Volume 21

Technology-enabled multidisciplinary team in-reach for oral corticosteroid stewardship and optimizing care of suspected airways disease exacerbations

Correspondence, Volume 21, Issue 4, Pages 165-208 (2022)

Overuse of corticosteroids is an important problem not only in asthma but also the management of other airways diseases including bronchiectasis and COPD and results in associated risks of serious side effects and irreversible harm. We report a pilot using an in-reach solution to review patients, optimise their care and facilitate early discharge. We discharged >20% of our patients immediately, which is potentially a significant reduction in hospital bed use and, most importantly, through this approach we were able to establish early diagnosis and reduce inappropriate oral corticosteroid use.

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Hypomagnesaemia Induced Reversible Cerebellar Syndrome

Case Reports, Volume 21, Issue 4, Pages 165-208 (2022)

Hypomagnesaemia may cause neurological symptoms as part of its presentation. This case demonstrates one such unusual example of a reversible cerebellar syndrome resulting from magnesium deficiency. An 81-year-old woman presented to the emergency department with a history of chronic tremor and other cerebellar signs. Severe hypomagnesaemia was detected within her initial biochemistry results. Correction of this deficiency led to a resolution in her symptoms.

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Can we improve patients’ physical activity levels after discharge by interventions on the Acute Medical Unit? The ‘teachable moment’

Original Articles, Volume 21, Issue 4, Pages 165-208 (2022)

Introduction: >30% of the population does less physical activity (PA) than recommended and few patients receive PA advice during a hospital admission (2,5). This study aimed to assess the feasibility of recruiting acute medical unit (AMU) in-patients and to examine the effect of delivering PA interventions to them.
Methods: In-patients who were inactive (<150mins/wk) were randomised to either a motivational interview (Long Interview, LI) or brief advice (Short Interview, SI). Participants’ physical activity levels were assessed at baseline and at two follow-up consultations. Results: 77 participants were recruited. At 12 weeks 22/39(56.4%) participants were physically active following the LI and 15/38(39.5%) following the SI. Discussion: Recruitment and retention of patients on the AMU was straightforward. PA advice helped a high proportion of participants become physically active.

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Clinical decision making in acute medicine

Original Articles, Volume 21, Issue 4, Pages 165-208 (2022)

Clinical decision-making is a core skill for the practice of medicine and yet during training there is often little formal analysis of the process of clinical reasoning or instruction about how to do it better. This paper reviews the process of clinical decision-making with a particular focus on diagnostic reasoning. Aspects of psychology and philosophy are applied to the process along with consideration of potential sources of error and the steps that can be taken to minimize this.

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Co-design of interventions to improve acute care in hospital: A rapid review of the literature and application of the BASE methodology, a novel system for the design of patient centered service prototypes

Original Articles, Volume 21, Issue 4, Pages 165-208 (2022)

Co-design in acute care is challenged by the inability of unwell patients to participate in the process and the often transient nature of acute care.
We undertook a rapid review of the literature on co-design, co-production and co-creation of solutions for acute care that were developed with patients. We found limited little evidence for co-design methods in acute care.
We adapted a novel design driven method (BASE methodology) that creates stakeholder groups through epistemological criteria for the rapid development of interventions for acute care. We demonstrated feasibility of the methodology in two case studies:
A mHealth application with checklists for patients undergoing treatment for cancer and a patient held record for self-clerking on admission to hospital.

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Blood Culture and Troponin Testing in Suspected Bacteraemic Admissions – Example of Risk Stratification Based on Clinical Testing

Original Articles, Volume 21, Issue 4, Pages 165-208 (2022)

Aim: To investigate the clinical predictive value of troponin (hscTnT) and blood culture testing.
Methods: We examined all medical admissions from 2011-2020. Prediction of 30-day in-hospital mortality, dependent on blood culture and hscTnT requests/results, was evaluated using multiple variable logistic regression. Length of stay was related to utilization of procedures/services with truncated Poisson regression.
Results: There were 77,566 admissions in 42,325 patients. With both blood cultures and hscTnT requested, 30-day in-hospital mortality increased to 20.9% (95%CI: 19.7, 22.1) vs 8.9% (95%CI: 8.5, 9.4) for blood cultures alone and 2.3% (95%CI: 2.2, 2.4) with neither. Blood culture 3.93 (95%CI: 3.50, 4.42) or hsTnT requests 4.58 (95%CI: 4.10, 5.14) were prognostic.
Conclusion: Blood culture and hscTnT requests and results predict worse outcomes.

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Patient Characteristics and Variables Influencing Acute Medical Flow

Original Articles, Volume 21, Issue 4, Pages 165-208 (2022)

Waiting times are the most widely used indicator of patient flow. This project aims to analyse 24-hour variation in referrals and waiting times for patients referred to the Acute Medical Service (AMS). A retrospective cohort study was conducted at the AMS of Wales’ largest hospital. Collected data included patient characteristics, referral times, waiting times and adherence to Clinical Quality Indicators (CQIs). Peak referral times were found between 11:00-19:00. Peak waiting times occurred between 17:00–01:00, which was longer on weekdays in comparison to weekends. Referrals between 17:00-21:00 had the longest waiting times with > 40% of patients failing both junior and senior CQIs. Mean and median age and NEWS were higher between 17:00-09:00. Weekday evening and nights are problematic for acute medical patient flow. Interventions, including workforce, should be targeted towards these findings.

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Editorial – The NHS urgent and emergency care crisis: how much worse could it get?

Editorials, Volume 21, Issue 4, Pages 165-208 (2022)

NHS urgent and emergency care is under intolerable strain. This strain is increasingly causing harm to patients. Timely and high-quality patient care is often not being delivered due to overcrowding driven by workforce and capacity constraints. This drives low staff morale perpetuating burn out and high absence levels which currently dominate. Whilst COVID19 has accentuated and arguably expedited the crisis; the spiral of decline in urgent and emergency care has been decade long and unless urgent action is taken, we may not yet have reached its nadir.

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Evaluation of a basic point-of-care ultrasound course for residents in internal medicine

Correspondence, Volume 21, Issue 3, Pages 121-164 (2022)

Point-of-care ultrasound (POCUS) integrates imaging into the physical examination at the bedside. This offers the advantage of instant clinical information and has shown to speed up the diagnostic process, and to improve diagnostic accuracy and correct treatment.

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