pages 1 - 48 (2016)

This T2 weighted MRI scan demonstrates a hyperintense trident shaped lesion extending from the pontomedullary junction to the midbrain with peripheral sparing (figure 2 – abnormality indicated by white arrows).

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