Acute Admissions Unit Research Articles

Investigation of the degree of organisational influence on patient experience scores in acute medical admission units in all acute hospitals in England using multilevel hierarchical regression modelling

ObjectivesPrevious studies found that hospital and specialty have limited influence on patient experience scores, and patient level factors are more important. This could be due to heterogeneity of experience delivery...

Hospital at Home as an Enhancement to an Existing Rapid Response Team in a Semirural setting in Scotland

Midlothian is the area to the south of Edinburgh with a population of 86,000 spread across an area of 354km2. Midlothian Council and NHS Lothian work together as a Health and Social Care Partnership governed by the Midlothian Integration Joint Board. The work described here is an example of fully integrated working at ground level. For many years, Midlothian has had a successful Rapid Response Team, with a team of Allied Health Professionals and carers who deal with a variety of crises in the community, including attending to people with falls, those that require intensive rehabilitation in their homes and anyone who has an immediate crisis affecting their care. In 2014, in conjunction with NHS Lothian, the team was enhanced by the appointment of a community based consultant geriatrician and four advanced nurse practitioners. This has enabled the provision of a “Hospital at Home” service for the population of Midlothian as a meaningful alternative to an acute hospital admission. Following the initial success of this venture, the team is expanding with further investment in additional nursing and medical time. The Hospital at Home team work with the pre existing Rapid Response Service and are fully integrated with them, working in the same office in a community setting. The doctor, nurses, physiotherapist and pharmacist are aligned with the NHS, while the administration staff, occupational therapists and carers are employed by the council. In practical terms the team functions as a single entity. This service is different from the other “Hospital at Home” teams around Scotland, as it has grown from its roots in Social Care, whereas other services have tended to be outreach ventures from hospital secondary care. The goal of the team is to offer an alternative to admission for frail older patients, though younger people can also be referred if appropriate. Patients are admitted to a “virtual ward” on the NHS Lothian computer based TRAK system and have identical access to the same medical investigations as acute hospital inpatients, including all laboratory tests, Radiology and physiological testing where appropriate. The patient however remains in their own home (or care home) throughout their admission. Usual length of stay in the “ward” is around 7- 10 days. Additional care support can be provided if needed and there is immediate access to allied health professionals as required. Daily observations are carried out by the nursing staff. For many patients the key intervention is adjustment of medication and support for the patient and their family through the acute illness. However a variety of more invasive treatments can be provided, including administration of intravenous or subcutaneous fluids. Intravenous antibiotics and also diuretics are also given. In the first 15 months of the service, up to September 2015, 294 patients were referred, of whom 260 (88%) were suitable. Of these 255 (87%) were referred by their GP, with 51 (17%) being referred by acute hospitals to support early discharge. The local Acute Medical Admissions Unit at Edinburgh Royal Infirmary has now started a daily geriatrician ward round and a rise in referrals is anticipated. Although somewhat subjective, the team’s perception was that hospital admission had been “definitely avoided” in 184 patients (63%), with another 49 (17%) “unable to comment”. Joining an ongoing National Multicentre Randomised Controlled Trial will help answer this question in future. As expected, the majority of the patients were elderly, with 221 (75%) over the age of 75 years. Females outnumbered males 59% to 41%. Patients are taken on with a wide variety of problems. The commonest scenario is of acute infection with 59 patients having this (20%). Cardiac problems accounted for 48 patients (16%) and those with respiratory issues including COPD numbered 34 (12%). Many have multiple problems, with falls, delirium and musculoskeletal problems being common in this population. In each case the benefits and risks of staying at home versus being admitted to acute care are carefully evaluated with the patient, their family and the GP. If the clinical situation changes, then patients can be admitted to the “real” hospital and the team is able to ensure this is to the most appropriate setting for them. This happens for around 10% patients. Until October 2015, the service was provided 5 days a week but it is now available 7 days, allowing a greater number of patients to be referred. The Midlothian Enhanced Rapid Response Service is popular with patients and staff. Ring fenced funding from an integrated Health and Social Care Board has been key to its success.

Cigarette smoking, nicotine dependence, and motivation to quit smoking in South African male psychiatric inpatients.

BackgroundSmoking is the leading cause of preventable death worldwide and the prevalence is particularly high among psychiatric patients but recent international studies demonstrated that psychiatric patients are able and motivated to quit. The aim of this study was to evaluate cigarette smoking, nicotine dependence, and motivation for smoking cessation in male psychiatric inpatients in a sample of South African acute-care male psychiatric inpatients.MethodsAll inpatients admitted during a 2-month period (April to May 2016) to the Stikland Hospital Acute Male Admissions Unit in Cape Town, Western Cape, were included. Subjects completed a survey including a set of tests: Global Adult Tobacco Survey (GATS), the Fagerström Test for Nicotine Dependence (FTND), and the Decisional Balance for Cigarette Smoking (DBCS) (6-item version). Demographic data were obtained from patients’ clinical charts.ResultsAmong the 160 new inpatients, 72.5% (n = 116) completed the survey. Of the 116 participants, 91.4% (n = 106) were current smokers of whom 82% (n = 87) smoked daily and 55.6% (n = 59) were identified as having high nicotine dependence (FTND ≥ 6). Although a large majority (71.7%; n = 76) of current smokers expressed positive perceptions regarding smoking, a notable proportion (59.4%; n = 63) still attempted to quit the habit in the preceding 12 months and daily smokers were less likely to quit. However, only a minor proportion of all current (43.4%; n = 46) and specifically daily (40.2%; n = 35) smokers were advised on smoking cessation by a health worker.ConclusionThis study confirms that, similar to populations elsewhere, rates of cigarette smoking among psychiatric inpatients in South Africa is exceedingly high. While patients are motivated to quit smoking, few were provided with the necessary advice. Our findings provide further support for the integration of smoking cessation support in mental health care.

A fuller picture: evaluating an art therapy programme in a multidisciplinary mental health service

Art therapy has a long history in mental healthcare, but requires an enhanced evidence base in order to better identify its precise role in contemporary services. This paper describes an...

Implementation and evaluation of a collaborative clinical pharmacist's medications reconciliation and charting service for admitted medical inpatients in a metropolitan hospital.

Medication errors on admission can persist throughout the episode of care and on to discharge leading to inappropriate management that can compromise patients' care. The aim of the study was to develop, implement and evaluate the role of pharmacist-led medication reconciliation and charting service for patients admitted to an Acute Assessment and Admission Unit via the Emergency Department in an electronic medication management environment at a metropolitan Australian hospital. Following the credentialing of an experienced clinical pharmacist to perform collaborative medication charting, a prospective parallel study of medication errors was undertaken. Patients were randomly allocated to an intervention (n = 56) or a usual care (control) (n = 54) arm. Medication orders were charted by the medical staff in the usual care arm, whereas the pharmacist charted the medications in the intervention arm. An independent clinical pharmacist reviewed all the medication orders at 24 h after admission and errors recorded. The severity of errors was rated by a 'blinded' consultant physician and an independent senior pharmacist according to a standardized matrix. The potential time saving for the medical staff was investigated. A survey was conducted to assess the perception, acceptance and satisfaction of the service. The intervention arm (reconciliation performed by pharmacist) achieved an error reduction greater than 80%. The average error rate decreased from 4·41 to 0·52 errors per patient (P < 0·0001) and 0·43-0·05 errors per order (P < 0·005). The severity of the errors was also diminished. Time evaluation estimated that the pharmacist can save more than 30 min per patient for the admitting medical officers. Staff satisfaction survey indicated that the service was well received by the medical staff. A model of a collaborative clinical pharmacist reconciliation and charting service for admitted medical patients in an Australian hospital was successfully implemented. The service was well received and has shown to save medical staff time allowing them to attend to other duties. Moreover, the pharmacist charting and reconciliation service has resulted in a statistically significant reduction in medication errors.

Consequence of delegating medication-related tasks from physician to clinical pharmacist in an acute admission unit: an analytical study

ObjectivesStudies have shown that medication histories obtained by clinical pharmacists (CPs) are more complete, and that medication reviews by CPs reduce healthcare costs, drug-related readmissions and emergency readmissions. The aim...

Significant benefit of a targeted HIV testing module on medical students' knowledge and confidence.

The objective was to evaluate the efficacy of a HIV targeted-testing teaching session in improving knowledge and confidence at a London medical school. A survey assessing knowledge of HIV testing guidelines, confidence to offer testing and outcomes of targeted-testing teaching was developed and distributed to fifth year medical students. Results were compared for students who had completed GU/HIV modules (GU+) and those who had not (GU-) and chi-squared testing was performed; 100 and 119 questionnaires were returned by GU+ and GU- students (response rate of 92.6% and 97.5%), respectively. For the three knowledge-based questions, GU+ students were significantly more likely to provide correct answers for two (p < 0.001). Similarly, they were significantly more likely to feel confident in offering an HIV test (p < 0.001). After targeted-testing teaching 92%, 98% and 62% felt more confident about when to test, how to discuss testing and more knowledgeable about testing, respectively. Most students were happy to offer HIV testing in different medical settings; significantly fewer reported this for an acute admissions unit compared with antenatal clinic (79% vs 96%). Students who had received targeted-testing teaching demonstrated better knowledge and confidence about HIV testing. We hope this study raises awareness of the need to include HIV testing teaching in medical school curricula.

Risk of prescribing errors in acutely admitted patients: a pilot study.

Background Prescribing errors in emergency settings occur frequently. Knowing which patients have the highest risk of errors could improve patient outcomes. Objective The aim of this study was to test an algorithm designed to assess prescribing error risk in individual patients, and to test the feasibility of medication reviews in high-risk patients. Setting The study was performed at the Acute Admissions Unit at Aarhus University Hospital, Denmark. Methods The study was an interventional pilot study. Patients included were assessed according to risk of prescribing errors with the aid of an algorithm called 'Medication Risk Score' (MERIS). Based on the score, high-risk patients were offered a medication review. The clinical relevance of the medication reviews was assessed retrospectively. Main outcome measure The number and nature of prescribing errors during the patients' hospitalisation. Results The study included 103 patients, all of whom could be risk assessed with the algorithm MERIS. MERIS stratified 38 patients as high-risk patients and 65 as low-risk patients. The 103 patients were prescribed a total of 848 drugs in which 88 prescribing errors were found (10.4%). Sixty-two of these were found in patients in the high-risk group. In general, the medication reviews were found to be clinically relevant and approximately 50% of recommendations were implemented. Conclusion MERIS was found to be applicable in a clinical setting and stratified most patients with prescribing errors into the high-risk group. The medication reviews were feasible and found to be clinically relevant by most raters.

Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital

ObjectivesReliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process...

Factors related to monitoring during admission of acute patients

Understanding the use of patient monitoring systems in emergency and acute facilities may help to identify reasons for failure to identify risk patients in these settings. Hence, we investigate factors related to the utilization of automated monitoring for patients admitted to an acute admission unit by introducing monitor load as the proportion between monitored time and length of stay. A cohort study of patients admitted and registered to patient monitors in the period from 10/10/2013 to 1/10/2014 at the acute admission unit of Odense University Hospital in Denmark. Admissions with at least one measurement were analyzed using quantile regression by looking at the impact of distance from nursing office, number of concurrent patients, wing type (medical/surgical), age, sex, comorbidities, and severity conditioned on how much patients were monitored during their admissions. We registered 11,848 admissions, of which we were able to link patient monitor readings to 3149 (26.6 %) with 50 % being monitored <1.4 % of total admission time. Distance from nursing office had little influence on patients monitored <10 % of their admission time. But for other patients, being positioned further away from the office reduced the level of monitoring. Higher levels of severity were related to higher degrees of monitoring, but being admitted to the surgical wing reduce how much patients were monitored, and periods with many concurrent patients lead to a small increase in monitoring. We found a significant variation concerning how much patients were monitored during admission to an acute admission unit. Our results point to potential patient safety improvements in clinical procedures, and advocate an awareness of how patient monitoring systems are utilized.

Measurement of generic patient reported outcome measures (PROMs) in an acute admission unit: A feasibility study

Objective: Measuring patient-reported outcome measures (PROMs) is a challenge in Acute Admission Units (AAUs), where patients present with a variety of pathologies. Generic PROMs may be used to measure the quality of care in this population. The main objective of this study was to assess the feasibility of measuring generic PROMs in a Dutch AAU. Design: Longitudinal cohort study Setting: An AAU of a tertiary hospital in Amsterdam, the Netherlands Participants: 123 patients admitted to the AAU during 5 weeks in May and June 2015 Methods: Patients admitted to the AAU were asked to fill out a questionnaire relating to three time points: 7 days before, during, and within 2 weeks after admission. Additionally, patients were asked to report on their experienced level of safety on the AAU and the contribution of the AAU to their recovery. Results: There were significant trends in generic PROMs for all three domains. Physical functioning decreased during hospital admission and almost fully returned to the previous level after discharge. Satisfaction with social role and anxiety significantly decreased over time. Conclusions: Measuring generic PROMs in the AAU is feasible. The analysis of the PROMs took little effort and results could be reported back to the healthcare workers on the AAU quickly. Patients appreciated being asked about their own perceived health and the quality of care. Given that this is the first study focusing on PROMs in AAU patients in the Netherlands, future studies with larger sample sizes, and from other nations are needed to further investigate PROMs in this patient group to establish International reference values.

Response of influenza vaccine in chronic obstructive pulmonary disease patients

Background: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. The World health Organization has suggested that elderly individuals with chronic lung disease to be targeted for immunization. In spite of all these recommendations, influenza vaccine is underused, especially in developing countries. Objective: This study aims to study the effect of influenza vaccine in patients with COPD in reducing acute exacerbations, emergency visits, sputum quantity, hospital admission, and Intensive Care Unit (ICU) admission in a 2-year period. Materials and Methods: Twenty-five patients of COPD were selected based on their forced expiratory volume in 1 s as having mild, moderate, severe, and very severe COPD. These patients were followed and evaluated for 2 years, 1 year before vaccination, and 1 year after vaccination. The parameters studied are, the number of acute episodes, emergency visits, hospital admission, ICU admissions, sputum quantity, and chest X-rays were evaluated before and after 1 year of vaccination. Results: The vaccine showed a significant decrease in all the parameters (P < 0.001), except for chest X-rays and ICU admission. The overall effectiveness of influenza vaccine was found to be 63.12%. Conclusions: Influenza vaccine is safe and effective among moderate, severe, and very severe COPD patients. It has also been found very effective in severe COPD patients associated with comorbidities.

Impact of clinical pharmacist intervention on length of stay in an acute admission unit: a cluster randomised study

ObjectivesPhysicians in acute admission units (AAUs) are obliged to obtain medication history and perform medication reconciliation, which is time consuming and often incomplete. Studies show that clinical pharmacists (CPs) can...

Consultant cover on an acute surgical GP admission unit–driving down waiting times in a North-West hospital

Consultant cover on an acute surgical GP admission unit–driving down waiting times in a North-West hospital

Estimated cost per HIV infection diagnosed through routine HIV testing offered in acute general medical admission units and general practice settings in England.

Following national guidelines to expand HIV testing in high-prevalence areas in England, a number of pilot studies were conducted in acute general medical admission units (ACUs) and general practices (GPs) to assess the feasibility and acceptability of testing in these settings. The aim of this study was to estimate the cost per HIV infection diagnosed through routine HIV testing in these settings. Resource use data from four 2009/2010 Department of Health pilot studies (two ACUs; two GPs) were analysed. Data from the pilots were validated and supplemented with information from other sources. We constructed possible scenarios to estimate the cost per test carried out through expanded HIV testing in ACUs and GPs, and the cost per diagnosis. In the pilots, cost per test ranged from £8.55 to £13.50, and offer time and patient uptake were 2 minutes and 90% in ACUs, and 5 minutes and 60% in GPs, respectively. In scenario analyses we fixed offer time, diagnostic test cost and uptake rate at 2 minutes, £6 and 80% for ACUs, and 5 minutes, £9.60 and 40% for GPs, respectively. The cost per new HIV diagnosis at a positivity of 2/1000 tests conducted was £3230 in ACUs and £7930 in GPs for tests performed by a Band 3 staff member, and £5940 in ACUs and £18 800 in GPs for tests performed by either hospital consultants or GPs. Expanded HIV testing may be more cost-efficient in ACUs than in GPs as a consequence of a shorter offer time, higher patient uptake, higher HIV positivity and lower diagnostic test costs. As cost per new HIV diagnosis reduces at higher HIV positivity, expanded HIV testing should be promoted in high HIV prevalence areas.

Detection of Patients at High Risk of Medication Errors: Development and Validation of an Algorithm.

Medication errors (MEs) are preventable and can result in patient harm and increased expenses in the healthcare system in terms of hospitalization, prolonged hospitalizations and even death. We aimed to develop a screening tool to detect acutely admitted patients at low or high risk of MEs comprised by items found by literature search and the use of theoretical weighting. Predictive variables used for the development of the risk score were found by the literature search. Three retrospective patient populations and one prospective pilot population were used for modelling. The final risk score was evaluated for precision by the use of sensitivity, specificity and area under the ROC (receiver operating characteristic) curves. The variables used in the final risk score were reduced renal function, the total number of drugs and the risk of individual drugs to cause harm and drug-drug interactions. We found a risk score in the prospective population with an area under the ROC curve of 0.76. The final risk score was found to be quite robust as it showed an area under the ROC curve of 0.87 in a recent patient population, 0.74 in a population of internal medicine and 0.66 in an orthopaedic population. We developed a simple and robust score, MERIS, with the ability to detect patients and divide them according to low and high risk of MEs in a general population admitted at acute admissions unit. The accuracy of the risk score was at least as good as other models reported using multiple regression analysis.

Four-Stage Audit Demonstrating Increased Uptake of HIV Testing in Acute Neurology Admissions Using Staged Practical Interventions.

BackgroundUK National Guidelines (UKNG) advise HIV testing in clinically indicated neurological presentations. We audited the impact of our practical strategies to increase uptake of HIV testing at a regional acute neurology admissions unit.MethodsWe audited HIV testing in 4 periods over 2 years: before we designed a UKNG-based “HIV testing in Neurology” protocol (“pre-protocol”); after dissemination of the protocol alone (“post-protocol”); post-protocol dissemination combined with both a tailored departmental admissions clerking proforma to prompt for HIV testing & consenting, and regular focussed tutorials to doctors on HIV testing in neurological patients (“post-proforma”); and finally one year after the post-proforma period (“+1 year”). We also looked at the total number of HIV tests sent from the unit during the two-year period. We assessed significance using Fisher’s exact test.Results47.8% of all acute neurology non-stroke admissions were eligible for HIV testing during all the audit periods. Testing rates were as follows: pre-protocol 21.9%; post-protocol 36.6%; post-proforma 83.3%; and at +1 year 65.4% (p<0.05 for both post-protocol and +1 year when compared to pre-protocol). Documentation of consent for HIV testing improved from 25% to 67.6% with the HIV-tailored clerking proforma. The total number of HIV tests requested from the unit doubled in the post-proforma period compared to pre-protocol (p<0.05).ConclusionIn conclusion: the combination of an HIV testing protocol, a tailored departmental clerking proforma and regular focussed teaching to doctors on indications for HIV testing led to a sustained increase in HIV testing uptake in our regional acute neurology admissions unit.

Targets and the emergency medical system – intended and unintended consequences

There is interest in health service reform and efficiencies; health service providers collect statistics, set targets and compare institutions. In January 2009, in Ireland, a national waiting time target of 6 h was set from registration in the emergency department (ED) to admission or discharge. The aim of this study was to assess the consequences of the introduction of this target on our institution and the Acute Medical Admission Unit. All emergency medical admissions were tracked over 7 years and in-hospital mortality, length of stay and ED 'wait' numbers and times were summarized. There were 43 471 admissions in 28 862 patients. In-hospital mortality for 2006-2008 averaged 5.9% [95% confidence interval (CI) 5.5-6.2%] compared with 4.8% (95% CI 4.6-5.1%) for 2009-2012 - a relative risk reduction of 18.3% (95% CI 11.5-24.5%) (P<0.001). The median length of stay was unaltered: 5.1 days (interquartile range 2.1-9.8) versus 5.0 days (interquartile range 2.0-9.5) (P=0.16). An ED 'first ward' allocation decreased six-fold with redistribution to the Acute Medical Admission Unit (two-fold increase) and the medical wards (four-fold increase). The time to on-call medical assessment decreased (time to team pre/post 4.5 vs. 4.2 h, P<0.001). However, calculations directly on the real-time log of arrival and first in-patient time showed a worsening of the position (time to ward pre/post 7.1 vs. 8.4 h, P<0.001). Target setting may result in unintended consequences in other areas in addition to its stated goal. These unintentional consequences of targets should be borne in mind by those planning and instituting healthcare reform.

Experiences of nurses caring for mental health care users in an acute admission unit at a psychiatric hospital in the Western Cape Province.

BackgroundCaring for mental health care users (MHCUs) with mental illnesses is a major task that confronts nurses globally. It has been argued that caring for this group of patients is accompanied by unique challenges. Despite the available abundance of data about nursing patients suffering from mental illnesses, little is known about the lived experiences of nurses who care for MHCUs in acute admission units in the Western Cape province.ObjectivesThis study’s aim is to explore and describe the lived experiences of nurses who care for MHCUs in an acute admission unit at a psychiatric hospital in the Western Cape province.MethodsA qualitative, descriptive, phenomenological study was conducted. A purposive sampling procedure was applied which resulted in a sample that comprised eight nurses. In-depth, individual, semi-structured interviews were conducted with these eight participants. Interviews were audio-recorded and transcribed verbatim and the researcher utilised Collaizzi’s method to analyse collected data.ResultsBoth positive and negative experiences were reported. Positive experiences were the recovery of patients, teamwork, and passion for caring. Negative experiences were the feelings of being unappreciated and unsupported by authorities. Physical assault by MHCUs, shortage of staff, increased workload and burnout was also reported.ConclusionsIn-service training about management of aggression needs to be provided, debriefing sessions to deal with burnout needs to be arranged, and research to quantify levels of burnout should be conducted.

Impact of clinical pharmacist intervention on acute admission unit length of stay

Background Quality and efficiency in the Emergency Department (ED) concerns clinicians and administrators worldwide because of an increasing number of patients and a desire for optimizing flow, avoiding crowding, and increasing the quality of the treatment. For patients referred to an Acute Admission Unit (AAU), which is a sub unit in the ED, the physicians have to obtain a medication history and medication reconciliation that are time consuming. Medication histories obtained by physicians are often incomplete. The objective of the study was to investigate the impact of a clinical pharmacist (CP) intervention on the patients’ AAU length of stay (AAU-LOS).