Acute Medicine最新文献

Background: Coronavirus disease 2019 has had a dramatic impact on the delivery of acute care globally. Accurate risk stratification is fundamental to the efficient organisation of care. Point-of-care lung ultrasound offers practical advantages over conventional imaging with potential to improve the operational performance of acute care pathways during periods of high demand. The Society for Acute Medicine and the Intensive Care Society undertook a collaborative evaluation of point-of-care imaging in the UK to describe the scope of current practice and explore performance during real-world application.

Methods: A retrospective service evaluation was undertaken of the use of point-of-care lung ultrasound during the initial wave of coronavirus infection in the UK. We report an evaluation of all imaging studies performed outside the intensive care unit. An ordinal scale was used to measure the severity of loss of lung aeration. The relationship between lung ultrasound, polymerase chain reaction for SARS-CoV-2 and 30-day outcomes were described using logistic regression models.

Results: Data were collected from 7 hospitals between February and September 2020. In total, 297 ultrasound examinations from 295 patients were recorded. Nasopharyngeal swab samples were positive in 145 patients (49.2% 95%CI 43.5-54.8). A multivariate model combining three ultrasound variables showed reasonable discrimination in relation to the polymerase chain reaction reference (AUC 0.77 95%CI 0.71-0.82). The composite outcome of death or intensive care admission at 30 days occurred in 83 (28.1%, 95%CI 23.3-33.5). Lung ultrasound was able to discriminate the composite outcome with a reasonable level of accuracy (AUC 0.76 95%CI 0.69-0.83) in univariate analysis. The relationship remained statistically significant in a multivariate model controlled for age, sex and the time interval from admission to scan Conclusion: Point-of-care lung ultrasound is able to discriminate patients at increased risk of deterioration allowing more informed clinical decision making.

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.

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.

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.

UK urgent care health policies advocate senior clinical decision-making at the point of referral into the system. The costs of employing senior clinicians in this role are substantial with little evidence of the value they bring over other strategies, particularly for patient outcomes. We sought to explore current remote and ambulatory emergency care decision-making in acute medical care in a large central healthcare system - NHS Scotland. We found that many sites use remote decision-making for some allocation decisions. However, involvement of clinical expertise varies, and available decision-aids are few. There is also variation in access to resources that facilitate non-admission. Research into the value that senior clinicians bring to this task over other strategies is required.

High quality discharge information communication has been linked to a reduction in the incidence of adverse events, decreasing the risk of prescription errors and lost follow up. In this paper we describe how our trust-wide quality improvement project, led by acute physicians, successfully improved discharge documentation. We demonstrate how we identified obstacles to continued success, and the interventions we implemented. We recommend how discharge summary quality can be optimised through training of junior doctors, recruitment of local champions, and use of novel methods to preserve engagement, such as gamification.

Inhalational lung injury should be considered in patients presenting with acute respiratory symptoms and a history of occupational or recreational exposure to toxic substances. We present the case of a 29-year-old patient who developed pneumonitis following usage of waterproofing sealant spray in an enclosed space, despite the use of a dust mask. The patient was managed with oxygen therapy, corticosteroids and bronchodilators. He made a complete clinical recovery with resolution of almost all changes seen on computerised tomography (CT) imaging within 7 days.