Acute Medical Admissions Research Articles

Substance misuse in acute general medical admissions.

We conducted a prevalence study of current substance misuse amongst acute general medical admissions, and compared the sociodemographic profile of this group of patients with total admissions and the local catchment population. Patients were included in the study if they were resident in the Lambeth, Southwark and Lewisham (LSL) Health Commission catchment area and were aged between 18 and 85 years. The prevalence of non-dependent misuse was of particular interest. Of 2988 acute admissions, 609 (20%) were identified as misusing alcohol and/or drugs, 277 (9%) being identified by the admitting doctor and 332 (11%) being identified by means of a Health and Lifestyle Questionnaire (HLQ) which included the Alcohol Use Disorders Identification Test (AUDIT). The majority 437 (72%) of the identified patients had an alcohol problem. A smaller proportion, 116 (19%) were currently using illegal drugs and 56 (9%) were polydrug users. Compared with patients who misused either drugs or alcohol, alcohol misusers were more likely to be older and Irish, whereas users of illegal drugs were more likely to be younger and Black. Significantly more 'at risk' drinkers were identified by the AUDIT questionnaire than by the admitting doctor. This study supports the policy of routine screening for health-damaging behaviours and the implementation of health promotion strategies in general hospitals.

Hypertension and renal failure in Kumasi, Ghana.

Hypertension is common in West Africa and likely to become more common as urbanisation increases. There are at present few facilities for the detection and management of hypertension so the influence it has on overall morbidity and mortality in the population is not clear. The objectives of the study were to assess: (a) renal disease and blood pressure related admissions and deaths among acute medical admissions to Komfo Anokye Teaching Hospital, Kumasi, during an 8-month period; and (b) the burden of renal disease among out-patient hypertensives at the same hospital. Ward admission books were examined in the four acute medical wards to ascertain admission diagnosis and cause of death (two 4-month periods in 1995 and 1996). Clinical assessment (blood pressure, plasma creatinine, proteinuria) was also made of 448 consecutive out-patient hypertensives seen between March 1995 and April 1996. Five hundred and ninety-three (17.9%) of 3317 acute medical admissions were ascribable to a cardiovascular cause (hypertension, heart failure, stroke); 171 (28.8%) of these died. One hundred and sixty-six (5.0%) had renal disease of whom 45 (27.1%) died, usually of end-stage renal disease. Among the 448 hypertensive out-patients, 30.2% (110 out of 365) had a plasma creatinine >140 micromol/l (48 > or = 400 micromol/l) and 25.5% (96 out of 376) had proteinuria. Eighty-nine of the 448 had a diastolic blood pressure > or =115 mm Hg; in this group 38 (42.7%) had a plasma creatinine of >140 micromol/l (and 18 or 20.2% > or =400 micromol/l). In conclusion, cardiovascular and renal disease are important contributors to morbidity and mortality among acute medical admissions to a large city hospital in Ghana. Among out-patient hypertensives renal disease is an important complication, especially in those with the more severe hypertension.

Oral Flora of Elderly Patients following Acute Medical Admission

The human oral microflora is diverse and is usually predominately composed of Gram-positive bacteria. It is uncommon to find Gram-negative bacilli (GNB) in healthy mouths. The incidence of infection with GNB rises in institutionalised, frail elderly subjects. There is also evidence of an association between intra-oral GNB presence and denture wearing. There have been few studies which have investigated intra-oral GNB carriage in acutely ill elderly patients. The aim of this study was to evaluate the oral flora of a group of elderly patients during an acute medical admission and to investigate any associations between the oral microflora and existing medical or oral factors. A total of 28 patients (17 females and 11 males; age: 74–93 years) on a care for the elderly ward were studied. Epidemiological data, detailed medical histories and oral examinations were undertaken. In addition, oral swabs of the palate area were taken to determine their oral flora. Twelve (43%) of the patients had GNB in their oral cavities. These patients were suffering from a variety of medical conditions and were on various drug regimes. There was a correlation between oral GNB presence and denture use. There was no association between GNB presence and denture hygiene. As oropharyngeal GNB colonisation can be associated with infections such as aspiration pneumonia, it is important in patients at risk that intra-oral organisms are identified and managed.

The management of acute headache in adults in an acute admissions unit.

There have been no previously published studies about acute admissions with headaches to a medical admissions ward. In our retrospective case-note study of all patients admitted with headaches to the acute medical admission ward of Ninewells Hospital, Dundee over a six-month period, there were 114 admissions with headache (2.4% of all admissions). CT scans were done in 68 (59.6%) and were abnormal in 21 patients. Twenty four patients (21.1%) had serious underlying causes for headaches. Predictors for CT abnormalities are discussed. Eighteen patients had lumbar punctures and six had abnormal results. Most patients were discharged after one day, nine were transferred to the neurosurgical unit and there were two deaths. Deficiencies in record keeping were identified as was a lack of precision in diagnosis. Changes in practice are needed to improve patient care and perhaps national guidelines are required.

DIAGNOSTIC TESTING FOR DRUG HYPERSENSITIVITY

Adverse drug reactions are important and frequent complications of medication therapy. Estimates are that 5% to 15% of patients develop adverse reactions to medication during treatment. 19,32 As many as 30% of hospitalized patients experience at least one adverse drug reaction. 10,32 Approximately 3% of all acute care medical admissions and 0.3% of all hospital admissions are attributed to adverse medication reactions. 19 Fatal drug reactions occur in 0.1% of medical in-patients and 0.01% of surgical in-patients. 19 Drug sensitivity has been implicated in 4.3% of deaths and 5.6% of cerebral damage in cases of anesthetic mishaps reported in the United Kingdom. 25 The first step in properly diagnosing adverse drug reactions is to understand the different types that can occur. There are certain adverse drug reactions that may occur in all individuals. 20 These reactions include overdoses, which are toxic reactions caused by excessive doses or impaired excretion or metabolism of a medication. Side effects are undesirable but are potentially unavoidable because of the pharmacologic action of the particular medication, such as tremors with use of beta agonists. Secondary effects are undesirable effects that are unrelated to the primary pharmacologic action of the medication, such as oral candidiasis secondary to the use of inhaled steroids. Drug interactions involve the interaction of two or more drugs causing toxicity that otherwise would not be present, such as that seen with the terfenadine–erythromycin interaction. Other adverse drug reactions occur only in susceptible patients in an unpredictable manner. These include drug intolerance, which is caused by a lower threshold to the normal pharmacologic action of a particular medication, such as tinnitus seen at low doses of salicylates in selected patients; idiosyncratic reactions, which usually result from a genetically determined metabolic or enzyme deficiency that is not expressed under normal situations, such as hemolytic anemia occurring in patients with glucose-6-phosphate dehydrogenase deficiency after receiving an oxidant drug; drug allergies that by definition involve immunologic mechanisms such as IgE penicillin anaphylaxis; and pseudo-allergies, which are reactions that have similar clinical manifestations as allergic reactions but the mechanism has been proven not to involve effector immune cells (antibodies or sensitized T lymphocytes). Allergic drug reactions (involving immunologic mechanisms) account for approximately 5% to 10% of adverse drug reactions. 5 Properly diagnosing an offending medication as a cause of an adverse drug reaction is often difficult. Multiple medications are sometimes in use at the same time, and the clinical symptoms of adverse drug reactions may overlap with symptoms of the underlying disease. A common example is a patient who develops an exanthem. It is often unclear if the cutaneous reaction is related to the antibiotic prescribed or to the underlying infectious process. Our general lack of knowledge of the immunochemistry of drug metabolism and immunoreactive metabolites also greatly hampers our ability to accurately use diagnostic tests to evaluate allergic drug reactions. Except for penicillin and to a lesser degree anticonvulsant medications and sulfonamides, our understanding of the immunoreactive metabolites and immunochemistry of medications is quite limited. At times we employ tests for drug-specific immune responses, but we lack knowledge of the positive and negative predictive value of these as diagnostic tests. This lack of knowledge is understandable because there are only a few studies in which large numbers of patients with negative and positive diagnostic tests have been rechallenged with the suspected medication. Despite these difficulties, it is worth attempting to diagnose immunologic drug reactions. It is important to define the causal agent to help guide the selection and use of future medications for a given patient and to properly manage the present adverse drug reaction. Labeling a patient inaccurately allergic to a medication may cause the future use of less effective or more toxic medications as substitutes for the preferred medication.

Delirium: prevalence, prognosis and management

Delirium has been recognized since ancient times and was first called delirium by Celsus in the first century AD. Variously termed delirium, phrenitis and lethargy, severe disturbances of thought, mood and action were often seen to be associated with physical disease. In the nineteenth century delirium developed into a rather broader description of confusion, a state which emphasized chaotic thinking and cognitive failure but which included what we now call dementia as well as confusion arising in the context of other functional psychoses. During the twentieth century the concept of delirium has continued to evolve. Kurt Schneider emphasized clouding of consciousness as central to delirium and this assumption has largely persisted. Delirium has developed as an acute condition, often precipitated by major medical illness. Increased interest in elderly people as a special group has led to the recognition that delirium is a frequent feature of acute medical admissions of elderly patients.

Some effects of the rising case load of adult HIV-related disease on a hospital in Nairobi.

Increasing numbers of HIV-infected adults in Africa need hospital care. It remains unclear what impact this has on health care services or on how hospitals respond. The aim of this study was to describe the effects of a rising case load of adult HIV-related disease by comparing results from a prospective cross-sectional study of acute adult medical admissions to a government hospital in Nairobi conducted in 1992 with results from a previous study done in 1988 and 1989 in the same hospital, using the same study design and protocol. Data on age, gender, number admitted, length of stay, HIV status, clinical AIDS, final diagnosis, case mix, and outcome were compared. In 1992, 374 consecutive patients were admitted in 15 24-hour periods (24.9 patients/period) compared with the 1988 to 1989 study, which enrolled 506 patients in 22 24-hour periods (23.0 patients/period). Patients' age, gender, and length of hospital stay were similar in both studies. In 1992, 39% of patients were HIV-positive compared with 19% in 1988 to 1989 (p < 10(-6)); whereas seropositive admissions rose 123% between the two periods (p < .0001), HIV-negative admissions declined 18% (p < .05). Clinical surveillance for AIDS consistently identified <40% of HIV-positive patients. Irrespective of HIV status, tuberculosis and pneumococcal pneumonia were the leading diagnoses in both surveys. No change was found in the diagnoses recorded for HIV-positive patients, but in HIV-negative patients, reductions were significant in the case mix (p < .00001) and range of diagnoses (p < .001) seen in 1992. Outcome remained unchanged for HIV-positive patients with approximately 35% mortality in both surveys. Outcome significantly worsened, in relative and absolute terms, for HIV-negative patients: in 1992, mortality was 23%, compared with 13.9% in 1988 to 1989 (p < .005), with 3.5 deaths per 24-hour period in 1992 compared with 2.6 deaths per 24-hour period in 1988 to 1989 (p < .05, one-tailed). These data suggest that increasing selection for admission is taking place as demand for care increases because of HIV/AIDS. This process appears to favor HIV-positive patients at the expense of HIV-negative patients who seem to be crowded out and, once admitted, experience higher mortality rates. The true social costs of the HIV epidemic are underestimated by not including the effects on HIV-negative people.

Pneumothoraces and chest drains: one year's experience

SUMMARY An audit of the management of pneumothoraces in acute medical admissions was conducted over one year to determine what intervention was effected and by whom. The group largely responsible for chest drain insertion was the senior house officers. This same group was found to be relatively inexperienced and largely unaware of the British Thoracic Society guidelines. Despite this, they were found to have a supervisory role for more junior staff. The authors have drawn attention to the difficulties in attaining experience and competence in performing this procedure. They have suggested the use of video training as an adjunct to clinical experience.

Acute Medical Admissions from Nursing Homes

Acute Medical Admissions from Nursing Homes

An Acute Medical Admission Unit: Is There a Place for an Occupational Therapist?

Since the Griffiths Report (1988), the profile of community care has risen. At the same time, economic constraints imposed on the health care system have led to increased pressure on acute hospital beds. This has had an effect on the nature of the occupational therapy service. At the Royal Infirmary of Edinburgh NHS Trust, a move has been taken to address this challenge by setting up an occupational therapy service in the Acute Medical Admission Unit (AMAU). This article examines the role of occupational therapy in this setting and provides details of a 6-month audit. It was identified that occupational therapy in this area enabled people to be discharged home successfully within a 48-hour period and, as a result of the early screening in the AMAU, the assessment of patients in the medical services began on average 3 days earlier.

Appropriateness of Acute Medical Admissions in the Elderly

Appropriateness of Acute Medical Admissions in the Elderly

Quality of General Practitioner Referral Letters for Acute Medical Admissions

Quality of General Practitioner Referral Letters for Acute Medical Admissions

Rising Acute Medical Admissions the Potential Role of the Geriatriclan

Rising Acute Medical Admissions the Potential Role of the Geriatriclan

Methicillin Resistance Staphyloccocus Aureus (Mrsa) in Elderly Acute Medical Admissions:- Morbidity, Mortality, Clearance and Relapse

Methicillin Resistance Staphyloccocus Aureus (Mrsa) in Elderly Acute Medical Admissions:- Morbidity, Mortality, Clearance and Relapse

ACUTE ADMISSIONS WITH HEART FAILURE TO A DISTRICT GENERAL HOSPITAL SERVING A MULTIRACIAL POPULATION

SUMMARYTo assess the incidence, clinical characteristics and current strategies in the management of patients with acute heart failure, we conducted a prospective survey of all acute medical admissions with heart failure to a district hospital serving a city centre population of 300,000 people in a multiracial community. Of 7451 such admissions, 348 (4.7%) were diagnosed as having acute heart failure: 265 Caucasian (76.1%), 27 black/Afro Caribbean (7.7%), 56 Indo‐Asian (16.1%). Complete clinical data were available from 260 patients. The main presenting symptom was dyspnoea in 233 patients (89.6%) and chest pain in 60 patients (23.1%); 139 patients (53.5%) had a history of ischaemic heart disease, 87 (33.5%) hypertension and 49 (18.8%) had diabetes; 103 patients (39.6%) had a previous history of heart failure; 75 patients (28.8%) were in atrial fibrillation. An echocardiogram was performed in 89 patients (34.2%). On admission, ACE inhibition was prescribed to only 78 patients (30.0). The diagnosis of heart failure was stated on the hospital inpatient data sheet (KMR‐1) in only 170 patients (65.4%). Following admission, 50 patients (19.2%) died while in the wards. Heart failure is a common problem among acute medical admissions and has a poor prognosis. The KMR‐1 diagnosis may underestimate the prevalence of heart failure.

Reducing acute medical admissions

Reducing acute medical admissions

Cross sectional study of contribution of clinical assessment and simple cardiac investigations to diagnosis of left ventricular systolic dysfunction in patients admitted with acute dyspnoea

Objective: To assess the comparative contribution of clinical assessment, electrocardiography, and chest radiography to the diagnosis of left ventricular systolic dysfunction in patients admitted to a general medical ward with...

ACUTE ADMISSIONS WITH ATRIAL FIBRILLATION IN A BRITISH MULTIRACIAL HOSPITAL POPULATION

SUMMARY To assess the clinical characteristics and management of patients with atrial fibrillation (AF), we performed a prospective survey of all acute medical admissions over six months to our hospital. Of 7451 such admissions, 245 had AF (110 male, 135 female; mean age 74.4 years). Of these, 213 were Caucasian, 10 black/Afro‐Caribbean and 22 Asian. Complete data were available for 185 patients. Of these, 82 had newly diagnosed AF, 83 had previous chronic AF and 20 had paroxysmal AF. The main presenting features was dyspnoea, stroke and syncope. A history of ischaemic heart disease was present in 64, heart failure in 46, hypertension in 51 and rheumatic heart disease in 13, while 31 had a previous stroke. Chest X‐ray showed cardiomegaly and pulmonary oedema in 121 patients, but was normal in 28. Echocardiography showed poor cardiac function in eight patients and enlarged left atria in five. Only 28% of those with previously diagnosed AF were on anticoagulation. Of the newly diagnosed patients, only 18% were started on anticoagulants. Cardioversion was attempted or planned in only 6%. The primary diagnosis on discharge was heart failure in 45, stroke in 24 and myocardial infarction in 12. AF remains a common arrhythmia among acute medical admissions and is commonly associated with heart failure and a high mortality. There is still a reluctance to start anticoagulant therapy or to perform cardioversion in such patients.

Patient and GP factors associated with emergency medical admissions to one UK district general hospital

Objectives: Despite international debate over growing pressures on hospital beds, particularly from rises in emergency admissions, there are few published data on the characteristics of patients admitted to hospital. Most research has attempted to explore the appropriateness of general practitioner (GP) admissions, yet even the proportion of emergency admissions made via the GP is not known. This study aimed to investigate GP and patient factors associated with acute medical admissions to one hospital in Birmingham, UK.Methods: A study was performed on all acute medical admissions made over one week to a district general hospital in Birmingham and local general practices referring acutely to it. Admissions were identified from routine hospital dataset and the information validated. Factors perceived as linked to admission were explored by semi-structured interview or postal questionnaire with the admitting doctors and with a proportion of patients. The subjects were 158 patients and the 84 GPs involved in a proportion of the admissions. Outcome measures were admission routes, diagnoses, linked medical and social factors.Results: Only 84 (53%) patients were admitted via their GP (or deputy). 47% were self-referrals or admitted via outpatients. Data on 16% patients could not be validated because of GP refusal (3 doctors, 15 patients) or untraceable doctor (10 patients). Most admissions were for respiratory problems (47, 30%), mainly cases of infective illness (13% all admissions, 43% respiratory). Cardiovascular disease involved 16% cases, principally myocardial infarction or angina. Drug overdose was the most frequent single diagnosis, almost 1 in 10 acute admissions. 69% of the GP admissions were over 65 years old (30% over 75) against 36% of the non-GP (p<0.01). Additional influences on GP admissions included: exacerbations of long-standing medical problems (29%); clarification of uncertain diagnoses (61%); and requests for advice (5%). Some admissions also resulted from social pressures including: pressure from carers (15%); visit occurred at night (4%); and even pressure from patients to avoid admission (8%). In 11% of cases, GP admission was stated as solely related to non-acute medical problems. The average length of stay was 10.6 days (range 1 to 120 days). Mean length of stay for patients admitted by a doctor was 13 days compared to 8 days for non-GP admissions (p=0.025). 13% of patients died during or shortly after admission.Conclusions: Most patients sent in by the GPs or selfreferring, in this small sample of urban emergency admissions, were admitted with serious medical problems, on the basis of the coded discharge diagnoses, and required extended hospital stays. GP admissions in this sample appeared a sicker, or less coping, cohort. There was evidence that GPs were attempting to maintain patients at home and felt that around 15% of their admissions might have been managed in some alternative ‘low technology’ environment.

Adverse drug reactions in a hospital general medical unit meriting notification to the Committee on Safety of Medicines.

1. We have retrospectively analysed data collected by a local adverse drug reactions reporting scheme in an acute hospital medical setting and have determined the numbers and types of reactions that would have merited notification as yellow card reports according to the guidelines of the Committee on Safety of Medicines. 2. The data related to 20,695 consecutive acute general medical admissions on seven general medical wards (140 beds) and were collected over 3 years, from April 1990 to March 1993. 3. Over 3 years there were 1420 reports of suspected adverse drug reactions, a rate of 68.7 per 1000 admissions. 4. If the guidelines for reporting issued by the Committee on Safety of Medicines had been strictly followed, 477 yellow cards would have been sent (23.1 per 1000 admissions). In 357 of these reports (74.8%), the reaction had caused admission to hospital. Only 31 of the 477 potential cards (6.5%) involved black triangle drugs and 10 of these were for minor reactions. 5. Only 30 of the 477 potential yellow cards (6.3%) were known to have been sent. The majority of those reactions not reported were for drug-related admissions, most of which were for well-known reactions to established drugs. 6. We have confirmed and quantified the extent of under-reporting of serious suspected adverse drug reactions to the Committee on Safety of Medicines from our hospital medical unit.