Acute Medicine最新文献

Aim: To determine the in-hospital mortality of eight physiological categories based on shock index, pulse pressure and ROX index, and to compare each category according to admission level of consciousness and National Early Warning Score.

Method: A non-interventional observational study of 122,262, unselected, adult emergency admissions between 2014 and 2022.

Results: In-hospital mortality increases according to physiological category and whether the admission NEWS was<3 or ≥3. For NEWS ≥3, patients were more likely to die when not alert. Irrespective of total NEWS, patients with a low ROX index <22 are more likely to die.

Conclusion: Patients with the same NEWS value can have different physiological derangements. Level of consciousness also provides greater insight than NEWS alone regarding the risk of in-patient mortality.

Background: Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a spectrum of high-mortality severe drug reactions. This study aimed to develop an in-hospital mortality risk calculator for SJS based on comorbidities for early risk prediction.

Methods: SJS/TEN patients were identified in National/Nationwide Inpatient Sample between Q4 2015-2020. Weight for each comorbidity was determined from a multivariable logistic regression to develop SJS Index.

Results: SJS Index had good discrimination power (c-statistic=0.704) and was well-calibrated (Brier score=0.049). SJS index had significantly better discriminative power than Elixhauser Comorbidity Index (p-value=0.001). SJS Index has good applicability in SJS-TEN and TEN. After adjusting for demographics, SJS Index had improved performance in all groups.

Conclusions: SJS Index effectively discriminates and predicts in-hospital mortality in SJS/TEN.

Background: Sepsis, a devastating syndrome of organ dysfunction triggered by a dysregulated host response to infection, remains a leading cause of global mortality. Statins, renowned for lipid-lowering, also exhibit potent anti-inflammatory and endothelial-stabilizing properties, offering a theoretical advantage in the septic milieu. This study investigated whether adjunctive atorvastatin could improve survival and modulate key sepsis-related outcomes.

Methods: In this open-label, randomized controlled trial conducted in the acute medical unit of a tertiary academic center, adult patients with sepsis (defined as suspected infection plus a SOFA score increment of ≥2) were allocated to receive either standard sepsis management plus daily oral atorvastatin 20mg or standard management alone for up to 28 days. The primary endpoint was 28-day all-cause mortality. Secondary endpoints included requirements for organ support, duration of hospitalization, and kinetic changes in C-reactive protein(CRP), procalcitonin(PCT), and lactate. Analysis adhered to intention-to-treat principles.

Results: Sixty-eight patients were randomized(36 atorvastatin, 32 control). While 28-day mortality trended lower in the atorvastatin arm(36% vs. 56% in controls; Risk Difference -20%, 95% CI -45% to 5%), this difference did not achieve statistical significance(p=0.10). Similarly, no significant benefits were observed in organ support needs or hospital stay. Critically, atorvastatin administration led to a significant and more pronounced reduction in both procalcitonin (median change -8 vs 0 ng/ml, p=0.005) and lactate levels(median change -0.95 vs -0.62 mmol/l, p=0.048) by day 7.

Conclusion: While adjunctive atorvastatin did not demonstrably reduce 28-day mortality in this sepsis cohort, its significant impact on attenuating procalcitonin and lactate levels suggests a beneficial modulation of underlying inflammatory and metabolic derangements.

Background: Medical ward rounds are essential to support care delivery, however a lack of multi-disciplinary team rounding may have a knock-on effect on care coordination and may lead to delayed discharges and increased length of stays.

Methods: The aim of this study was to improve patient outcomes by improving communication and coordination surrounding medical ward rounds through bringing disciplines together during medical ward rounds or at post-round operational huddles. The primary outcome measure was to improve the number of patients discharged by noon.

Results: At the end of the study there was no impact on our primary outcome measure. Efforts for improvement were redirected from the micro- to the meso- and macrosystem of the organisation.

Conclusion: While developing this complex project, we found reforms at a macrosystem of how care is provided are needed including ward-based care. Reforms must balance system resilience and efficiency while ensuring 'slack' in the system to support communication, relationship building and coordination of care.

Background and importance: Long waiting times in the emergency department (ED) is an increasing problem in the recent years and is expected to become an even bigger problem in the future Objective: We aimed to test the hypothesis whether increasing awareness of the time lapse with the treating physician, 2 hours after patient arrival, can reduce long patient turnaround time (TAT).

Method: In this prospective single-center cohort study we compared and analyzed patient TAT in the ED before and after implementation of a so called 'traffic light' moment 2 hours after patient arrival. At this 'traffic light' moment a team member contacted the treating physician to increased awareness over the time lapse. Difference in percentage of patients who stayed more than 4 hours in the ED before and after intervention was the primary outcome Results: Between October 2nd 2021 and January 2nd,2022 1494 patients were included for primary outcome analysis. A total of 419 patients (n=740, 56.6%) had a TAT of less than 4 hour in the ED before intervention, compared to 497 (n=754, 65.9%) after intervention (p <0.001). Median time spent in de ED before intervention was 3:40 (IQR 2:24 - 5:04) compared to 3:15 (IQR 2:03 - 4:38) after intervention (p<0.001).

Conclusion: This simple and low-cost intervention reduces the ED length of stay significantly. Although multiple interventions will be required to ensure less patients spending more than 4-hours in the ED, a 'traffic light' moment can be a simple and an effective tool.

Cardio-Renal-Metabolic (CaReMe) diseases, in the form of heart failure, chronic kidney disease and diabetes mellitus, justify prescription of multiple prognostically beneficial medications, specifically renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter-2 inhibitors. Use of these medications is complicated by association with adverse effects, particularly acute kidney injury and hyperkalaemia. Balancing risk and benefit is a common dilemma in acute medicine, with increasingly frequent and complex treatment decisions. Physicians should contemplate adjustments to medications within the context of not just acute illness but also long-term benefit. In the setting of hyperkalaemia, potassium-binding medications can be utilised. At hospital discharge optimisation of therapy can be achieved through clear safety netting advice, scheduled biochemical follow-up, and planned clinical review.

Nursing staff, healthcare assistants (HCAs) and other healthcare professionals on the Acute Medical Unit (AMU) at Royal Berkshire Hospital (RBH) were taught a Point of Care Ultrasound (POCUS) skill during a twenty minute session. Practitioners learned how to take bladder volume measurements with the Butterfly iQ, a portable ultrasound device which provides a visually-aided method of volume measurement. A Likert scale was used to measure the confidence that staff had in performing volume measurements with the AMU automated scanners, and with the semi-automated Butterfly iQ. After the teaching session, confidence reported by practitioners in using the semi-automated visual method was significantly higher than confidence reported in using the automated non-visual scanners (t < 0.001). Minimal time and expense was required to teach practitioners how to perform this skill. Training nurses in POCUS for bladder visualisation and bladder volume calculation is easy and practicable.

Background and aims: Despite published guidelines, telemetry use is inappropriate in 25-43% of cases. This impacts patient safety and telemetry effectiveness. QI methodology was used to review telemetry in a hospital acute medical unit with the aim of reducing inappropriate use and addressing alarm fatigue.

Methods: A 'Telemetry Indication Form' was created. Eight weeks of baseline data was collated before introducing the 'Indication Form'. Four plan-do-study-act cycles were conducted. At each cycle, data was analysed using statistical process control charts.

Results: Inappropriate telemetry use significantly reduced from 32% to 4%. Total telemetry use also fell. Unfortunately, interventions to address alarm rates did not result in significant reduction in false alarms.

Conclusions: A 'Telemetry Indication Form' has significant potential to improve patient safety through reducing inappropriate use.

Objective: To determine whether front-door discharge decision tools operate at different mortality thresholds.

Methods: Three databases  searched, for studies testing, deriving or validating front-door risk prediction tools or discharge decision aids, with  defined discharge 'cut-off', reporting mortality or readmission rates. Studies supporting tools' inclusion in national guidelines were also included.

Results: Twenty-four studies were included, frequently for acute chest pain. Mortality rates among those discharged based on tools 0-1.7%. Eight studies reported readmission rates, 0-8% among those discharged early or deemed low-risk.

Conclusion: Although mortality rates were lower for those deemed low-risk by decision aids than those admitted or control groups, readmission rates tended to be higher among low-risk or discharged patients, than among control group or admitted patients.

Objective: To describe the change in admission rate and demographic profile of patients admitted to ICUs throughout Denmark before and during first wave of the SARS-CoV-2 pandemic.

Methods: A register-based national observational study of all patients admitted to ICU from December 2019 until April 2020, comparing ICU admission before and after lockdown.

Results: The number of admissions declined, especially in the age groups below 18 and above 70. The sex distribution and the comorbidity-level remained unchanged. The length of hospital stay prior to ICU admission increased. Overall fewer patients were admitted electively.

Conclusion: Fewer patients were admitted to ICU and waited longer for admission during the first wave of the COVID-19 pandemic.