Volume 22, Issue 3, Pages 109 – 168 (2023)

A case of a diabetic woman with an uncontrollable arm

Case Reports, Volume 22, Issue 3, Pages 109 – 168 (2023)

We present the case of an 83-year-old female patient with left-side hemichorea and hemiballism associated with poorly controlled type 2 diabetes mellitus. Hyperintensity in the right basal ganglia was evident in T1-weighted brain magnetic resonance. Clinical and radiological findings were consistent with diabetic striatopathy.

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Nitrogen-Phosphorus-Potassium containing liquid fertilizer intoxication presenting with extreme hyperkalemia, metabolic acidosis and ECG changes

Case Reports, Volume 22, Issue 3, Pages 109 – 168 (2023)

Liquid fertilizers are widely used for fertilizing in- and outdoor vegetation. Despite the easy accessibility and widespread use, serious intoxications are rare.
This case report describes a 61-year-old woman who was treated for life-threatening hyperkalemia, metabolic acidosis and ECG changes after intentional ingestion of liquid fertilizer. Our case shows that intake of liquid fertilizer, though infrequent, can cause serious, life threatening complications.

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Renal replacement and extracorporeal therapies in critical care: current and future directions

Review Articles, Volume 22, Issue 3, Pages 109 – 168 (2023)

There are a wide number of indications for extracorporeal therapies in the critical care environment. A common indication seen by the acute physician is continuous renal replacement therapy (CRRT) in a proportion of patients with acute kidney injury. It is therefore important that acute physicians have a sound understanding of the principles of CRRT in the acutely unwell patient. This review will outline the indications for its use, commonly used methods and anticoagulation considerations. It will discuss when to start and stop CRRT as well as describing potential treatment complications. This review will also discuss the role of therapeutic plasma exchange in critical care and novel extracorporeal therapies including blood purification in sepsis and carbon dioxide removal in acute respiratory distress syndrome and acute exacerbations of obstructive lung disease. Extracorporeal membrane oxygenation is outside of the scope of this article.

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Artificial Intelligence: its Future and Impact on Acute Medicine

Review Articles, Volume 22, Issue 3, Pages 109 – 168 (2023)

This commentary explores the potential impact of artificial intelligence (AI) in acute medicine, considering its possibilities and challenges. With its ability to simulate human intelligence, AI holds the promise for supporting timely decision-making and interventions in acute care. While AI has significantly contributed to improvements in various sectors, its implementation in healthcare remains limited. The development of AI tools tailored to acute medicine can improve clinical decision-making, and AI’s role in streamlining administrative tasks, exemplified by ChatGPT, may offer immediate benefits. However, challenges include uniform data collection, privacy, bias, and preserving the doctor-patient relationship. Collaboration among AI researchers, healthcare professionals, and policymakers is crucial to harness the potential of AI in acute medicine and create a future where advanced technologies synergistically enhance human expertise.

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Becoming the medical registrar: a qualitative study of a professional transition as a transformative learning event

Original Articles, Volume 22, Issue 3, Pages 109 – 168 (2023)

Background: The medical registrar is a daunting role to take on for the first time. While studies have explored how preparedness can be improved through simulation, less has been written about how doctors learn to be registrars through clinical practice.
Method: Doctors working as medical registrars were invited to participate in semi-structured interviews. The qualitative data collected underwent thematic analysis.
Results: The clinical environment was considered fertile ground for transformative experiential learning, but opportunities for debriefing and guided reflection were rare. Participants felt they needed additional support from supervisors after difficult experiences and mistakes, but this support was not always forthcoming.
Conclusion: Acute physicians involved in supervising new medical registrars must facilitate meaningful independent practice to encourage the next generation of medical generalists.

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Society for Acute Medicine’s Patients: Learning from Experience Report (SAM-PLER) A service evaluation of patient reported experience in Acute Medicine – establishing the feasibility of a quality improvement collaborative

Original Articles, Volume 22, Issue 3, Pages 109 – 168 (2023)

Patient reported experience measures (PREMS) are a key part of measured quality. There is no tool currently used in the UK in Acute Medicine.
On the 8th of September 2022 10 units based in England, Scotland and Wales collected data for the validated PREM, alongside the EQ-5D and variables from the Society for Acute Medicine’s Benchmarking Audit (SAMBA) dataset.
365 patients were screened, 200 were included (55%): 159 patients from AMUs and 41 from SDEC units. Overall experience of patients was rated 8.5/10, patients rated their experience of safety, trust and listening highly.
Collection of PREMS was feasible. Further research is required to link experience to clinical outcome and explore tools that capture experience of patients with altered mental status.

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Acute Medicine: How will we grow? – An analysis of organisational capabilities for quality improvement, research & education from SAMBA 2021

Volume 22, Issue 3, Pages 109 – 168 (2023)

Background: Education, research, and Quality Improvement (QI) are key enablers for high quality care. We aimed to map the capability of Acute Medical Units (AMUs) to facilitate excellence in these areas.
Methods: AMUs were surveyed in an organisational questionnaire within the Society for Acute Medicine Benchmarking Audit 2021.
Results: 143 units participated. 80 units had a QI lead, 24 had a research lead and 99 had a medical education lead. 15 units had all three leadership roles. Most QI work considered service structure rather than changes in processes or care outcomes.
Conclusion: The organisational capability of AMUs in the strategic areas considered is variable. Improving leadership and disseminating learning could help build a strategic foundation for acute medicine to grow.

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Both acuity and long term prognosis are important Emergency Department metrics: comparison of mobility assessment with the Emergency Severity Index

Original Articles, Volume 22, Issue 3, Pages 109 – 168 (2023)

Objective: To compare the SUHB mobility scale (i.e., stable(S), unstable gait(U), needing help to walk(H), or bedridden(B)) and the Emergency Severity Index (ESI) associations with admission and mortality outcomes.
Design: Post-hoc analysis of a prospective observational study including all consenting presenting to the ED over a period of 3 weeks. Odd ratios and AUCs were calculated to assess predictive performance of SUHB and compared with ESI.
Results: Out of 2422 patients, 65% presented with a stable gait, 45% with an ESI level 3. With increasing mobility impairment on the SUHB scale, the probability for admission and mortality increased. SUHB had a higher AUC than ESI for 1-year mortality.
Conclusion: SUHB was a better predictor than ESI of long-term mortality. The scale, which is rapid, requires little additional training, and no extra costs, could be used as a useful supplement to the triage process.

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Emergency admissions’ diagnoses and risk ofin-hospital death according to the primary ICD-10 chapter assigned at discharge and the National Early Warning Score on admission

Original Articles, Volume 22, Issue 3, Pages 109 – 168 (2023)

Background: The relationship between diagnosis, illness severity, and mortality risk for unselected emergency admissions is poorly defined.
Aim: To define primary ICD-10 diagnostic chapters at discharge, admission illness severity by the National Early Warning Score, and in-hospital mortality for all unselected emergency admissions.
Method: Retrospective, observational, cohort study of 122,259 unselected, adult emergency admissions to Salford Royal Hospital between 2014 and 2022.
Results: In-hospital mortality was 4.3% but most patients had an ICD-10 chapter associated with a lower risk of death. 60% of in-hospital deaths were in four chapters, infections, circulatory and respiratory diseases, or neoplasms. An admission NEWS ≥3 was associated with earlier mortality and an eight-fold increased risk of in-hospital mortality. 45% of all in-hospital deaths occurred in patients with an admission NEWS <3. Conclusion: Mortality in emergency hospital admissions is associated with illness severity and four diagnostic chapters. NEWS should not be the only arbiter of hospital admission, as for certain diagnostic chapters the risk of death is high even if vital signs on presentation are normal.

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Guest Editorial – Bad NEWS: standing still is risky for patients admitted to hospital (even with normal vital signs)

Volume 22, Issue 3, Pages 109 – 168 (2023)

Acute Physicians care for acutely unwell patients. Recognising and prioritising those at greatest risk of death is therefore at the heart of our specialty. The risk of catastrophic deterioration in the Acute Medical Unit is usually quantified through the measurement of vital signs. These are being summarised into the National Early Warning Score or similar instruments. Those with higher Early Warning Scores are usually prioritised by clinicians in and out of hospital1,2 and being seen before those with lower grades of abnormalities and preferably assessed by a more senior clinician.

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