Volume 16, Issue 2, Pages 49 – 100 (2017)

The ability to predict the future would be a useful skill for anyone working in the acute medical unit. While crystal balls have not yet become standard issue for acute medicine trainees, a variety of tools now exist to help identify the likely outcome for patients referred for hospital admission – and enable their management to be planned. Two articles in this summer edition of Acute Medicine highlight this important issue. The team from Athens led by Sotirios Kakavas have investigated the prognostic value of beta-2 microglobulin in patients admitted to hospital with pulmonary embolism. Higher levels of this inflammatory protein were associated with a worse outcome, suggesting that it may have a role in identifying those patients who would benefit from management in a higher dependency setting. All patients in their cohort were admitted to hospital, which is clearly different to the established practice in many UK acute medical units where significant proportions of patients are now managed via ambulatory care. Identification of the low-risk patient who can safely be managed without in-patient monitoring will still require a different approach. However, the results of this study suggest that there may be a role for beta-2 microglobulin, either alone or in combination with other markers, in future prognostic modelling.

The ALICE score, developed by the acute medicine team in Plymouth, appears to perform well in a variety of hospitals in predicting length of stay for patients admitted to hospital. The paper by Dan Wilding and Kate Evans indicates that a lower score predicts a shorter hospital stay, which could have
significant implications. It is well established that unnecessary in-patient transfers can result in delays in care which may extend a patient’s time in hospital. Accurate, early identification of those patients who are most likely to be able to go home within 48-72hours may help to reduce transfers and improve the efficiency of the service. Of course, this will still be dependent on there being sufficient capacity to enable patients to remain on the acute medical unit for this time pending discharge, as well as good communication with bed management teams. The overnight transfer of patients whose discharge from hospital the next day was predicted and planned is a common source of frustration, when hospital capacity is under duress – as now seems to the case in most hospitals throughout the year.

This edition includes just a single case report, although we have several lined up for future editions later in the year. Although liver abscess is not an uncommon problem, the case highlights the important issue of ‘source control’ in the management of sepsis. The patient described was clearly unwell at the time of admission, and deteriorated further, despite rapid initiation of antibiotics and other ‘sepsis 6’ measures. The clinical and radiological evidence of pneumonia was compelling, but recognition, and early drainage of the abscess resulted in a rapid improvement, as well as confirmation of the causative organism. Clues to the cause included a past history of complicated diverticular disease and mild derangement of liver function, but relatively little in the way of abdominal findings such that this would have been an easy diagnosis to miss, if the acute medicine team had not been alert to this possibility. We must never be afraid to challenge out initial presumptions, particularly when a patient’s condition fails to improve.

I am delighted that Mark Holland has provided a ‘Viewpoint’ article for this edition, reflecting on his tenure as President of the Society for Acute Medicine. Mark hands over to Nick Scriven in the Autumn – no doubt, he will be feeling a sense of relief tinged with a little sadness, which I remember well when my time in the role came to an end in 2013. Mark has been a great asset to the Society and should be very proud of his achievements in raising the profile of the Speciality of Acute Medicine.
I hope you enjoy whatever remains of summer, and that you can all manage some respite before the start of the ‘predictable’ pressures of the months which follow.