Acute Medical Admissions Research Articles

Monitoring respiratory rate in adults.

British Journal of NursingVol. 29, No. 1 ClinicalMonitoring respiratory rate in adultsBarry Hill, Sarah H AnnesleyBarry Hill(E-mail Address: [email protected])Senior Lecturer in Adult Nursing, Northumbria University, Newcastle upon TyneSearch for more papers by this author, Sarah H AnnesleySenior Lecturer in Adult Nursing, Northumbria University, Newcastle upon TyneSearch for more papers by this authorBarry Hill; Sarah H AnnesleyPublished Online:9 Jan 2020https://doi.org/10.12968/bjon.2020.29.1.12AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References British Lung Foundation. What causes breathlessness? 2019. https://tinyurl.com/rrmo4yd (accessed 6 December 2019) Google ScholarBritish Thoracic Society and Scottish Intercollegiate Guidelines Network. BTS/SIGN guideline for the management of asthma. SIGN 158. Revised 2019. https://tinyurl.com/y6quo7so (accessed 6 December 2019) Google ScholarCretikos MA, Bellomo R, Hillman K, Chen J, Finfer S, Flabouris A. Respiratory rate: the neglected vital sign. Medical Journal of Australia. 2008;188(11):657-659. https://doi.org/10.5694/j.1326-5377.2008.tb01825.x Crossref, Medline, Google ScholarDougherty L, Lister S. The Royal Marsden manual of clinical nursing procedures. Student edition. 8th edn. Oxford: Wiley-Blackwell; 2011 Google ScholarElliott M. Why is respiratory rate the neglected vital sign? A narrative review. International Archives of Nursing and Health Care. 2016;2(3):1-4. https://tinyurl.com/qo2sx33 (accessed 6 December 2019) Google ScholarGlobal Initiative for Asthma. Global strategy for asthma management and prevention. 2019. https://ginasthma.org/gina-reports (accessed 6 December 2019) Google ScholarHartley J. Respiratory rate 2: anatomy and physiology of breathing. Nursing Times. 2018;104(6):43–44 Google ScholarHunter J, Rawlings-Anderson K. Respiratory assessment. Nurs Stand. 2008;22(41):41–43. https://doi.org/10.7748/ns2008.06.22.41.41.c6576 Crossref, Google ScholarKelly C. Respiratory rate 1: why accurate measurement and recording are crucial. Nurs Times. 2018;114(4):23–24 Google ScholarMok W, Wang W, Cooper S, Ang EN, Liaw SY. Attitudes towards vital signs monitoring in the detection of clinical deterioration: scale development and survey of ward nurses. Int J Qual Health Care. 2015;27(3):207-13. https://doi.org/10.1093/intqhc/mzv019 Crossref, Medline, Google ScholarNational Clinical Guideline Centre. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update of CG12) (full original NICE guideline). 2010. https://tinyurl.com/txddga5 (accessed 6 December 2019) Google ScholarNational Institute for Health and Care Excellence. Breathlessness. 2017. https://cks.nice.org.uk/breathlessness#!scenario (accessed 6 December 2019) Google ScholarNational Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE guideline NG115. 2019a (updated from 2018). https://www.nice.org.uk/guidance/NG115 (accessed 6 December 2019) Google ScholarNational Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management (CG191). Pneumonia in adults: diagnosis and management. 2019b (updated from 2014). https://www.nice.org.uk/guidance/cg191 (accessed 6 December 2019) Google ScholarNHS website. Changes in the last hours and days: end of life care. 2019. https://tinyurl.com/tg83khp (accessed 6 December 2019) Google ScholarO'Driscoll BR, Howard LS, Earis J, Mak V for the BTS Emergency Oxygen Guideline Development Group. British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respiratory Research. 2017;4:e000170. https://doi.org/10.1136/bmjresp-2016-000170 Crossref, Medline, Google ScholarResuscitation Council UK. The ABCDE approach. 2019. https://tinyurl.com/RCUK-ABCDE-2019 (accessed 23 December 2019) Google ScholarRoyal College of Physicians. National Early Warning Score (NEWS) 2. 2017. https://tinyurl.com/y5kbsnoa (accessed 6 December 2019) Google ScholarSimpson H. Respiratory assessment. Br J Nurs. 2006;15(9):484-388. https://doi.org/10.12968/bjon.2006.15.9.484 Link, Google ScholarSubbe CP, Davies RG, Williams E, Rutherford P, Gemmell L. Effect of introducing the Modified Early Warning score on clinical outcomes, cardio-pulmonary arrests and intensive care utilisation in acute medical admissions. Anaesthesia. 2003;58(8):797–802. https://doi.org/10.1046/j.1365-2044.2003.03258.x Crossref, Medline, Google ScholarWatson F, Rebair A. The art of noticing: essential to nursing practice. Br J Nurs. 2014;23(10):514–517. https://doi.org/10.12968/bjon.2014.23.10.514 Link, Google Scholar FiguresReferencesRelatedDetails 9 January 2020Volume 29Issue 1ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 9 January 2020 Published in print 9 January 2020 Information© MA Healthcare LimitedPDF download

Prediction of general medical admission length of stay with natural language processing and deep learning: a pilot study.

Length of stay (LOS) and discharge destination predictions are key parts of the discharge planning process for general medical hospital inpatients. It is possible that machine learning, using natural language processing, may be able to assist with accurate LOS and discharge destination prediction for this patient group. Emergency department triage and doctor notes were retrospectively collected on consecutive general medical and acute medical unit admissions to a single tertiary hospital from a 2-month period in 2019. These data were used to assess the feasibility of predicting LOS and discharge destination using natural language processing and a variety of machine learning models. 313 patients were included in the study. The artificial neural network achieved the highest accuracy on the primary outcome of predicting whether a patient would remain in hospital for > 2days (accuracy 0.82, area under the received operator curve 0.75, sensitivity 0.47 and specificity 0.97). When predicting LOS as an exact number of days, the artificial neural network achieved a mean absolute error of 2.9 and a mean squared error of 16.8 on the test set. For the prediction of home as a discharge destination (vs any non-home alternative), all models performed similarly with an accuracy of approximately 0.74. This study supports the feasibility of using natural language processing to predict general medical inpatient LOS and discharge destination. Further research is indicated with larger, more detailed, datasets from multiple centres to optimise and examine the accuracy that may be achieved with such predictions.

Exploring Motivational Interviewing as a Technique for Physical Activity Promotion on an Acute Medical Unit Setting – A Qualitative Study

Research Question: Could the self-perceived physical activity levels of acute in-patients be improved by offering motivational interviews prior to discharge from the Acute Medical Unit: A Qualitative Study. Aims: To explore how the patients on an acute medical unit perceive Motivational Interviewing (MI) as a method of encouraging physical activity (PA) for them, in relation to any change in their perceived involvement in PA after 6-8 weeks and to explore patients’ feedback of motivational interview and their preferences as to its technique and manner of delivery to them. Methods: Participants were recruited from an acute medical admissions unit. Eligibility criteria was patients’ ability to walk 10m on the flat ground, with or without an aid and identified as being close to discharge by ward staff. Participants answered the Global Physical activity Questionnaire (GPAQ), following which they were offered MI by their bed side. 6-8weeks later, participants answered the same questionnaire and participated in a semi-structured interview, which was verbatim transcribed and analysed using an inductive thematic analysis. Ethical approval was gained from the London - Brighton & Sussex Research Ethics Committee and Local Human Research Authority (REC reference 18/LO/0496). Results: 7 out of 10 participants found MI, helpful at improving their participation in PA. Although certain barriers were identified that limited PA participation such as perceived fears, concerns and misconceptions of PA, where participants expressed preference for these barriers to be tackled individually in conjunction with motivational interview techniques. Conclusions: MI is a feasible method of encouraging PA, which could be impactful on the PA participation of the patients on an AMU. Future studies may consider combining approaches towards tackling perceived barriers in conjunction with MI when delivering this intervention to the patients in this setting.

Diffusion of knowledge and behaviours among trainee doctors in an acute medical unit and implications for quality improvement work: a mixed methods social network analysis

ObjectivesTo describe the social networks that diffuse knowledge, attitudes and behaviours relating to different domains of practice within teams of trainee doctors in an acute hospital medical setting. The domains...

Can Waterlow score predict 30-day mortality and length of stay in acutely admitted medical patients (aged ≥65 years)? Evidence from a single centre prospective cohort study

ObjectiveThis study aimed to explore the potential for the Waterlow score (WS) to be used as a predictor of 30-day mortality and length of hospital stay (LHS) in acutely admitted...

Differences in function and recovery profiles between patterns of multimorbidity among older medical patients the first year after an acute admission—An exploratory latent class analysis

IntroductionMultimorbidity is common among older people and may contribute to adverse health effects, such as functional limitations. It may help stratify rehabilitation of older medical patients, if we can identify differences in function under and after an acute medical admission, among patient with different patterns of multimorbidity. AimTo investigate differences in function and recovery profiles among older medical patients with different patterns of multimorbidity the first year after an acute admission. MethodsLongitudinal prospective cohort study of 369 medical patients (77.9 years, 62% women) acutely admitted to the Emergency Department. During the first 24 h after admission, one month and one year after discharge we assessed mobility level using the de Morton Mobility Index. At baseline and one-year we assessed handgrip strength, gait speed, Barthel20, and the New Mobility Score. Information about chronic conditions was collected by national registers. We used Latent Class Analysis to determine differences among patterns of multimorbidity based on 22 chronic conditions. ResultsFour distinct patterns of multimorbidity were identified (Minimal chronic disease; Degenerative, lifestyle, and mental disorders; Neurological, functional and sensory disorders; and Metabolic, pulmonary and cardiovascular disorders). The “Neurological, functional and sensory disorders”-pattern showed significant lower function than the “Minimal chronic disease”-pattern in all outcome measures. There were no differences in recovery profile between patients in the four patterns. ConclusionThe results support that patients with different patterns of multimorbidity among acutely hospitalized older medical patients differ in function, which suggests a differentiated approach towards treatment and rehabilitation warrants further studies.

Sensitivity of Administrative Coding in Identifying Inpatient Acute Strokes Complicating Procedures or Other Diseases in UK Hospitals.

BackgroundAdministrative hospital diagnostic coding data are increasingly used in “big data” research and to assess complication rates after surgery or acute medical conditions. Acute stroke is a common complication of several procedures/conditions, such as carotid interventions, but data are lacking on the sensitivity of administrative coding in identifying acute stroke during inpatient stay.Methods and ResultsUsing all acute strokes ascertained in a population‐based cohort (2002–2017) as the reference, we determined the sensitivity of hospital administrative diagnostic codes (International Classification of Diseases, Tenth Revision; ICD‐10) for identifying acute strokes that occurred during hospital admission for other reasons, stratified by coding strategies, study periods, and stroke severity (National Institutes of Health Stroke Score</≥5). Of 3011 acute strokes, 198 (6.6%) occurred during hospital admissions for procedures/other diseases, including 122 (61.6%) major strokes. Using stroke‐specific codes (ICD‐10=I60–I61 and I63–I64) in the primary diagnostic position, 66 of the 198 cases were correctly identified (sensitivity for any stroke, 33.3%; 95% CI, 27.1–40.2; minor stroke, 30.3%; 95% CI, 21.0–41.5; major stroke, 35.2%; 95% CI, 27.2–44.2), with no improvement of sensitivity over time (P trend=0.54). Sensitivity was lower during admissions for surgery/procedures than for other acute medical admissions (n/% 17/23.3% versus 49/39.2%; P=0.02). Sensitivity improved to 60.6% (53.6–67.2) for all and 61.6% (50.0–72.1) for surgery/procedures if other diagnostic positions were used, and to 65.2% (58.2–71.5) and 68.5% (56.9–78.1) respectively if combined with use of all possible nonspecific stroke‐related codes (ie, adding ICD‐10=I62 and I65–I68).ConclusionsLow sensitivity of administrative coding in identifying acute strokes that occurred during admission does not support its use alone for audit of complication rates of procedures or hospitalization for other reasons.

Reduced kidney function at presentation in unselected acute emergency medical admissions: incidence, outcome and associated factors

We sought to assess the impact of renal impairment on acute medical admissions and to identify potential contributory factors to admissions involving renal impairment at presentation. In a prospective cohort study, 29.5% of all acute medical emergency admissions had an eGFR &lt; 60 ml/min/1.73m2 at presentation. Of these, 19.9 % had definite chronic kidney disease and 8.4 % had definite acute kidney injury. Detailed analysis of a random subset of patients with an eGFR &lt;60ml/min/1.73m2 at presentation demonstrated that the major reasons for admission included falls, dehydration and fluid overload. 46% were on diuretics and 53% were on an ACEI or ARB or both. Gastrointestinal disturbance and recent medication changes were common and diuretic use persisted even with diarrhoea or vomiting.

Outcomes in acute medicine - Evidence from extended observations on readmissions, hospital length of stay and mortality outcomes

BackgroundThe Acute Medical Admission Unit (AMAU) model of care has been widely deployed, we examine changes in hospital readmission rates, length of stay (LOS) and 30-day in-hospital mortality over 16 years. MethodsAll emergency medical admissions between 2002 and 2017 were examined. We assessed 30-day in-hospital mortality, readmission rates, and LOS using logistic regression and margins statistics modelled outcomes against predictor variables. ResultsThere were 106,586 admissions in 54,928 patients over 16 years. Calculated per patient the 30-day in-hospital mortality was 8.9% (95%CI 8.6% to 9.2%) and showed a relative risk reduction (RRR) of 61.1% from 12.4% to 4.8% over the 16 years (p = .001). Calculated per admission the 30-day in-hospital mortality was 4.5% (95%CI 4.4% to 4.6%) with a RRR of 31.9% from 2002 to 2017. Over this extended period 48.7% of patients were readmitted at least once, 9.3% >5 times and 20 patients >50 times each. The median LOS was 5.9 days (IQR 2.4, 12.9) with no trend of change over time. Total readmissions increased as a time dependent function; early readmissions (<4 weeks) fluctuated without time trend at 10.5% (95%CI 9.6 to 11.3). A logistic regression model described the hospital LOS as a linear function both of comorbidity and the utilisation of inpatient procedures and services. Conclusion30-day in-hospital mortality showed a linear trend to reduce over time at unaltered LOS and readmission rates. LOS showed linear dependency on clinical complexity; interventions aimed at reducing LOS may not be appropriate beyond a certain point.

Greater illness severity characterises steroid diabetes following acute hospitalisation

Over 10% of hospital inpatients receive treatment with glucocorticoids and yet the incidence of steroid diabetes (SD), and therefore monitoring requirements, in these patients is unknown. Acute illness can also induce hyperglycaemia through neuroendocrine and inflammatory responses, which may be exacerbated by use of glucocorticoids. We determined the incidence of SD in acute medical admissions and whether SD corresponds to illness severity rather than to the dose of glucocorticoid administered.

Hospital avoidance: an integrated community system to reduce acute hospital demand.

Growth in emergency department (ED) attendance and acute medical admissions has been managed to very low rates for 18 years in Canterbury, New Zealand, using a combination of community and hospital avoidance strategies. This paper describes the specific strategies that supported management of acutely unwell patients in the community as part of a programme to integrate health services. Community-based acute care was established by a culture of close collaboration and trust between all sectors of the health system, with general practice closely involved in the design and management of the services, and support provided by hospital specialists, coordination and diagnostic units, and competent informatics. Introduction of the community-based services was aided by a clinical guidance website and an education programme for general practice teams and allied health professionals. Attendance at EDs and acute medical admission rates have been held at low growth and, in some cases, shorter lengths of hospital stay. This trend was especially evident in elderly patients and those with ambulatory care sensitive or chronic disorders. A system of community-based care and education has resulted in sustained gains for the Canterbury health system and freed-up hospital resources. This outcome has engendered a sense of empowerment for general practice teams and their patients.

Pilot Study of a Transitional Intervention for Family Caregivers of Older Adults.

The intervention aimed to provide emotional support, information on community resources, and information and support for development of coping skills for the caregivers of patients aged 65 and older who were to be discharged home from an acute medical hospital admission. We used a one-group, pre- and three-month post-test study design. Ninety-one patient-caregiver dyads were recruited. Of these, 63 caregivers (69%) received all five planned intervention sessions, while 60 (66%) completed the post-test. There were significant reductions in caregiver anxiety and depression following the intervention, and high rates of satisfaction. This transitional intervention should be further evaluated, preferably with a control group, either as a stand-alone intervention or as one component of a comprehensive transitional intervention for older patients and their caregivers.

Practices of Pediatric Nurses Versus Mothers Having Children With Respiratory Problems regarding Chest Physiotherapy

Background: Respiratory problems are the commonest illness of childhood they account for 30-40% of acute medical admission to the hospital in children Aim of the study: the aim of the study was to assess the practices of nurses versus mothers having children suffering from respiratory problemsregarding chest physiotherapy .Design: A descriptive design. Subjects & Methods: Thisstudy was conducted at emergency pediatric department and outpatient clinic and pediatric intensive care unit at Children's Hospital, affiliated to Ain Shams University's Hospital. The total sample was 150 pediatric nurses and 150 mothers having children suffering from respiratory problems. Tools: data collection involved: structured interviewing questionnaire sheet to assess characteristics of the studied nurses and mothers of children as well, their knowledge about chest physiotherapy, observation checklists to assess the practices of the pediatric nurses as well as mothers regarding the procedure of chest physiotherapy. Results: The present study revealed that, the mean age of the studied nurses 25.56±5.73, while, the mean age of the studied mothers was 26.07±2.04. There was statistically significant relation between characteristics nurses and their total level of Knowledge about chest physiotherapy. There was no statistically significant relation between characteristics of nurses' and their total level of practices regarding chest physiotherapy. Also, there was statistically significant relation between characteristics mothers and their Knowledge about chest physiotherapy. Conclusion: nurses and mothers were had satisfactory or sufficient regarding chest physiotherapy. Almost, the majority of studied nurses had incompetent or incorrect practice meanwhile; all mothers had incompetent practice regarding chest physiotherapy. there is difference between practices of nurses and mothers regarding chest physiotherapy for children suffering from respiratory problems Recommendation: Training programs should be on a regular basis for pediatric nurses with professional physiotherapists and conduction for awareness session about chest physiotherapy for mothers having children suffering from respiratory problems

Risk prediction for acute kidney injury in acute medical admissions in the UK.

Acute Kidney Injury (AKI) is associated with adverse outcomes; therefore identifying patients who are at risk of developing AKI in hospital may lead to targeted prevention. We undertook a UK-wide study in acute medical units (AMUs) to define those who develop hospital-acquired AKI (hAKI); to determine risk factors associated with hAKI and to assess the feasibility of developing a risk prediction score. Prospective multi-centre cohort study across 72 AMUs in the UK. Data collected from all patients who presented over a 24-h period. Chronic dialysis, community-acquired AKI (cAKI) and those with fewer than two creatinine measurements were excluded. Primary outcome was the development of h-AKI. Two thousand four hundred and fourty-six individuals were admitted to the seventy-two participating centres. Three hundred and eighty-four patients (16%) sustained AKI of whom two hundred and eighty-seven (75%) were cAKI and ninety-seven (25%) were hAKI. After exclusions, chronic kidney disease [Odds Ratio (OR) 3.08, 95% Confidence Interval (CI) 1.96-4.83], diuretic prescription (OR 2.33, 95% CI 1.5-3.65), a lower haemoglobin concentration and elevated serum bilirubin were independently associated with development of hAKI. Multi-variable model discrimination was only moderate (c-statistic 0.75). AKI in AMUs is common and associated with worse outcomes, with the majority of cases community acquired. Only a small proportion of patients develop hAKI. Prognostic risk factor modelling demonstrated only moderate discrimination implying that widespread adoption of such an AKI clinical risk score across all AMU admissions is not currently justified. More targeted risk assessment or automated methods of calculating individual risk may be more appropriate alternatives.

The Prevalence of Atrial Fibrillation Among Acute Medical Admission in Kuwait University Hospital in Sana'a City

Objectives: The aim of the study is to Determine, prevalence, possible risk factors, aetiology and outcome of patient with atrial fibrillation admitted into medical and cardiac units at Kuwait University hospital during 2014-2017. Methods and patients: Cross sectional retrospective review of all files of patients admitted to hospital during 2014 t0 2017. We reviewed 2030 Cardiac cases among which 179 were atrial fibrillation. Special form was designed to record general characters, risk factors &amp; out come during hospitalization. Results: The prevalence of atrial fibrillation (A F) was 8% (179/2030). The male to female ratio was 5:4 and their main age was 54±9. The common risk factors were ischemic heart disease, Qat chewer, hyperlipidemia, rheumatic heart disease and smoker represented to (46%,41%, 39%, 38%,38%) respectively. Transthoracic echo was performed for all patients and revealed that 92 (51.9%) had systolic dysfunction, while only 34(18.9%) patient had diastolic dysfunction. Mitral stenosis was detected in 30 (16.7%) patients among rheumatic heart disease (RHD). Regarding outcome of AF we found that 137(77%) was improved and discharged, while 42 (13.4%) was expired, however, 18 patients (10%) was referred to other hospitals. Conclusion: The prevalence of AF in this study was higher than that reported from other countries, and occurred in younger age group. Ischemic heart disease and RHD were prominent risk factors for AF in this study.

Lung function and outcomes in emergency medical admissions

BackgroundWe examine the ability of pre-existing measures of Forced Expiratory Volume in 1 s (FEV1), and Diffusion Capacity for Carbon Monoxide (DLCO) to determine the subsequent 30-day mortality outcome following unselected acute medical admission. MethodsBetween 2002 and 2017, we studied all emergency medical admissions (106,586 episodes in 54,928 patients) of whom 8071 were classified as respiratory. We employed logisitic multiple variable regression models to evaluate the ability of FEV1 or DLCO to predict the 30-day hospital mortality outcome. ResultsThe 30-day hospital episode mortality outcome demonstrated curvilinear relationships to the underlying FEV1 or DLCO values; adjusted for major outcome predictors, a higher FEV1 – OR 0.85 (95% CI: 0.82, 0.89) or DLCO OR 0.76 (95% CI: 0.73, 0.79) values predicted survival. The range of predicted mortalities was from 3.3% (95% CI: 2.5, 4.0) to 23.5% (95% CI: 20.8, 26.2); the FEV1 (Model1) and DLCO (Model2) outcome prediction was essentially equivalent (Chi2 = 2.9: p = 0.08). ConclusionThe 30-day mortality outcome was clearly related to the pre-admission FEV1 and DLCO value. The outcome relationship was curvilinear. Either parameter appears a useful tool to explore hospital outcomes. Previously suggested cut-points are likely an artefact and not supported by these data.

Incidence and outcomes of long QTc in acute medical admissions.

SummaryAimsProlonged QT interval on electrocardiogram (ECG) increases the risk of ventricular arrhythmia. Patients admitted to acute medical units (AMU) may be at risk of QT prolongation from multiple, recognised risk factors. Few data exist regarding incidence or outcomes of QT prolongation in acute general medical admissions.The aims were to determine the incidence of Bazett's‐corrected QT (QTc) prolongation upon admission to AMU; the relationship between QTc and inpatient mortality, length of stay and readmission; proportion with prolonged QTc subsequently administered QT interval‐prolonging drugs.MethodsRetrospective, observational study of 1000 consecutive patients admitted to an AMU in a large urban hospital. Exclusion criteria: age <18 years, ventricular pacing, poor quality/absent ECG . QTc determined manually from ECG obtained within 4‐hours of admission. QTc prolongation considered ≥470 milliseconds (males) and ≥480 milliseconds (females). In both genders, >500 milliseconds was considered severe. Study end‐points, (a) incidence of QTc prolongation at admission; (b) inpatient mortality, length of stay and readmission rates; (c) proportion with QTc prolongation subsequently administered QT interval‐prolonging drugs.ResultsOf 1000 patients, 288 patients were excluded, therefore final sample was n = 712. Patient age (mean ± SD) was 63.1 ± 19.4 years; females 49%. QTc prolongation was present in n = 50 (7%) at admission; 1.7% had QTc interval >500 ms. Of the 50 patients admitted with prolonged QTc, 6 (12%) were subsequently administered QT interval‐prolonging drugs. QTc prolongation was not associated with worse inpatient mortality or readmission rate. Length of stay was greater in those with prolonged QTc, 7.2 (IQR 2.4‐13.2) days vs 3.3 (IQR 1.3‐10.0; P = 0.004), however, in a regression model, presence of QTc did not independently affect length of stay.Conclusions QTc interval prolongation is frequent among patients admitted to AMU. QT interval‐prolonging drugs are commonly prescribed to patients presenting with prolonged QTc but whether this affects clinical outcomes is uncertain.

Physician and Parental Decision-Making Prior to Acute Medical Paediatric Admission.

Background: The number of acute medical paediatric emergency admissions is rising. We undertook qualitative interviews with parents and clinicians to better understand what factors, other than the health status of the child, may influence decision making leading to emergency admission. Methods: Semi-structured interviews were conducted with parents; clinicians working in general practice, out-of-hours or the emergency department (referring clinicians); and doctors working in acute medical paediatrics (receiving clinicians). Results: Ten parents, 7 referring clinicians and 10 receiving clinicians were interviewed. Parents described “erring on the side of caution” when seeking medical opinion and one mentioned anxiety. Among themes seen among referring clinicians, “erring on the side of caution” was also identified as was managing “parental anxiety” and acting on “gut instinct”. Among receiving clinicians, themes included managing parental anxiety and increasing parental expectations of the health service. Conclusions: The study of parent and referring clinician decision-making prior to a hospital admission can identify “teachable moments” where interventions might be delivered to slow or even arrest the rise in short-stay acute medical admissions in Britain and other countries. Interventions could assure parents or referring clinicians that hospital referral is not required and help clinicians understand what they perceive as “parental anxiety”.

WED 026 ‘creating a neurological exam template for acute medical admissions’

IntroductionThere is sub optimal documentation of neurological exam findings in patient’s hospital records. Documented Neurological findings are often incomplete, omitted or scattered in various places in the clinical notes. This is important in the setting of acute neurological emergencies, where accurate documentation is vital in gauging potential deterioration/improvement in a patient’s condition.MethodA chart review was performed on 80 patients referred to the Neurology consult service in St James’s Hospital between January-February 2018. All aspects of the Neurological exam findings documented in these charts were noted. A gold standard template for accurate recording of Neurological exam findings was then created and circulated to all Hospital NCHD’s. A repeat chart review was performed on 80 patients referred to Neurology Consults between March-May 2018 (following the circulation of this template) and results were compared.DiscussionRecord keeping varied according to different clinical parameters, being lowest for speech at just over 20% and highest for muscle power at over 70%. Globally there was a small but significant improvement (P Value&lt;0.001) in the documentation rates of neurological exam parameters following circulation of the template. We plan to apply this template to all acute medical admissions in St James’s Hospital.

The ICE-AKI study: Impact analysis of a Clinical prediction rule and Electronic AKI alert in general medical patients.

BackgroundAcute kidney injury (AKI) is assoicated with high mortality and measures to improve risk stratification and early identification have been urgently called for. This study investigated whether an electronic clinical prediction rule (CPR) combined with an AKI e-alert could reduce hospital-acquired AKI (HA-AKI) and improve associated outcomes.Methods and findingsA controlled before-and-after study included 30,295 acute medical admissions to two adult non-specialist hospital sites in the South of England (two ten-month time periods, 2014–16); all included patients stayed at least one night and had at least two serum creatinine tests. In the second period at the intervention site a CPR flagged those at risk of AKI and an alert was generated for those with AKI; both alerts incorporated care bundles. Patients were followed-up until death or hospital discharge. Primary outcome was change in incident HA-AKI. Secondary outcomes in those developing HA-AKI included: in-hospital mortality, AKI progression and escalation of care. On difference-in-differences analysis incidence of HA-AKI reduced (odds ratio [OR] 0.990, 95% CI 0.981–1.000, P = 0.049). In-hospital mortality in HA-AKI cases reduced on difference-in-differences analysis (OR 0.924, 95% CI 0.858–0.996, P = 0.038) and unadjusted analysis (27.46% pre vs 21.67% post, OR 0.731, 95% CI 0.560–0.954, P = 0.021). Mortality in those flagged by the CPR significantly reduced (14% pre vs 11% post intervention, P = 0.008). Outcomes for community-acquired AKI (CA-AKI) cases did not change. A number of process measures significantly improved at the intervention site. Limitations include lack of randomization, and generalizability will require future investigation.ConclusionsIn acute medical admissions a multi-modal intervention, including an electronically integrated CPR alongside an e-alert for those developing HA-AKI improved in-hospital outcomes. CA-AKI outcomes were not affected. The study provides a template for investigations utilising electronically generated prediction modelling. Further studies should assess generalisability and cost effectiveness.Trial registrationClinicaltrials.org NCT03047382.