Editorial

Abstract

The ability to identify and discharge the low-risk patient, and to predict those cases where deterioration is likely is already a key element of the practice of acute medicine . This is an area which has been extensively examined in the past, but two articles in this edition add an interesting dimension to the literature. The use of physiological variables to calculate risk enables fluctuations in a patient’s condition over time can be monitored, allowing appropriate escalation measures to be instituted. The National Early Warning Score has already been implemented in Wales and roll-out across England is expected imminently. Austen and colleagues have highlighted some of the advantages that a standardised system will provide in comparison to their locally-developed Early Warning Score; however the problem of under-scoring due to incomplete or inaccurate recording remains and will continue until electronic solutions are more widespread. Scoring systems utilising laboratory data from admission are less useful for ongoing monitoring but could provide clinicians with an objective measure of risk at the time of initial assessment. As austerity measures bite, the pressure to direct our limited resources to the most appropriate cases will undoubtedly intensify, making this increasingly important. The rigorous quality control mechanisms in laboratories ensure the reliability of biochemical test results; furthermore most hospitals have electronic systems for recording and displaying results which limits the risk of errors from human transcription. O’Sullivan et al have utilised the extensive database from St James’ hospital in Dublin to develop a score based on a number of biochemical and haematological tests. Although this will need to be prospectively validated, retrospective analysis using a huge sample over a number of years, suggests their score may be highly predictive of good and poor outcome. This has great potential to support clinical decision making at the ‘front door’ and improve utilisation of resources. If variety is the ‘spice of life’, then Acute Medicine is certainly the ‘vindaloo’ of the modern hospital. The enormous breadth of clinical problems encountered on the AMU is apparent from the data gathered in York Hospital during the 15 months prior to April 2011. Variety is a key attraction for many junior doctors considering their career choice, at a time when many areas of hospital practice are becoming increasingly specialised. The acute medicine curriculum has ensured that trainees undertake blocks of training in respiratory medicine and cardiology, which is clearly important given that these areas reflected almost 50% of patients. However the authors highlight that the infrequency of certain problems, such as cord compression and diabetic ketoacidosis might also need to be addressed with training outside the AMU in neurology and endocrinology to ensure adequate exposure to these conditions. The rise in alcohol-related admissions is also highlighted in this article, and our trainee section includes a problem based review of the management of these problems. The obesity epidemic, as well as the proliferation of weight-loss surgery and its complications is another area which increasingly challenges our AMU resources. The article by Fiona Maggs provides some practical advice on how to address these issues. I hope you enjoy this edition, and the summer months ahead...