Volume 19, Issue 4, Pages 173 – 252 (2020)

Triage Into the Community for COVID-19 (TICC-19) Patients Pathway – Service evaluation of the virtual monitoring of patients with COVID pneumonia

Original Articles, Special Article, Volume 19, Issue 4, Pages 173 – 252 (2020)

Introduction: COVID-19 pneumonia presented a unique problem for healthcare systems with the potential to overwhelm hospitals and lead to unnecessary morbidity and mortality. Safe triage and follow up systems are required to manage this unprecedented demand.

Methods: We designed a pathway for the triage and assessment of patients based on their resting oxygen saturations and response to a 30 metre rapid walking test. We admitted patients to a ‘Virtual Ward’ for remote oximetry monitoring from the Emergency Department, step down from inpatient wards and from the local Primary Care ‘Hot Hub’. This allowed the safe and managed readmission of those patients who deteriorated at home.

Results: During the first wave of COVID-19 we entered 273 onto the pathway for Virtual Ward follow up. Of these, 31 patients were readmitted to hospital, two were admitted to Intensive Care and one patient died. Median oxygen saturation at presentation was 97 % (IQR 96-98%) and following a 30 metre walk test 96% (IQR 94-97%). Median NEWS-2 score was 2 (IQR 1-3). On feedback 99.5% of patients were likely or extremely likely to recommend the service to their family and friends. There was a cost avoidance of £107,600 per month.

Conclusion: It is safe, feasible and cost effective to set up a triage system with remote oximetry monitoring for patients with COVID-19 and overwhelmingly patients find it a positive experience.

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Acute, non-COVID related medical admissions during the first wave of COVID-19: A retrospective comparison of changing patterns of disease

Original Articles, Volume 19, Issue 4, Pages 173 – 252 (2020)

COVID-19 may have altered the case-mix of non-COVID acute medical admissions. Retrospective analysis of acute medical admissions to University Hospitals Birmingham NHS Foundation Trust, showed that medical admissions decreased in April 2020 compared to April 2019. The proportion of young adults, non-cardiac chest pain, musculoskeletal conditions and self-discharges decreased. The proportion of admissions due to alcohol misuse, psychiatric conditions, overdoses and falls increased. There were a higher number of patients admitted to ICU and greater inpatient mortality but not once COVID diagnoses were excluded. There was a significant change in hospitalised case-mix with conditions potentially reflecting social isolation increasing and diagnoses which rarely require hospital treatment, reducing. This analysis will help inform service planning.

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Point-of-care lung ultrasound in the assessment of suspected COVID-19: a retrospective service evaluation with a severity score

Original Articles, Volume 19, Issue 4, Pages 173 – 252 (2020)

Introduction: Point-of-care lung ultrasound (POCUS) has been advocated as a tool to assess the severity of COVID19 and thereby aid risk stratification.

Methods: We conducted a retrospective service evaluation between the 3rd March and the 5th May 2020 to describe and characterise the use of POCUS within an acute care pathway designed specifically for the assessment of suspected or confirmed COVID-19. A novel POCUS severity scale was formulated by assessing pleural and interstitial abnormalities within six anatomical zones (three for each lung). An aggregated score was calculated for each patient and evaluated as a marker of disease severity using standard metrics of discriminatory performance.

Results: POCUS was performed in the assessment of 100 patients presenting with suspected COVID-19. POCUS was consistent with COVID-19 infection in 92% (n = 92) of the patients assessed. Severity, as assessed by POCUS, showed good discriminatory performance to predict all-cause inpatient mortality, death or critical care admission, and escalated oxygen requirements (AUC .80, .80, 82). The risk of all-cause mortality in patients with scores in lowest quartile was 2.5% (95%CI 0.12- 12.95) compared with 42.9% (95CI 15.8 – 75.0%) in the highest quartile. POCUS assessed severity correlated with length of stay and duration of supplemental oxygen therapy.

Conclusion: A simple aggregated score formed by the summating the degree of pleural and interstitial change within six anatomical lung zones showed good discriminatory performance in predicting a range of adverse outcomes in patients with suspected COVID-19.

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Point-of-Care Screening Echocardiograms and their Potential Utility in the Acute Inpatient Medical Setting

Original Articles, Volume 19, Issue 4, Pages 173 – 252 (2020)

Demands on echocardiography services are increasing annually. This Quality Improvement Project aimed to see whether a point of care screening echocardiography (SE) service in the acute inpatient medical setting might help reduce demand on full trans-thoracic echocardiography services (FE). The indication and results of all FE requests on the admission ward were analysed over a three-month period. Following this, it was considered whether a theoretical SE occurring prior, would have changed the on-going utilisation of FE resources. Of the 67 requests analysed, 57 underwent FE. 25% revealed no abnormality. In 47%, a SE prior may have changed the future use of FE resources. This small retrospective review highlights the potential benefits of a SE service and further work is required.

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Society for Acute Medicine Benchmarking Audit 2019 (SAMBA19): Trends in Acute Medical Care

Original Articles, Volume 19, Issue 4, Pages 173 – 252 (2020)

Introduction: The eighth Society for Acute Medicine Benchmarking Audit (SAMBA19) took place on Thursday 27th June 2019. SAMBA gives a broad picture of acute medical care in the UK and allows individual units to compare their performance against their peers.

Method: All UK hospitals were invited to participate. Unit and patient level were collected. Data were analysed against published Clinical Quality indicators (CQI) and standards. This was the biggest SAMBA to date, with data from 7170 patients across 142 units in 140 hospitals.

Results: 84.5% of patients had an Early Warning Score measured within 30 minutes of arrival in hospital (SAMBA18 84.1%), 90.4% of patients were seen by a competent clinical decision maker within four hours of arrival in hospital (SAMBA18 91.4 %) and 68.6% of patients were seen by a consultant within the timeframe standard (SAMBA18 62.7%). Ambulatory Emergency Care is provided in 99.3% of hospitals. 61.8% of patients are initially seen in the Emergency Department (ED). Since SAMBA18 death rates and planned discharge rates, while the use of NEWS2 increased from 2.5% to 59.2% of hospitals.

Conclusion: SAMBA19 highlighted the evolving complexity of acute medical pathways for patients. The challenge now is to increase sample frequency, assess the impact of SAMBA open a broader debate to define optimal CQIs.

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Acute care service performance during winter: report from the winter SAMBA 2020 national audit of acute care

Original Articles, Volume 19, Issue 4, Pages 173 – 252 (2020)

The Winter Society for Acute Medicine Benchmarking Audit (SAMBA) provides the first comparison of performance within acute medicine against clinical quality indicators during winter, a time of increased pressure and demand on acute services.

105 hospitals participated in Winter SAMBA, collecting data over 24-hours on 30th January 2020. 5626 patients were included. Participating units saw a median of 48 patients (range 13-131).

Comparison between Winter SAMBA and SAMBA19 found less patients had an early warning score within 30 minutes during winter (74.3% vs 78.9%) and less were seen by a clinical decision maker within four hours (84.9% vs 87.9%). Unplanned admissions represented a higher proportion of workload (92.5% vs 90.1%). Patients were more likely to have a NEWS2 score of 3 or higher (30.1% vs 25.7%).

Performance is poorer in winter, and patients are more unwell, needing prompt treatment. Services should ensure high quality care can be maintained through times of increased pressure, including winter.

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Approach to dyspnoea in pregnancy in the COVID-19 era

Case Reports, Volume 19, Issue 4, Pages 173 – 252 (2020)

Importance: Dyspnoea and hypoxia in pregnant women during the COVID-19 pandemic may be due to causes other than SARS Co-V-2 infection which should not be ignored. Shared decision-making regarding early delivery is paramount.

Objective: To highlight and discuss the differential diagnoses of dyspnoea and hypoxia in pregnant women and to discuss the risks versus benefit of delivery for maternal compromise.

Design, setting and participants: Case series of two pregnant women who presented with dyspnoea and hypoxia during the COVID-19 pandemic.

Results: Two pregnant women presented with dyspnoea and hypoxia. The first case had COVID-19 infection in the 3rd trimester. The second case had an exacerbation of asthma without concurrent COVID-19. Only the first case required intubation and delivery. Both recovered and were discharged home.

Conclusion and relevance: Our two cases highlight the importance of making the correct diagnosis and timely decision-making to consider if delivery for maternal compromise is warranted. Whilst COVID-19 is a current healthcare concern other differential diagnoses must still be considered when pregnant women present with dyspnoea and hypoxia.
Objective: To highlight and discuss the differential diagnoses of dyspnoea and hypoxia in pregnant women and to discuss the risks versus benefit of delivery for maternal compromise.

Design, setting and participants: Case series of two pregnant women who presented with dyspnoea and hypoxia during the COVID-19 pandemic.

Results: Two pregnant women presented with dyspnoea and hypoxia. The first case had COVID-19 infection in the 3rd trimester. The second case had an exacerbation of asthma without concurrent COVID-19. Only the first case required intubation and delivery. Both recovered and were discharged home.

Conclusion and relevance: Our two cases highlight the importance of making the correct diagnosis and timely decision-making to consider if delivery for maternal compromise is warranted. Whilst COVID-19 is a current healthcare concern other differential diagnoses must still be considered when pregnant women present with dyspnoea and hypoxia.

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Biomarker negative pancreatitis caused by Influenza B infection. A case presentation and review of the literature

Case Reports, Volume 19, Issue 4, Pages 173 – 252 (2020)

Background: Influenza B is considered to cause milder illness compared to influenza A. There has been no known  association between influenza B and acute pancreatitis.

Case report: We present a case of an influenza B infection complicated with acute pancreatitis. Furthermore, the biochemical markers that are used to diagnose pancreatitis were normal in this case.

Discussion: We present the case that Influenza B can present with severity compared to this of Influenza A. We review the literature on infectious causes and diagnostic criteria for acute pancreatitis and on acute pancreatitis with normal pancreatic enzymes.

Conclusion: Influenza B can rarely cause acute pancreatitis. The absence of biochemical confirmation should not exclude the diagnosis of pancreatitis in the appropriate clinical setting.

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Idiopathic Pulmonary Arterial Hypertension Unmasked by Pregnancy

Case Reports, Volume 19, Issue 4, Pages 173 – 252 (2020)

A 31-year old woman presented to the acute medical unit 9 days post-partum with shortness of breath and peripheral oedema. Initially suspected to have either a pulmonary embolism or post-partum cardiomyopathy, she proceeded to have imaging including a CT Pulmonary angiogram and echocardiogram, which were suggestive of pulmonary hypertension and severe right heart failure. Her history and other investigations did not reveal any obvious cause for this. She was transferred to a specialist centre where she was diagnosed with Idiopathic Pulmonary Arterial Hypertension (IPAH), previously known as primary pulmonary hypertension. Shortness of breath during pregnancy and in the postpartum period is a relatively common acute medical presentation. Whilst IPAH is a rare diagnosis, it carries a high mortality rate, particularly in pregnancy, and requires prompt specialist investigation, diagnosis and management.

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What the acute physician needs to know about Anti-NMDA receptor encephalitis: two case presentations

Case Reports, Volume 19, Issue 4, Pages 173 – 252 (2020)

These case reports look at two patients with anti-N-methyl-D-aspartate receptor (NMDAr) encephalitis presenting to the same acute medical unit within a month of each other. The following covers the characteristic signs, symptoms and timeline associated with this condition and discusses whether we should be sending CSF for anti-NMDAr antibody testing more readily.

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