Editorial

Abstract

After a gruelling winter and depressingly damp spring, the UK was certainly due a halfdecent summer. For once, I am told that even Scotland enjoyed some sunny intervals and the opportunity to dust off barbeques and patio furniture unused for the past few years. Hopefully you have all had a chance to recharge the batteries and prepare for whatever autumn and winter will offer up in the coming months. A surgical consultant once described to me the difference between surgeons and physicians: ‘Surgeons save lives’, he said: ‘Physicians just delay deaths’. A sweeping generalisation, of course, and thankfully the vast majority of patients admitted to the AMU continue to lead long and fulfilling lives following their hospital stay. However despite the relative infrequency of death as an outcome from medical admission, it appears that hospital mortality rate will remain a key quality indicator for the foreseeable future. Indeed, the notion of ‘excess’ hospital deaths has filled many column inches across medical and Lay Press over the summer months. For those of you who remain mystified by this complex area I would encourage you to read Ian Crossingham’s excellent summary of this issues involved in calculating mortality rates and ratios on p129 of this edition. The importance of accurate coding in calculating the Hospital Standardised Mortality Ratio (HSMR) is well recognised, but the rules around what information can be utilised to define acuity of illness in coding are complex. The table on p133 illustrates how differences in systems of acute and speciality care between different hospitals can have a major impact on how the patient’s illness is defined. Acute physicians need to understand these issues properly in order that these figures can be interpreted – if patients leave the AMU without a clear ‘working diagnosis’, acuity may be based on admission symptoms, potentially resulting in a higher HSMR. Those who are attending the October meeting of the Society for Acute Medicine will no doubt relish the opportunity to hear directly from Professor Brian Jarmann, the instigator of the HSMR and a key contributor to the recent debates on this issue. Another highlight in this edition is the problem-based review on ‘Acopia’ by Kate Granger and her geriatric colleagues from Wakefield. The authors leave no doubt in readers’ minds about their view of this term, which they describe as ‘offensive and lazy’, asserting that it is generally the doctor (and not the patient) who ‘should be able to cope better’. The article also provides an excellent summary of comprehensive geriatric assessment and how this can be applied in an acute medical setting. The need to define lists of acute and background problems in order to establish priorities for care in frail and elderly patients is highlighted, along with the danger of over-interpretation of an abnormal urine dipstick analysis. The authors helpfully provide us with some ligitimate definitions of ‘Acopia’ – apparently it can be used to describe an inability to copy and a small town in Peru without causing steam to emit from your local geriatrician. Hopefully the ‘inability to cope with a stressful situation leading to tears and breakdown’ doesn’t resonate in other ways over coming months… There is a wide variety of other articles in this edition which I hope many of you will find interesting; if you have any feedback on these or would like to correspond on any of these topics I would be delighted to receive letters which we will try to publish in future editions of the journal.