Acute Medical Admissions Research Articles

Emergency department census of patients awaiting admission following reorganisation of an admissions process

Objectives: To determine the impact of reorganisation of an acute admissions process on numbers of people in the emergency department (ED) awaiting admission to a hospital bed in a major...

Vitamin D insufficiency in older female community-dwelling acute hospital admissions and the response to supplementation

A significant proportion of the older population may exhibit vitamin D insufficiency. We sought to establish the proportion of 25-hydroxyvitamin D (25OHD) insufficient individuals in an older female cohort presenting for acute medical admission and how they responded to supplementation. A prospective cohort study. Hospital admissions followed up as a population-based study. A total of 114 consecutive female acute medical admissions aged over 65 years from November 2003 to January 2004 were enrolled. All admissions with hypercalcaemia, metabolic bone disease (other than osteoporosis/osteomalacia) and creatinine > 150 micromol/l were excluded. iPTH, calcium and 25OHD levels were measured in each patient. Of the total, 22 were already receiving calcium and vitamin D supplementation at enrolment. The remaining 92 were commenced on 800 IU of vitamin D and 1 g calcium, and levels were reassessed after supplementation for 3 months. 25-Hydroxyvitamin D insufficiency, as defined by a 25OHD concentration of < 50 nmol/l, was present in 86 (75.4%) patients at initial assessment (mean 35.8 nmol/l, s.d. 23.3). Secondary hyperparathyroidism was present in only 36.7% of those with 25OHD deficiency at baseline. Of the total, 51 (44.7%) patients presented for follow-up. 25-Hydroxyvitamin D concentration increased in this group from 42.1 nmol/l (s.d. 26.6) to 59.5 nmol/l (s.d. 27.4) after supplementation, P < 0.001, but 18(35.3%) still remained deficient. There was no significant change in iPTH or calcium following supplementation. Assessment of compliance revealed 6 (11.7%) admitted to partial or non-compliance. Insufficiency of 25OHD was very common in this cohort. Despite calcium and vitamin D supplementation, 25OHD concentrations failed to reach normality in a significant proportion. Maintaining vitamin D and calcium intake at the level of current recommended doses may not be sufficient to ensure adequate 25OHD stores.

Barriers to implementing a policy not to attempt resuscitation in acute medical admissions: prospective, cross sectional study of a successive cohort

Objective To establish whether acutely unwell patients admitted to hospital wish to participate in discussions about resuscitation.Design Prospective, cross sectional study of a successive cohort of patients.Setting Admission through the...

The impact of weekends on outcome for emergency patients

Levels of staffing and access to diagnostics at weekends are recognised to be significantly lower than on weekdays. It is unclear if subsequent inpatient mortality and readmission rates for acute medical admissions are increased for weekend admissions compared to those on a weekday. A large Canadian study demonstrated increased weekend mortality but does the Edinburgh healthcare model support these findings? This study analysed all hospital admissions in 2001 to the Royal Infirmary of Edinburgh for six predetermined diagnoses (total 3,244): chronic obstructive pulmonary disease, cerebrovascular accidents, pulmonary embolism, pneumonia, collapse and upper gastrointestinal bleed. We compared hospital mortality rates, readmission rates and hospital length of stay for weekend admissions as compared to those on a weekday. Weekend admission was not associated with significantly higher in-hospital mortality, readmission rates or increased length of stay compared to the weekday equivalent for any of the six conditions. The implementation of an acute medical admissions unit in the Royal Infirmary of Edinburgh, with consistent staffing levels and 24-hour access to diagnostics for the early phase of critical illness, may have helped address the discrepancy in care suggested by previous studies.

The causes of musculoskeletal chest pain in patients admitted to hospital with suspected myocardial infarction

Background We wished to investigate the causes and characteristics of musculoskeletal chest pain leading to acute medical admission. Methods We studied patients admitted to Queen Elizabeth Hospital, Gateshead, over a 10-week period. Patients with chest pain for which no acute cardiorespiratory cause was evident were identified and only included if they were tender on anteroposterior chest compression, thoracic spine rotation or firm sternal pressure. A detailed clinical history, anxiety and depression scale and a focussed physical examination were done to define the nature of musculoskeletal disease and their therapeutic requirements. Results Fifty patients satisfying the inclusion criteria were admitted in the 10-week period and comprised 54% females with a mean age of 57 years (S.D. = 13.48). Chest pain lasted for 1 h or less in 24 patients and was mostly anterior. Three distinct groups of patients were identified. Twelve patients had evidence of inflammatory joint disease, thirteen had fibromyalgia and half had regional syndromes with pain arising from the shoulder, neck, thoracic spine or sternocostal areas. Visual analogue scores were highest in fibromyalgia for pain, and highest in inflammatory arthritis for impaired mobility. Anxiety and depression scores were highest in fibromyalgia and lowest among patients with regional syndromes. Conclusions Musculoskeletal causes for acute chest pain are common and varied. Most patients have an identifiable cause of pain, but accurate diagnosis is needed to select the most appropriate intervention. Anxiety and depression are frequent, with much self-reported pain and dysfunction. However, all patients in this study had a disorder that was amenable to treatment and diagnosis. Management needs to be actively pursued in all patients.

COMBINING THE AUDIT QUESTIONNAIRE AND BIOCHEMICAL MARKERS TO ASSESS ALCOHOL USE AND RISK OF ALCOHOL WITHDRAWAL IN MEDICAL INPATIENTS

Alcohol consumption is often under-reported in patients admitted to general hospitals with acute illness. For alcohol-dependent individuals hospital admission results in an enforced period of abstinence with potential alcohol withdrawal symptoms, and possible life threatening complications. Early detection of alcohol use is therefore beneficial to patients and health services. The purpose of this study was to investigate the performance of the alcohol use disorders identification test (AUDIT) questionnaire in the acute medical setting, and the effect of combining routine biological markers-glutamyltransferase, alanine aminotransferase, aspartate aminotransferase, and mean corpuscular volume (MCV) on its performance in the early identification of in-patients with alcohol use disorders and at risk of developing symptoms of alcohol withdrawal. Prospective study in consecutive patients admitted to an acute medical admissions ward. All patients were screened using the AUDIT questionnaire and routine blood tests. Patients were then monitored for symptoms of withdrawal using clinical institute withdrawal assessment for alcohol (CIWA-Ar). Of the 874 patients screened using the AUDIT, 98 (11%) screened positive of whom 17 (2% of the 874) experienced clinically significant alcohol withdrawal symptoms, when using serial CIWA-Ar. The AUDIT and serial CIWA-Ar detected all patients who went on to manifest acute withdrawal symptoms. There was no loss of sensitivity at an AUDIT cut-off of 13 or more compared with the lower cut-off of 8 or more. A positive predictive value of 17.3% for an AUDIT score of 8 or more in the detection of withdrawal, increased to 47.1% when found in combination with at least two abnormal biological markers whilst maintaining a sensitivity of 94.1% and specificity of 97.9%. These findings confirm that AUDIT is a useful alcohol screen in general medical settings and that its ability to correctly predict which patients will experience alcohol withdrawal is increased when used in combination with biological markers.

Differences between self-referred and physician-referred hospital admissions

Compare self- and physician-referred hospital admissions. Analysis of data prospectively collected on 3,076 consecutive acute medical admissions to a small hospital. Self-referred patients were younger (50.6 vs. 63.7 years) and more likely to be smokers and drinkers. Conversely, physician-referred patients were more likely to present later, be ex-smokers, ex-drinkers and have poor prior health. More self-referred admissions were related to parasuicide and/or alcohol (27% vs. 4.5%). The physical, x-ray and laboratory findings of both types of patient were similar. Although self-referred patients had a shorter length of stay (3.8 days vs. 6.0 days) and a lower death rate (1.5% vs. 3.8%),they had higher 30-day readmission rates (14.6% vs. 8.5%). Self-referred patients are less sick than those referred for hospital admission by a physician, have less psychosocial support, more alcohol-related illness and are nearly twice as likely to be readmitted within 30 days of discharge

Management of incidental hyperglycaemia in acute medical emergencies

To assess whether compliance with management guidelines for hyperglycaemia in acute medical emergencies was affected by prior diagnosis of diabetes, and to assess the effect of an educational campaign upon management. Prospective study of management of adult patients admitted to an acute medical admissions unit in 2002, with repeat in 2003 after an educational campaign. The management of 251 patients in 2002 and 357 patients in 2003 was examined. In patients with no prior diagnosis of diabetes, unsatisfactory management was observed in 60% compared with only 30% of those with known diabetes (P < 0.02). In 2003 these proportions fell to 46 and 16%, respectively, but remained significantly different (P < 0.02). Overall, 30 of 70 (42.9%) patients with hyperglycaemia were managed strictly according to the guidelines in 2002 compared with 33 out of 59 (55.9%) in 2003 (P = 0.14). Satisfactory management was delivered in 55.7% in 2002 and 78% in 2003 (P < 0.01). The reluctance of doctors to manage incidental hyperglycaemia in acute medical admissions was especially common when the patient was not known to have diabetes. This was only modestly improved by an educational campaign, even though this group are known to have a greater response in terms of morbidity and mortality. Widespread debate of this issue is required to minimize morbidity and mortality due to hyperglycaemia.

Managing exacerbations of chronic obstructive pulmonary disease

The worldwide incidence of chronic obstructive pulmonary disease (COPD) is increasing and, in parallel, so is the social and economic burden. Mortality data underestimate COPD as a cause of death because the disease is more likely to be cited as a contributory rather than as an underlying cause of death, or may not be cited at all. By 2020, COPD is expected to be the third most common cause of death worldwide yet it receives less funding, publicity and fewer resources than is deemed necessary. The major burden of COPD falls on the patient and carer, and it is difficult to quantify. The quality of life of patients is evident and depends on the severity of their disease and their ability to adapt physically, socially and emotionally to the resulting disability. COPD leads to 30000 deaths per year in the UK. It is a considerable load to the NHS, particularly in the winter months when exacerbations occur most commonly; it results in 13% of all acute medical admissions.

Does a Hospital Formulary Influence Prescribing Practice in an Acute Medical Admissions Unit?

To assess the extent to which prescribing of cardiovascular medications in a busy medical unit deviates from the local joint primary and secondary care drug formulary guidelines. A retrospective audit of the case notes, prescription charts and discharge summaries of 150 randomly selected emergency medical admissions over a 4 month period. No patient receiving a non-formulary cardiovascular drug on admission had the choice reviewed in line with formulary recommendations. One third of new cardiovascular medications commenced in hospital were not compliant with formulary recommendations. Decisions about drug therapy were rarely justfied in the written hospital record. Our results demonstrate that in a busy acute medical admissions' unit there is a clear failure to amend or query non-formulary prescribing at the time of admission and a tendency to exacerbate it during the inpatient period. This potentially undermines the purpose of a joint drug formulary as a guideline for safe, evidence-based and cost-effective prescribing.

Impact of an acute medical admission unit on length of hospital stay, and emergency department 'wait times'

While many UK hospitals have introduced an acute medical admissions unit (AMAU) to facilitate an efficient emergency admission process and reduce length of hospital stay (LOS), there is a lack of such data in the Republic of Ireland. To determine the impact of an AMAU on emergency department (ED) wait times for a hospital bed, consultant practice, and LOS. Retrospective analysis of data recorded in the hospital in-patient enquiry (HIPE) system. We studied all emergency medical patients admitted to St James' Hospital Dublin between 1 January 2002 and 31 December 2003. In 2002, patients were admitted directly to a variety of wards, many of which were not affiliated with a medical specialty, under the care of a named consultant physician. In 2003, two centrally located wards were re-configured to function as an AMAU, and all emergency patients were admitted to this unit. For all physician teams, median LOS shortened significantly from 2002 to 2003 (6 vs. 5 days, p<0.0001). Overall, patients seen by general physicians had a shorter LOS (5 days) than that of those seen by sub-specialists (6 days) (p<0.0001). The number of patients waiting in the ED for a hospital bed was reduced by 30% from 2002 to 2003 (p<0.001). Extrapolated cost savings for the hospital with the introduction of the AMAU were estimated at approximately 4039 bed-days and 1 714 152. Introduction of the AMAU speeded access to acute medical service and reduced costs.

An educational intervention can prevent delirium on acute medical wards

Delirium is a common disorder in hospitalised older people and established cases may have a poor outcome that is not readily improved by intervention. Prevention of cases through education of medical and nursing staff has not been fully studied. To test the hypothesis that an educational package for medical and nursing staff would both reduce the number of incident cases of delirium and increase recognition of cases of delirium within an acute medical admissions ward. Single-blind case-control study. Two acute admissions wards in a busy inner-city teaching hospital. 250 acute admissions over the age of 70 years. An educational package for staff on one ward consisting of a 1 hour formal presentation and group discussion, written management guidelines and follow-up sessions. The follow-up sessions, which were based on one-to-one and group discussions, aimed at providing continuous support of staff through emphasising learning and testing knowledge. Diagnosis and management of some discharged delirium patients were also discussed to allow staff to learn from previous experience. The main outcome measures are point prevalence of delirium established by researchers, and recognition and case-note documentation of delirium by clinical staff. The point prevalence of delirium was significantly reduced on the intervention compared to the control ward (9.8% versus 19.5%, P < 0.05) and clinical staff recognised significantly more delirium cases that had been detected by research staff on the ward where the educational package had been delivered. A focused and inexpensive educational programme can decrease the prevalence of delirium among older inpatients.

The Prevalence of Atrial Fibrillation among Acute Medical Admissions in Kuwait

Objective: To establish the prevalence of atrial fibrillation (AF) among acute medical admissions to the Adan Hospital, Kuwait, and to evaluate the clinical features of the patients. Subjects and Methods: Of 2,833 acute medical admissions to the Adan Hospital from January 1 to May 31, 2003, 120 patients with AF were included in the study. The patients were divided into paroxysmal or persistent (PPAF), and chronic atrial fibrillation (CAF). The prevalence of stroke and clinical features of the CAF patients with and without strokes were studied. All the patients with AF underwent echocardiography to evaluate left ventricular ejection fraction (LVEF) and left atrial dimension (LAD). Results: The prevalence of AF in the study period was 4.24%, of which 68.3% had CAF and 31.7% had PPAF. The prevalence of heart failure, ischemic heart disease, systemic hypertension, and diabetes mellitus was 27.5, 55.8, 65.8, and 53.3%, respectively. Patients with CAF were older and had a higher prevalence of heart failure compared to PPAF patients. Of the patients with CAF, 26.8% had at least one episode of stroke. The CAF patients had lower LVEF and larger LAD than PPAF patients. Stroke patients with CAF had lower LVEF and larger LAD as compared to those without stroke. Conclusion: Atrial fibrillation is a common admission diagnosis in our hospital. Patients with AF commonly suffer from heart failure, hypertension, diabetes mellitus, and ischemic heart disease. There was a high prevalence of stroke among CAF patients.

An audit of anticipated discharge planning for acute medical and orthopaedic admissions

The authors of this article audited an anticipated discharge survey on acute medical and orthopaedic admissions to a UK hospital over a 2-month period. An anticipated discharge form was filled in on admission by an experienced clinician and a discharge date set based on the patient's clinical condition, age and social circumstances. In total, 31 patients (51%) went home on the day planned or within one day of this date. The reasons for delays in discharge included failure of doctors to review patients, slow response to treatment and waiting for social services. Slow mobilization in eight patients accounted for the longest length of stays. The authors found that discharge plans may break down at weekends and are exploring innovative ways of solving this problem.

Evaluation of the use of the X-ray department with regard to plain chest radiography on acute general medical admissions in the context of recently introduced UK guidelines.

Evaluation of the use of the X-ray department with regard to plain chest radiography on acute general medical admissions in the context of recently introduced UK guidelines.

Resource utilisation, length of hospital stay, and pattern of investigation during acute medical hospital admission

Objectives: To describe the patient demographic characteristics and organisational factors that influence length of stay (LOS) among emergency medical admissions. Also, to describe differences in investigation practice among consultant physicians...

Pancreatic diseases.

Pancreatic diseases.

Liver disease in Europe

Liver disease refers to a wide spectrum of both acuteconditions caused by various injurious agents, such asviruses, toxins, alcohol and pharmacological agents, aswell as chronic liver diseases, which may over time leadto cirrhosis. Cirrhosis, from whatever cause, predisposesto hepatocellular carcinoma, a primary liver cancer,particularly if the cirrhosis is caused by hepatitis B or Cinfection.Most acute liver diseases can be managed conserva-tively or by withdrawing the hepatotoxic agent respon-sible. Severe acute liver damage may result in liverfailure, or be so overwhelming as to induce irreversibleliver damage (fulminant liver failure), which is associ-ated with significant mortality rates.A proportion of acute infections and diseases maycause ongoing liver injury, resulting in chronic liverdisease and cirrhosis. Like acute liver damage, chronicdisease often goes undiagnosed during the early stagesof the condition. Many cases only present to practi-tioners when substantial permanent damage hasalready occurred, at which time signs of liver failureand or cirrhosis are apparent. A minority of cases aredetected at an earlier stage, either as a result ofscreening of families for inherited liver disease or as aresult of abnormal liver function being found on bloodtests performed during a routine medical examination.The liver is the major organ involved in a numberof key metabolic processes. Damaged or reducedfunctional capacity can result in jaundice, hypogly-caemia, prolonged blood clotting, protein malnutri-tion, increased risk of infection, confusion, impairedlung and kidney function, fluid retention and fatigue.In addition, severe liver disease is often linked tovague symptoms such as malaise and fatigue, all ofwhich results in significant morbidity, greatly impair-ing an individual’s quality of life. Liver failure of anydegree, once present, is associated with a significantlyincreased risk of premature death.The major liver diseases from a public health perspec-tive are hepatitis C and B infection, alcoholic liverdisease, primary liver cancer and haemochromatosis.The substantial public health impact of chronic liverdisease can be gauged from the reported death rate per100 000 population, although the figures may not betruly representative as mortality figures are underesti-mated in some countries. Data are available for thecurrent EU states (Table 1).The differences observed between countries mainlyreflect regional variations in the incidence of hepatitisB and hepatitis C infection (Figure 1, 2). Unfortu-nately, comparative figures for countries on theeastern and southern borders of the European Unionare not available. However, World Health Organiza-tion data on the incidence of viral hepatitis per100 000 population clearly shows the very greatburden of hepatitis, even with the likelihood of under-reporting. The incidence of hepatitis C is reported as:Czechoslovakia 3.11, Estonia 26.65, Latvia 12.52,Russia 22.12, Ukraine 9.46, Croatia 3.38, Macedonia1.28, Albania 4.37; and of hepatitis B: Romania12.01, Russia 44.18, Ukraine 18.85, Belarus 9.34,Georgia 10.22, Moldavia 17.58, Yugoslavia 3.68.These data are relevant as several of these states arejoining the European Union in the near future, and inaddition many economic migrants and asylum seekerswho journey to the European Union originate fromthis part of the world. It would therefore appear thatboth hepatitis B- and C-induced liver damage areconditions that will account for significantly moremorbidity and mortality in the European Union in thefuture.

Psychiatric Assessment and Management of Deliberate Self-poisoning Patients

<h2>Abstract</h2> In the UK, deliberate self-poisoning is the most common reason for acute medical admission of women to hospital, and is second only to ischaemic heart disease for admission of men. In a family practice of 2500 patients, an average of five to seven per year will be referred to hospital after deliberate self-poisoning.

Heart failure in a multiethnic population in Kuala Lumpur, Malaysia.

There are established differences in cardiovascular disease in different racial groups. Worldwide, the literature regarding the clinical epidemiology of congestive heart failure (CHF) in non-white populations is scarce. To document the prevalence of CHF in the multiracial population of Malaysia, and to describe the clinical features and management of these patients. Busy city centre general hospital in Kuala Lumpur, Malaysia. Of 1435 acute medical admissions to Kuala Lumpur General Hospital over the 4-week study period, 97 patients (6.7%) were admitted with the primary diagnosis of CHF. Coronary artery disease was the main aetiology of CHF, accounting for almost half (49.5%) the patients, followed by hypertension (18.6%). However, there were variations in associated aetiological factors between ethnic groups, with diabetes mellitus affecting the majority of Indians-as well as underutilisation of standard drugs for CHF, such as the angiotensin converting enzyme (ACE) inhibitors, which were only used in 43.3%. Amongst acute medical admissions to a single centre in Malaysia the prevalence of CHF was 6.7%. Coronary artery disease was the major aetiological factor in heart failure accounting for almost half the admissions. The under-prescription of ACE inhibitors was similar to other clinical surveys carried out amongst Caucasian populations in the West.