Acute Medical Admissions Unit Research Articles

210 Screening for frailty in the Acute Medical Admissions Unit and examining referral patterns to physiotherapy

Abstract Background Frailty predisposes older people to adverse outcomes following hospitalisation. Physiotherapy can reduce the risk of adverse frailty-related outcomes including functional decline. Research examining frailty and physiotherapy referral in Acute Medical Units is limited. The objective of this study was to estimate the prevalence of frailty in older adults admitted to an Acute Medical Admissions Unit (AMAU), and to explore factors associated with early physiotherapy referral in the frail group. Methods A prospective cohort study was conducted in the AMAU of a large acute hospital in Ireland. Participants were those over 65 years who were admitted to the AMAU. All participants underwent frailty screening on admission using both the Clinical Frailty Scale and Program of Research to Integrate Services for the Maintenance of Autonomy-7 questionnaire. They were defined as frail if positive on at least one of the tools. Referral to physiotherapy and time to referral during hospitalisation was recorded. Multivariable logistic regression was used to explore factors associated with early physiotherapy referral (within 24 hours) for frail participants. Results 210 participants (mean age = 78.3 years, 51.9% female) were included. Frailty prevalence was 71% (n = 149) (95% CI = 64.3–77.0%). Within the frail group, 61.1% (n = 91) experienced early referral to physiotherapy, 15.4% (n = 23) were referred after >24 hours and 23.5% (n = 35) were not referred during hospitalisation. Falls history (Odds Ratio [OR]: 4.08; 95% Confidence Interval [CI]: 1.82–1.94), older age (OR: 1.05; 95%CI: 1.00–1.10) and mobilising with an aid or assistance (OR: 2.42; 95% CI: 1.11–5.27) were associated with early physiotherapy referral in the frail group. Sex and living alone were not. Conclusion Frailty screening in AMAU may increase identification of older people at risk of experiencing adverse outcomes. Routine referral to physiotherapy for people who are deemed frail would ensure more equal access to physiotherapy assessment and treatment which could reduce the risk of adverse outcomes including falls, functional decline, and frailty progression.

Cultural and religious barriers in the Middle East leading to delayed management of acute HIV case resulting in irreversible blindness: a case report.

A 26-year-old male who resides in a country in the Middle East visited the local general hospital emergency department on 17 July 2018. He presented with symptoms of persistent upper respiratory tract infection, dysphagia, and generalized fatigue. Denied any previous history of sexual contact, smoking, drinking, or using illicit drugs. This patient repeatedly attended the emergency department seeking medical attention and was treated for viral and bacterial upper respiratory tract symptoms by conservative and antibiotic therapy, yielded in short term relief but recurrence and worsening symptoms, especially dysphagia symptoms. On examination, the patient looked unwell, cachectic, and frail with normal vital signs and no positive findings on chest and abdominal examination; however, Ear Nose and Throat and oral examination revealed extensive oropharyngeal candidiasis. That is when he was suspected of having an immunodeficiency syndrome of some sort, and based on those serious findings, he was advised hospital admission for further investigations, diagnosis and management. The patient refused hospital admission against medical advice despite all the potential risks explained clearly, as he had a pre-planned family reunion holiday to Turkey, which was again strongly advised against as likely he will deteriorate while on holiday, but he went on with his plan, accordingly, oropharyngeal candidiasis was successfully treated with oral antifungal tablets, pending further investigations and definitive management. Then in 24 July 2018, he travelled to Turkey, where he developed symptoms of shortness of breath and dry a cough then he became systemically unwell and was admitted to a local hospital in Turkey where he was diagnosed with a lower respiratory tract infection and treated with intravenous antibiotics for 7 days; then on 6 August 2018, he flew back on an emergency flight to his home country, where he was admitted to the acute medical admission unit and arranged to have patient laboratory investigations. The results revealed positive HIV infection with a plasma HIV viral load was greater than 3000000 copies/ml, and advanced immunosuppression with CD3+/CD4+ T-lymphocyte was 40 cells/mm3. The social aspect of this case was apparent from denying sexual contact. The patient did not have any history of surgical operations, no family history of HIV infection, no previous blood transfusion, or use of contaminated syringes. By exclusion sexual mode of transmission is the only possible way of contracting HIV infection in this case, considering the fact that he was outside his country as single man for few years while studying. In the Middle East countries, due to religious and cultural reservations coupled with HIV diagnosis stigma, the diagnosis of the serious sexually transmitted infections such as HIV is usually delayed, as a result these patients will go on and develop late-stage disease and irreversible complications when diagnosed, entering the AIDS stage with rapid progression of irreversible complications like Cytomegalovirus, Ear Nose and Throat retinitis and blindness before they start definitive treatment. The oropharyngeal candidiasis and repeated upper and lower respiratory tract infections that are non-responding to therapy are usually red flag signs of immunosuppression, which warrants high clinical vigilance from the clinician side to take a detailed sexual history and rule out acute HIV infection by testing for it at early stages, in patients with high clinical suspicion , in addition to the other possible causes of immunosuppression. Therefore, assuring confidentiality, taking a careful sexual history and gathering data in an acceptable way for these patients and considering a holistic approach yield a better management outcome.

1103 AN EVALUATION OF A GERIATRICIAN-LED ACUTE MEDICAL ADMISSION UNIT AT MORRISTON HOSPITAL, SWANSEA

Abstract Introduction The medical intake at Morriston Hospital is accepted on two units; Rapid Assessment Unit (RAU) and Acute Medical Assessment Unit. Both were acute physician-led until July 2021 Method (Phase 1). From July 2021, RAU became geriatrician-led (Phase 2). This evaluation concerns the performance of RAU. Phase 1 (Acute Physician-Led Unit) Between 01/08/2020-30/06/2021, there were 3102 admissions with a median length of stay (LOS) of 2 days on RAU. 37.2% of patients were discharged directly from the unit. (SBUHB data). A detailed analysis of 496 patients consecutively assessed between November 2020–January 2021 showed a median LOS on RAU of 1, 28.8% were discharged directly from RAU. Overall health board (HB) median LOS for the cohort was 7. In over 70 years, median LOS on RAU was 1, overall HB LOS 9. Phase 2 (Geriatrician-Led Unit) 1237 patients were assessed July-December 2021, with a median LOS of 2 days. 42.8% of patients were discharged from RAU. (SBUHB data). A detailed analysis of 566 patients consecutively assessed between September-November 2021 showed a median LOS on RAU of 2, 41.7% discharged directly from RAU. Overall HB median LOS for the entire cohort was 5. For the > 70 years, median LOS on RAU was 2, overall HB LOS was 7. Patient flow through assessment areas is dependent on the function of downstream medical wards. Mean LOS within medicine at Morriston increased 1.5 days between Phase 1 and Phase 2. Results Acute geriatricians have delivered the 72hr LOS standard that SBUHB has set for assessment areas. The unit has achieved a reduction in overall LOS for the cohort of patients evaluated (p<.01), especially for the > 70 years (p=.007). Conclusion This data supported a change in practice; RAU has taken a frailty specific intake since January 2022.

The appropriateness of abdominal X-ray requests in the acute medical initial admissions unit.

Abdominal X-rays are frequently requested by clinicians in the Aberdeen Royal Infirmary acute medical initial assessment unit. The proportion of indicated abdominal X-rays requested within 24 hours of admission was retrospectively examined. This process was repeated after displaying an educational poster with the Royal College of Radiologists guidelines (cycle 2) and a graded assertive communication poster (cycles 3 and 4); a tool to enable junior doctors to challenge inappropriate requests for abdominal X-rays from seniors. Only 47.2% of abdominal X-ray requests were deemed appropriate in cycle 1. A 1.54% reduction in abdominal X-ray requests and an 11.5% increase in indicated abdominal X-rays were noted after cycle 2. Cycle 3 led to a statistically significant improvement with 2.6% fewer patients undergoing an abdominal X-ray and a 24.6% increase in indicated abdominal X-rays. This improvement was sustained in cycle 4. Promoting graded assertive communication is an effective means of helping junior doctors to challenge seniors requesting non-indicated abdominal X-rays.

What influences prescribing decisions in a multimorbidity and polypharmacy context on the acute medical unit? An interprofessional, qualitative study.

The primary aim of the study was to understand the mindset of doctors and pharmacists, as they embark upon prescribing in a multimorbidity and polypharmacy context during routine practice at a hospital acute admissions unit. The study also aimed to evaluate to what extent attitudes, embedded within real-life decision-making scenarios, relate to existing theory and models of prescribing decisions. Anonymized case studies were identified from the medical notes of patients aged 65 and over with conditions likely to be associated with multimorbidity, medication issues and polypharmacy: namely: fall, urinary tract infection, confusion or lower respiratory tract infection. A total of 39 doctors based on the acute medical admissions unit and 9 pharmacists were recruited to one of three focus groups. Patient case-studies provided the context for discussion from which verbatim transcripts were thematically analyzed using an interpretative, qualitative approach. Sub-themes were matched to Murshid and Mohaidin's proposed model of physician prescribing decisions. Seven principal themes were identified that were associated with prescribing decisions on the acute medical unit, namely, "patient characteristics," "drug characteristics," "pharmacist factors," "trustworthiness," "reliability of medication history," "competing priorities" and "responsibilities of prescribers." Prescribing decisions on the acute medical admissions unit were influenced by a variety of factors, some of which have already been acknowledged within existing theories and models. The findings provisionally offer new insights, which, subject to confirmation by further research, bring to light three attitudinal characteristics that may impact negatively upon the quality of prescribing decisions. These include, first, how perceived poor reliability of medication history may result in information gaps that compromise prescribing decisions; second, how competing priorities restrict doctors' aptitude to conduct a review of medication and finally, how doctors may rationalize the assignment of medication review to the GP.

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...

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.

Fifteen-year outcomes of an acute medical admission unit.

The Acute Medical Admission Unit (AMAU) model of care has been associated with improved short- and medium-term outcomes; whether these improvements are sustained remains unclear. We report on the 15-year outcomes of an AMAU in our institution. All emergency medical admissions between 2002 and 2016 were examined and 30-day in-hospital mortality, admission rates, readmission rates and length of stay (LOS) assessed. We used logistic and Poisson regression and margin statistics to evaluate outcomes. There were 96,305 admissions in 50,612 patients. By admission, the 30-day in-hospital mortality averaged 5.6% (95% CI 5.4 to 5.7%); there was a relative risk reduction (RRR) of 33.9% between 2002 and 2016, from 7.0 to 4.6% (p = 0.001), number need to treat (NNT) 41.9. By unique patient the 30-day in-hospital mortality averaged 10.5% (95% CI 10.3 to10.8%); there was a RRR of 61.7% between 2002 and 2016, from 15.1 to 5.8% (p = 0.001), NNT 10.7. The median LOS was 5.0days (IQR 2.1, 9.8) and was unaltered over time. Deprivation status strongly influenced the admission rate/1000 population increasing from Q1 7.7 (95% CI 7.6 to 7.8) to Q5 37.8 (95% CI 37.6 to 38.0); this showed a slight trend to increase over time. Total readmissions increased as a function of time; early readmissions (< 4weeks) remained constant 10.5% (95% CI 9.6 to 11.3). The 30-day in-hospital mortality showed a linear trend to reduce over the 15years following the institution of an AMAU; other key parameters were unaltered.

Intermediate-term and long-term mortality among acute medical patients hospitalized with community-acquired sepsis: a population-based study

Admission with severe sepsis is associated with an increased short-term mortality, but it is unestablished whether sepsis severity has an impact on intermediate-term and long-term mortality following admission to an acute medical admission unit. This was a population-based study of all adults admitted to an acute medical admission unit, Odense University Hospital, Denmark, from September 2010 to August 2011, identified by symptoms and clinical findings. We categorized the mortality periods into intermediate-term (31-180 days) and long-term (181-365, 366-730, and 731-1096 days). Mortality hazard ratios (HRs), comparing patients admitted with sepsis with those of a well-defined background population, were estimated using multivariable Cox regression. HRs were presented with 95% confidence intervals. In total, 621 (36.3%) presented with sepsis, 1071 (62.5%) presented with severe sepsis, and 21 (1.2%) presented with septic shock. Thirty-day all-cause mortality for patients with sepsis, severe sepsis, and septic shock was 6.1, 18.8, and 38.1%, respectively. The adjusted HR among patients with sepsis of any severity within the time periods 31-180, 181-365, 366-720, and 721-1096 days was 7.1 (6.0-8.5), 2.8 (2.3-3.5), 2.1 (1.8-2.6), and 2.2 (1.7-2.9), respectively. Long-term mortality was unrelated to sepsis severity [721-1096 days: sepsis HR: 2.2 (1.5-3.2), severe sepsis HR: 2.1 (1.5-3.0)]. Patients admitted with community-acquired sepsis showed high intermediate-term mortality, increasing with sepsis severity. Long-term mortality was increased two-fold compared with sepsis-free individuals, but might be explained by unmeasured confounding. Further, long-term mortality was unrelated to sepsis severity.

Improving handover between triage and locality wards in a large mental health trust

BackgroundSouth London and Maudsley NHS Foundation Trust is the largest mental health trust in the UK, serving four boroughs in South East London. In 2014, the ‘triage ward’ system was introduced in three boroughs. Similar to an acute medical admission unit, the triage ward would rapidly assess and treat all new admissions. The patients would either be discharged or admitted to a ‘locality ward’ for further treatment.ProblemThe unforeseen consequences of the ‘triage ward’ system were duplications and omissions of medical tasks on receiving wards, which affected efficiency and quality of care. This was due to a lack of formal medical handover. We aimed to improve efficiency and patient safety by formalising the junior doctor handover between triage and locality wards, ensuring every patient transferred had a documented handover in their electronic notes.MethodWe consulted our colleagues with a survey, ascertaining their views on the current system, the need for a more formalised system and what form that system should take. Using their feedback, we devised a handover template, to be completed for all patients transferred to locality wards. We then rolled the project out to the other two boroughs using the same methodology.ResultsA follow-up survey showed improvement in our baseline results and that the majority of transferred patients were formally handed over. Serious incident data showed a decrease in incident rates pre-intervention and post-intervention. The intervention was sustained a year later. The transfer of the intervention to other sites was problematic.DiscussionThe project showed the lack of handover was a concern shared by colleagues, and they considered our template a useful way of addressing this. The results suggested that the intervention was sustainable despite frequent rotations of staff. The difficulties in transferring an intervention to new sites are discussed.

209The Introduction of A Falls Huddle in an Acute Medical Admissions Unit

209The Introduction of A Falls Huddle in an Acute Medical Admissions Unit

A hyperacute neurology team – transforming emergency neurological care

We present the results of an 18-month study of a new model of how to care for emergency neurological admissions. We have established a hyperacute neurology team at a single district general hospital. Key features are a senior acute neurology nurse coordinator, an exclusively consultant-delivered service, acute epilepsy nurses, an acute neurophysiology service supported by neuroradiology and acute physicians and based within the acute medical admissions unit. Key improvements are a major increase in the number of patients seen, the speed with which they are seen and the percentage seen on acute medical unit before going to the general wards. We have shown a reduced length of stay and readmission rates for patients with epilepsy. Epilepsy accounted for 30% of all referrals. The cost implications of running this service are modest. We feel that this model is worthy of widespread consideration.

Readmission and mortality in patients discharged with a diagnosis of medical observation and evaluation (Z03*-codes) from an acute admission unit in Denmark: a prospective cohort study

BackgroundWe assessed the 30-day risk of readmission and mortality among patients receiving an International Classification of Diseases 10th edition diagnosis of medical observation and evaluation (Z03*) following admission to an acute medical admission unit (AMAU), stratified on any further specification of diagnosis during hospital stay.MethodsWe used Central Denmark’s (Midt)-Electronic Patient Journal to identify patients with a Z03*-diagnosis among patients admitted to the AMAU, Aarhus University Hospital Nørrebrogade from April 2012 to March 2013, and noted any specification of diagnosis. Patients were followed from hospital discharge until death, emigration, or completion of 30 days follow-up.ResultsOf 409 patients with an initial Z03* diagnosis at the AMAU, 55% (n = 226) received a more specific discharge diagnosis after transferral to other departments. Among patients discharged to home with a Z03*-diagnosis, 30% were readmitted within 30 days, while the corresponding figure was 23% for patients receiving a specific diagnosis (p = 0.06). In contrast, corresponding figures for 30-day mortality were 3% for Z03*-diagnosed patients and 10% for those who obtained a specific diagnosis (p = 0.003).ConclusionsPatients diagnosed with Z03* at hospital discharge have a substantially lower 30-day mortality, but a higher readmission-rate, compared to patients who obtain a specific diagnosis during the entire hospital stay.

P-43 Evaluation of opiate prescribing and adjustment in renal impairment in an acute medical admissions unit

Background Incorrect opioid prescribing can have significant consequences for patient safety and quality of care (1), adjustment of opioid is often needed in renal impairment (2,3). The audit aimed to assess if an acute medical assessment unit (AMU) was meeting current guidance regarding opioid prescribing in acute medical admissions Methodology A retrospective case note audit was conducted of all patients admitted to AMU who were prescribed an opioid from 1 st to 7 th March 2016. Notes were reviewed to establish: the opioid and dose prescribed; any change to an established opioid or dose on admission; initiation dose of opioid if opioid naive; any documentation of a rationale behind prescribing in impaired renal function. Laboratory results were reviewed to look for AKI and calculate eGFR. The audit standards used were the local trust guidelines (4) and the North of England Cancer Network Palliative Care Guidelines (5). Results 14 patients were prescribed an opioid and only 5 met the audit standards. 4 out of 6 opioid naive patients commenced on morphine IR solution were prescribed a dose higher than recommended. 1 of 5 patients on a long-acting opioid had a correct PRN dose prescribed. A half of patients with a reduced eGFR were prescribed morphine. There was no documentation regarding rationale behind opioid prescribing. Conclusion The results demonstrated that opioid prescribing on AMU did not adhere to local or regional guidance. Recommendations 1. Conduct a live audit of patients admitted to AMU over two weeks to expand data 2. Develop specific guidance for opioid adjustment in AKI and for initiating opioids in patients with a reduced eGFR on AMU. 3. Share audit findings and conduct teaching for acute medicine trainees regarding opioid prescribing in acute medical admissions. 4. Repeat audit after interventions taken place.

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.

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.

PTU-319 A prospective audit of alcohol screening in an acute medical admissions unit – are we meeting national targets?

<h3>Introduction</h3> Alcohol misuse can cause significant harm to an individual’s physical and psychosocial wellbeing costing the NHS £3.5 billion/year.¹Both NICE²and NCEPOD³recommend alcohol screening and appropriate referral to alcohol support services for all hospital patients. <h3>Method</h3> 100 unselected adult medical admission proformas were prospectively analysed against NICE/NCEPOD guidance. The presence and quality of alcohol screening was compared against the AUDIT-C screening tool. Documentation on advice given and referral to alcohol support services was also recorded. <h3>Results</h3> Of 100 admissions, 6 were directly alcohol related (4 in patients with known alcohol misuse). Overall 51% were not appropriately screened for alcohol misuse: 33% had no documented alcohol history and 18% categorised as “vague”. Only 3% of patients reported drinking above the recommended weekly amount. AUDIT-C screening (see Table 1below) on the same cohort identified 16% of patients with potentially harmful drinking (score 5+), none of whom were referred to alcohol services. <h3>Conclusion</h3> Alcohol screening in acute medical admissions is often vague or incomplete. Potentially at risk patients are not appropriately identified and referral to alcohol services needs improvement. Abbreviated screening tools such as AUDIT-C should be used to improve the sensitivity of alcohol screening and dedicated local alcohol care pathways are needed to reduce the burden of alcohol related admissions. As a result of this audit, an alcohol awareness day was held in January 2015 to educate both patients and staff on weekly recommended intake and effective alcohol screening. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Lifestyle Statistics, Health and Social Care Information Centre (2014) Statistics on Alcohol: England NICE (2010) Alcohol use disorders: preventing the development of hazardous and harmful drinking. NICE clinical guideline NCEPOD (2013) Alcohol Related Liver Disease: Measuring the Units

Evaluation of a consultant audit and feedback programme to improve the quality of antimicrobial prescribing in acute medical admissions.

This study aims to evaluate the effectiveness and acceptability of a pharmacist-led antimicrobial stewardship intervention, consisting of consultant performance audit and feedback, on antimicrobial prescribing quality. From October 2010 to September 2012, the prescribing performance of medical consultant teams rotating on the acute medical admissions unit was measured against four quality indicators. Measurements were taken at baseline then at quarterly intervals during which time consultants received feedback. Proportion of prescriptions adhering to each indicator was compared with baseline using paired sample z-test (significance level P < 0.01, Bonferroni corrected). Consultants' views were explored using anonymous questionnaires. Overall, 2609 antimicrobial prescriptions were reviewed. Improvement from baseline was statistically significant in all follow-up periods for two indicators: 'antimicrobials should have a documented indication in the medical notes' and 'antimicrobials should adhere to guideline choice or have a justification for deviation', reaching 6.0% (95% CI 2.5, 9.6) and 8.7% (95% CI 3.7, 13.7), respectively. Adherence to the indicator 'antimicrobials should have a documented stop/review prompt' improved significantly in all but the first follow-up period. For the indicator: 'antimicrobial assessed by antimicrobial specialists as unnecessary', improvement was statistically significant in the first (-4.7%, 95% CI -8.0, -1.4) and fourth (-4.2%, 95% CI -7.7%, -0.8%) periods. Service evaluation showed support for the pharmacist-led stewardship activities. There were significant and sustained improvements in prescribing quality as a result of the intervention. Consultants' engagement and acceptance of stewardship activities were demonstrated.

P92 Improving Diagnosis And Management Of Patients With Copd In The Acute Medical Admission Unit: A "right Care" Approach

Introduction COPD is the second most common cause of emergency admission and 5th cause of readmission to hospital. Appropriate identification and treatment is crucial to make every bed day count and reduce the burden of COPD. Characterising COPD exacerbations (ECOPD) and excluding differential diagnoses in acutely unwell co-morbid patients can be challenging. This study aimed to evaluate the accuracy of diagnoses/management of patients on the acute medical unit (AMU) in an inner London teaching hospital with 300 ECOPD admissions/yr, and to develop an improvement plan. Methods Admission records for COPD patients admitted acutely with increased shortness of breath, cough and/or wheeze over 6 weeks (Jan/Feb 2014) were reviewed. Diagnostic criteria and treatment were compared to national standards. 21 AMU junior staff completed a COPD knowledge questionnaire. An ECOPD pathway was developed, highlighting diagnostic and treatment differences between infective (IECOPD), non-infective COPD exacerbations (NIECOPD) and community acquired pneumonia (CAP), supported by electronic prescribing order sets. An online learning module was developed to support junior doctors. Results 44 COPD patients (26M, 18F) were admitted to AMU. 20% had an incorrect diagnosis. Of NIECOPD patients (20%): 66% received antibiotics; 11% did not receive prednisolone. Of IECOPD patients (47%): 65% received iv or incorrect oral antibiotics; 14% did not receive prednisolone. Of CAP patients (32%): in CURB Conclusion COPD patients commonly present acutely with ECOPD, NIECOPD or CAP. This can cause diagnostic uncertainty in an AMU setting. A right care approach focusing on accurate diagnosis first time and guideline based therapy, supported by joint working, education and electronic prescribing can improve staff knowledge and patient management.