Acute Medical Admissions Research Articles

Emergency admission preceding malignancy diagnosis: Insights from a study at a tertiary care hospital

BACKGROUND: A considerable number of cancer patients are diagnosed following presentation at emergency department with symptoms related to their condition, yet research in this area remains scarce. This study aimed to identify the clinical characteristics and evaluate the health outcomes of patients who presented to the emergency department with symptoms of cancer. MATERIALS AND METHODS: We analyzed data for patients diagnosed with cancer postemergency department presentation at a tertiary care hospital between 2015 to 2021. Data on patient characteristics, clinical features, and health outcomes was abstracted through meticulous review of the patients’ medical record. SPPS was used for data analysis. Wilcoxon rank-sum test and Chi-square or Fisher’s exact test as appropriate, were used to determine statistical significance for continuous and categorical variables, respectively. Regression analysis determined factors associated with treatment and mortality. Kaplein-Meier analysis was performed to determine survival time. RESULTS: During the study period, 108 patients were diagnosed with new malignancies following acute medical admission. The median age of these patients was 67 years (interquartile range [IQR]: 56–75), and 58 (53.7%) of these patients were men. The most common presenting complaints were pain (55.6%), weight loss (44.4%), and poor appetite (36.1%). The median time from the onset of symptoms to hospital presentation was 30 days (IQR 8–62). The most common types of malignancies diagnosed in the study were hepatobiliary (18.5%), gastroesophageal (15.7%), and lung cancer (14.8%). Two-thirds of patients had Stage IV malignancy, and 64.81% presented with distant metastatic disease at the time of diagnosis. Older age (69 vs. 61.5 years; P = 0.04), lower level of general education and higher attainment (11.4% vs. 44.4%; P < 0.01), advanced malignancy stages (P < 0.01), and metastatic disease at diagnosis (75.4% vs. 44.4%; P = 0.01) were associated with higher mortality. CONCLUSION: Emergency presentations for newly diagnosed cancer, often seen in older patients with lower education and multiple comorbidities, were generally associated with poor survival rates owing to advanced disease with distant metastasis. Enhancing awareness of critical symptoms could improve early detection rates.

Delirium Assessment And Documentation As Part Of An Acute Medical Admission

Abstract Background Delirium is a prevalent issue affecting older patients in acute hospitals. National guidelines mandate that all patients >65 years old admitted to an acute hospital setting are screened for delirium. Prompt assessment and management of delirium is vital in delivering optimal care to the older patient. In our institution, delirium can be under recognised and not assessed routinely as part of the medical admission. Our aim was to assess delirium documentation rates and utilising the 4AT as part of the acute medical admission in a service development project. Methods A retrospective assessment of patient demographics and documentation of delirium and 4AT in the medical admission was carried out for January, February and March 2023 and compared to the same 3-month period in 2024 post set up of a new specialist geriatric ward (SGW) as part of a service development project. This was in tandem to targeted interventions for improving delirium education and management. Results Mean age was 83 years in both groups. 11% (18/157) in the cohort pre SGW and 30% (40/134) post setup of the SGW had a diagnosis of dementia. 13% (20/157) in the pre SGW cohort had delirium documented in the admission note and 23% (31/134) post. 24% (32/134) had a 4AT documented in the admission note post SGW setup compared with 6% (10/157) previously. Conclusion There was suboptimal documentation of the 4AT and delirium in the acute medical admission note. An acute medical admission proforma is being developed and implemented in our institution which will include a 4AT delirium screening tool. We will reassess this in 6 months’ time to ascertain whether there is an improvement in delirium and 4AT documentation. We will also give education to the medical NCHD group carrying out the admissions to emphasise the importance of utilising the 4AT and delirium documentation.

Impact of Early Comprehensive Geriatric Assessment on Unscheduled Acute Medical Admissions through an Age Related Assessment Unit

Abstract Background Older patients often face prolonged hospital stays, leading to increased healthcare costs and potential complications. Comprehensive geriatric assessment (CGA) at the point of hospital entry may reduce length of stay (LOS) by addressing the multifaceted needs of older patients promptly. This study evaluates the potential impact of early targeted CGA on the length of hospital stay for older patients admitted unscheduled to our hospital. Methods A retrospective review of all admissions by our Age Related Assessment Unit (ARAU) Team was conducted from January to April 2024. A total of 82 admissions were analysed. Two patient pathways were identified: 84% (69 patients) were admitted via Pathway 1 for acute medical intervention only. 16% (13 patients) were admitted via Pathway 2 requiring acute medical admission plus additional care needs/supports to facilitate discharge. These 13 patients had inpatient stays exceeding 20 days, either requiring additional support for discharge (long-term care/home care package), or a period of rehabilitation. Results Patients on Pathway 1 had an average LOS of 6.6 days, in contrast to those on Pathway 2 who had an average LOS of 35.2 days. According to our annual hospital report from 2022, patients over 75 years old typically had an average LOS of 16.3 days. Conclusion Early commencement of a CGA enables a targeted approach for the effective treatment of older adults presenting via unscheduled care, significantly reducing the length of stay for patients on Pathway 1. This positively impacts patient outcomes by mitigating the risks associated with prolonged hospital admissions and lowering related costs. However, additional focus and resources are needed to further reduce the length of stay for patients requiring extra support to facilitate discharge from the acute care setting.

Discharge Destination, Mortality Outcomes and Rehabilitation Utilization, a One Year Follow Up of Frail Older Medical Inpatients

Abstract Background Patients with increasing frailty constitute a large proportion of acute hospital admissions. Deconditioning is a known complication of acute medical admission. This study reviews the outcomes for a population identified as frail during their admission, including utilisation of formal rehabilitation and discharge destination. Mortality rates at 6 and 12 months are also reviewed to assess if frailty could be used as a prognostication tool. Methods The patients selected were included in a hospital wide point prevalence study in 2023. Patients included were over 70 years of age and admitted under a medical team. Clinical frailty scale (CFS) score was recorded on all patients. The hospital electronic record provided information on transfer for formal rehabilitation, discharge home with home care package or discharge to long term care. The cohort were coded based on discharge destination. Mortality outcome at 6 and 12 months were also obtained via electronic record and RIP.ie. Results 233 patients were included, 177 (75.9%) were identified as frail. Only 8 (3.43%) of the group were discharged to formal rehabilitation. 52 (22.3%) were transferred directly to Long term care from hospital without a trial of formal rehabilitation. 8 of this group had specific rehab needs documents, all 8 were alive at 6 and 12 months. Approximately 40% of the total group had died within 12 months. Conclusion Rehabilitation benefits the individual patient and the health service as a whole, by impacting care needs and facilitating discharge home (Van Craen et al., 2010). This study has shown that approximately 1 in 4 patients over 70 were discharged directly to long term care without appropriate rehabilitation. Just over 3.4% of the group received formal rehabilitation outside of the acute hospital. This has highlighted the need to radically act on egress pathways to provide appropriate rehabilitation and care for our patients.

Reduced 30-day in-hospital but increased long-term mortality for weekend vs weekday acute medical admission

BackgroundAcute medical admission at the weekend has been reported to be associated with increased mortality. We aimed to assess 30-day in-hospital mortality and subsequent follow-up of all community deaths following discharge for acute medical admission to our institution over 21 years.MethodsWe employed a database of all acute medical admissions to our institution over 21 years (2002–2023). We compared 30-day in-hospital mortality by weekend (Saturday/Sunday) or weekday (Tuesday/Wednesday) admission. Outcome post-discharge was determined from the National Death Register to December 2021. Predictors of 30-day in-hospital and long-term mortality were analysed by logistic regression or Cox proportional hazards models.ResultsThe study population consisted of 109,232 admissions in 57,059 patients. A weekend admission was associated with a reduced 30-day in-hospital mortality, odds ratio (OR) 0.70 (95%CI 0.65, 0.76). Major predictors of 30-day in-hospital mortality were acute illness severity score (AISS) OR 6.9 (95%CI 5.5, 8.6) and comorbidity score OR 2.4 (95%CI 1.2, 4.6). At a median follow-up of 5.9 years post-discharge, 19.0% had died. The strongest long-term predictor of mortality was admission AISS OR 6.7 (95%CI 4.6, 9.9). The overall survival half-life after hospital discharge was 16.6 years. Survival was significantly worse for weekend admissions at 20.8 years compared to weekday admissions at 13.3 years.ConclusionWeekend admission of acute medical patients is associated with reduced 30-day in-hospital mortality but reduced long-term survival.

Multimorbidity-associated emergency hospital admissions: a “screen and link” strategy to improve outcomes for high-risk patients in sub-Saharan Africa: a prospective multicentre cohort study protocol

Background The prevalence of multimorbidity (the presence of two or more chronic health conditions) is rapidly increasing in sub–Saharan Africa. Hospital care pathways that focus on single presenting complaints do not address this pressing problem. This has the potential to precipitate frequent hospital readmissions, increase health system and out-of-pocket expenses, and may lead to premature disability and death. We aim to present a description of inpatient multimorbidity in a multicentre prospective cohort study in Malawi and Tanzania. Primary objectives Determine prevalence of multimorbid disease among adult medical admissions and measure patient outcomes. Health Economic: Measure economic costs incurred and changes in health-related quality of life (HRQoL) at 90 days post-admission. Situation analysis: Qualitatively describe pathways of patients with multimorbidity through the health system. Secondary objectives Determine hospital readmission free survival and markers of disease control 90 days after admission. Health Economic: Present economic costs from patient and health system perspective, sub-analyse costs and HRQoL according to presence of different diseases. Situation analysis: Understand health literacy related to their own diseases and experience of care for patients with multimorbidity and their caregivers. Methods This is a prospective longitudinal cohort study of adult (≥18 years) acute medical hospital admissions with nested health economic and situation analysis in four hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Malawi; 3) Hai District Hospital, Boma Ng’ombe, Tanzania; 4) Muhimbili National Hospital, Dar-es-Salaam, Tanzania. Follow-up duration will be 90 days from hospital admission. We will use consecutive recruitment within 24 hours of emergency presentation and stratified recruitment across four sites. We will use point-of-care tests to refine estimates of disease pathology. We will conduct qualitative interviews with patients, caregivers, healthcare providers and policymakers; focus group discussions with patients and caregivers, and observations of hospital care pathways.

Improving the efficiency of clerking patients under an acute medical admission by introducing allied healthcare professionals to the clerking process

Improving the efficiency of clerking patients under an acute medical admission by introducing allied healthcare professionals to the clerking process

Rates of venous thromboembolism associated with acute psychiatric admission: A retrospective cohort study.

The present study aimed to identify rates of venous thromboembolism (VTE) amongst patients treated in inpatient mental health units using linked primary care and mental health care records. Patients resident in the London Borough of Lambeth admitted to mental health units in Southeast London between January 2008 and March 2019 were included, as well as a control group of patients being treated in the community for mental illness. The primary outcome measure was a diagnosis of VTE being recorded in GP records during or within 3 months of an admission to a mental health unit. For 7,198 psychiatric inpatient admissions, 11 episodes of VTE (1.5/1,000 admissions) were identified, with no VTE cases identified in 4,561 patients being treated in the community for mental illness during an equivalent window. This finding indicates that VTE rates following psychiatric inpatient admission might be similar to those following unselected acute medical admission. Larger scale studies are required to confirm the estimated incidence of VTE in patients with mental health conditions and the contribution of acute psychiatry hospitalisation to VTE risk.

Multimorbidity-associated emergency hospital admissions: a "screen and link" strategy to improve outcomes for high-risk patients in sub-Saharan Africa: a prospective multicentre cohort study protocol.

The prevalence of multimorbidity (the presence of two or more chronic health conditions) is rapidly increasing in sub-Saharan Africa. Hospital care pathways that focus on single presenting complaints do not address this pressing problem. This has the potential to precipitate frequent hospital readmissions, increase health system and out-of-pocket expenses, and may lead to premature disability and death. We aim to present a description of inpatient multimorbidity in a multicentre prospective cohort study in Malawi and Tanzania. Clinical: Determine prevalence of multimorbid disease among adult medical admissions and measure patient outcomes. Health Economic: Measure economic costs incurred and changes in health-related quality of life (HRQoL) at 90 days post-admission. Situation analysis: Qualitatively describe pathways of patients with multimorbidity through the health system. Clinical: Determine hospital readmission free survival and markers of disease control 90 days after admission. Health Economic: Present economic costs from patient and health system perspective, sub-analyse costs and HRQoL according to presence of different diseases. Situation analysis: Understand health literacy related to their own diseases and experience of care for patients with multimorbidity and their caregivers. This is a prospective longitudinal cohort study of adult (≥18 years) acute medical hospital admissions with nested health economic and situation analysis in four hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Malawi; 3) Hai District Hospital, Boma Ng'ombe, Tanzania; 4) Muhimbili National Hospital, Dar-es-Salaam, Tanzania. Follow-up duration will be 90 days from hospital admission. We will use consecutive recruitment within 24 hours of emergency presentation and stratified recruitment across four sites. We will use point-of-care tests to refine estimates of disease pathology. We will conduct qualitative interviews with patients, caregivers, healthcare providers and policymakers; focus group discussions with patients and caregivers, and observations of hospital care pathways.

The association of demographics, frailty and multiple health conditions with outcomes from acute medical admissions to hospitals in England: exploratory analysis of an administrative dataset

Emergency and acute hospital services in England are under increasing pressure. The aim of this study was to investigate the association between key case-mix indicators and outcomes for adults admitted to hospital with an acute medical condition in England. All patients aged ≥16 years admitted to hospital in England as an acute unselected medical admission and who survived to discharge during the financial year 2021-2022 were included. Length of hospital stay was the primary outcome of interest. Data were available for 1,586,168 unique patients. A case-mix index was developed with a score that ranged from 0 to 12. Frailty was the most important variable in the index, followed by multiple health conditions and patient age. The mean case-mix score across hospital trusts in England ranged from 5.3 to 7.8. The case-mix index will support initiatives to better understand factors contributing to outcomes from acute medical admissions to hospital.

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.

Duration of consultant experience and patient outcome following acute medical unit admission: an observational cohort study

The effect of the duration of consultant experience on clinical outcomes in the acute medical unit (AMU) model remains unknown. Unscheduled AMU admissions (n=66,929) admitted by 56 consultant physicians between 2017 and 2020 to two large teaching hospital AMUs in Lothian, Scotland were examined. The associations of consultant experience on AMU with patient discharge, mortality, readmission and postdischarge death were calculated adjusting for clinical acuity, pathology and comorbidity. Increasing consultant experience was associated with a continuous increase in likelihood of early AMU discharge (odds ratio (OR) 1.08; 95% confidence interval (CI) 1.07-1.10; p<0.001 per 5 years' experience), which persisted after adjustment for confounders (OR 1.06; 95% CI: 1.01-1.11; p=0.01). There was no association with early readmission, death after discharge or 30-day inpatient mortality. The marginal effect estimate translates into 31 (95% CI: 25-36), 41 (95% CI: 30-53) and 52 (95% CI: 35-71) additional safe discharges per 1,000 admissions for clinicians of 15, 20 and 25 years' experience, respectively compared with those recently completing training. Increasing consultant physician experience associates with early safe discharge after AMU admission. These data suggest that the support and retention of experienced clinicians is vital if escalating pressures on unscheduled medical care are to be addressed.

Red Cell Distribution Width as a Prognostic Indicator in Acute Medical Admissions.

The red cell distribution width (RDW) is the coefficient of variation of the mean corpuscular volume (MCV). We sought to evaluate RDW as a predictor of outcomes following acute medical admission. We studied 10 years of acute medical admissions (2002-2011) with subsequent follow-up to 2021. RDW was converted to a categorical variable, Q1 < 12.9 fl, Q2-Q4 ≥ 12.9 and <15.7 fL and Q5 ≥ 15.7 fL. The predictive value of RDW for 30-day in-hospital and long-term mortality was evaluated with logistic and Cox regression modelling. Adjusted odds ratios (aORs) were calculated and loss of life years estimated. There were 62,184 admissions in 35,140 patients. The 30-day in-hospital mortality (n = 3646) occurred in 5.9% of admissions. An additional 15,086 (42.9%) deaths occurred by December 2021. Admission RDW independently predicted 30-day in-hospital mortality aOR 1.93 (95%CI 1.79, 2.07). Admission RDW independently predicted long-term mortality aOR 1.04 (95%CI 1.02, 1.05). Median survival post-admission was 189 months. For those with admission RDW in Q5, observed survival half-life was 133 months-this represents a shortfall of 5.7 life years (33.9%). In conclusion, admission RDW independently predicts 30-day in-hospital and long-term mortality.

Short- and long-term mortality following acute medical admission.

Short-term in-hospital mortality following acute medical admission has been widely investigated. Longer term mortality, particularly out-of-hospital mortality, has been less well studied. The aim of this study is to evaluate short- and long-term mortality, and predictors of such, following acute medical admission. Retrospective database study. We evaluated all acute medical admissions to our institution over 10 years (2002-11) with a minimum of a further 10 years follow-up to 2021 using the Irish National Death Register. Predictors of 30-day in-hospital and long-term mortality were analysed with logistic and Cox regression, with loss of life years estimated. The 2002-11 cohort consisted of 62 184 admissions in 35 140 patients. 30-Day in hospital mortality (n = 3646) per patient was 10.4% and per admission was 5.9%. There were an additional 11 440 longer-term deaths by 2021-total mortality was 15 086 (42.9%). Deaths post hospital discharge had median age at admission of 75.4 years [interquartile range (IQR) 63.7, 82.8] and died at median age of 80 years (IQR 69, 87). The half-life of survival following admission was 195 months-representing a short fall of 8 life years (32.9%) compared with the projected population reference of 24.3 years. Age [odds ratio (OR) 1.73 (95% confidence interval (CI) 1.64, 1.81)], acute illness severity score [OR 1.39 (95% CI 1.36, 1.43)] and comorbidity score [OR 1.09 (95% CI 1.08, 1.10)] predicted long-term mortality. Similar factors influence both short- and long-term mortality following acute medical admission, the magnitude of effect is attenuated over time.

Improving Transitional Care for Older Adults: Results of a Patient-Centred Quality Improvement Intervention.

The objective of this study was to evaluate the implementation and outcomes of a quality improvement intervention for older adults discharged from hospital to home, that used a patient-centred discharge education tool called the Patient-Centered Discharge Plan (PCAP). We conducted a pre-post evaluation of PCAP implementation among patients 65 years and older and discharged home from an acute medical or geriatric admission at two general hospitals. Two patient cohorts, PRE and POST, were analysed using administrative data (n = 3,309) and post-discharge structured interviews in a subset of patients (n = 326). Outcomes were 90-day readmissions and return emergency department (ED) visits, and transition experiences (10-item scale). The PCAP was provided to 20 per cent of 1,683 patients. Transition experience scores increased from PRE to POST at both hospitals (adjusted beta 1.3; 95% CI: 0.8, 1.7), and return ED visits declined in one of the two hospitals (adjusted decline 1.3%; 95% CI: -3.7, 6.2). In conclusion, dedicated resources are needed to support future PCAP implementation.

Predicting length of stay for acute medical admissions in New Zealand: the MALICE score.

Predicting length of stay (LoS) in hospital can help guide patient placement, facilitate rapid discharge and aid identification of patients at risk of prolonged stay, in whom early multidisciplinary intervention is warranted. We aimed to pilot the applicability of a modified decision aid (MALICE score) for predicting LoS for acute medical admissions at a New Zealand hospital. A prospective pilot study of 220 acute general medical admissions was performed. Clinical records were reviewed and MALICE scores were calculated for each patient and compared with LoS data using the Kruskal-Wallis H test. A statistically significant increase in LoS was seen with rising MALICE scores (H value 26.85, P < 0.001). MALICE scoring could be employed to guide patient placement and identify patients at risk of prolonged stays, though further study of bedside feasibility and applicability is required.

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.

Association Between Prehospital Blood Glucose Levels and Outcomes in Patients With COVID-19 Infection: A Retrospective Cohort Study.

Hyperglycaemia is associated with worse outcomes in many settings. However, the association between dysglycaemia and adverse outcomes remains debated in COVID-19 patients. This study determined the association of prehospital blood glucose levels with acute medical unit (intensive care unit or high dependency unit) admission and mortality among COVID-19-infected patients. This was a single-centre, retrospective cohort study based on patients cared for by the prehospital medical mobile unit from a Swiss university hospital between March 2020 and April 2021. All adult patients with confirmed or suspected COVID-19 infection during the study period were included. Data were obtained from the prehospital medical files. The main exposure was prehospital blood glucose level. A 7.8 mmol/L cut-off was used to define high blood glucose level. Restricted cubic splines were also used to analyse the exposure as a continuous variable. The primary endpoint was acute medical unit admission; secondary endpoints were 7-day and 30-day mortality. Multivariable logistic regressions were performed to compute odds ratios. A total of 276 patients were included. The mean prehospital blood glucose level was 8.8 mmol/l, and 123 patients presented high blood glucose levels. The overall acute medical unit admission rate was 31.2%, with no statistically significant difference according to prehospital blood glucose levels. The mortality rate was 13.8% at 7 days and 25% at 30 days. The 30-day mortality rate was higher in patients with high prehospital blood glucose levels, with an adjusted odds ratio of 2.5 (1.3-4.8). In patients with acute COVID-19 infection, prehospital blood glucose levels do not seem to be associated with acute medical unit admission. However, there was an increased risk of 30-day mortality in COVID-19 patients who presented high prehospital blood glucose levels.

Opioid-related deaths during hospital admissions or shortly after discharge in the United Kingdom: A thematic framework analysis of coroner reports.

People who use heroin and other illicit opioids are at high risk of fatal overdose in the days after hospital discharge, but the reasons for this risk have not been studied. We used the National Programme on Substance Abuse Deaths, a database of coroner reports for deaths following psychoactive drug use in England, Wales, and Northern Ireland. We selected reports where the death occurred between 2010 and 2021, an opioid was detected in toxicology testing, the death was related to nonmedical opioid use, and death was either during an acute medical or psychiatric hospital admission or within 14 days after discharge. We used thematic framework analysis of factors that may contribute to the risk of death during hospital admission or after discharge. We identified 121 coroners' reports; 42 where a patient died after using drugs during hospital admission, and 79 where death occurred shortly after discharge. The median age at death was 40 (IQR 34-46); 88 (73%) were male; and sedatives additional to opioids were detected at postmortem in 88 cases (73%), most commonly benzodiazepines. In thematic framework analysis, we categorised potential causes of fatal opioid overdose into three areas: (a) hospital policies and actions. Zero-tolerance policies mean that patients conceal drug use and use drugs in unsafe places such as locked bathrooms. Patients may be discharged to locations such as temporary hostels or the street while recovering. Some patients bring their own medicines or illicit opioids due to expectations of low-quality care, including undertreated withdrawal or pain; (b) high-risk use of sedatives. People may increase sedative use to manage symptoms of acute illness or a mental health crisis, and some may lose tolerance to opioids during a hospital admission; (c) declining health. Physical health and mobility problems posed barriers to post-discharge treatment for substance use, and some patients had sudden deteriorations in health that may have contributed to respiratory depression. Hospital admissions are associated with acute health crises that increase the risk of fatal overdose for patients who use illicit opioids. Hospitals need guidance to help them care for this patient group, particularly in relation to withdrawal management, harm reduction interventions such as take-home naloxone, discharge planning including continuation of opioid agonist therapy during recovery, management of poly-sedative use, and access to palliative care.

Frequent need for apixaban dose adjustment for atrial fibrillation in an unselected acute medical admission population during the COVID 19 pandemic

Abstract Funding Acknowledgements Type of funding sources: None. Background During the COVID-19 pandemic, systematic switching patients of eligible patients with atrial fibrillation from warfarin to direct oral anticoagulants (DOACs) was encouraged to simplify drug dosing and obviate the need for regular monitoring. Regional exclusions to switching included mechanical heart valves, moderate to severe mitral stenosis and stage 5 chronic kidney disease (estimated glomerular filtration rate [eGFR]&amp;lt; 15ml/min/1.73m2). However, each DOAC requires dose adjustment depending on renal function and other patient factors. Purpose Failure to dose reduce when indicated leads to excessive serum drug concentration and increased risk of major haemorrhage, particularly in patients who are acutely unwell. We thus quantified the likelihood of need for dose adjustment in an unselected acute medical admission population. Methods While on call, a single investigator prospectively identified all patients admitted on the acute medical or cardiology take-in between 1/12/21 and 1/2/22 who were taking apixaban for atrial fibrillation. Apixaban was selected as the study DOAC as it was the most commonly used DOAC but had the most complex dose adjustment algorithm and hence risk of dose error. In order to determine the appropriate drug dosage, patient age, weight, serum creatinine and eGFR were recorded. Dose reduction to 2.5mg was required if the patient meet 2 of the following 3 criteria of [age&amp;gt;80 years, weight &amp;lt;60kg, serum creatinine &amp;gt;133umol/l], or a single criterion, had an eGFR &amp;lt;30ml/min/1.73m2. Drug discontinuation was required if eGFR was &amp;lt;15ml/min/1.73m2. Results All patients identified (n=50) had a CHA2DS2-VASc score of ≥2. Patients with active COVID-19 infection were excluded. Mean age was 77.2 years (range 46-102). Mean weight was 78kg (range 52-101). Mean serum creatinine was 212umol/l (range 62-595). Mean eGFR was 33ml/min/1.73m2 (range 8 to &amp;gt;60). Of the 50 patients, 24 (48%) were taking the appropriate apixaban dose on admission which did not require dose adjustment (18 of whom were appropriately taking 5mg bd and 6 were taking 2.5mg bd). Dose reduction from 5mg bd to 2.5mg bd was required in 17 (34%) patients. Stopping treatment, at least temporarily due to eGFR&amp;lt;15ml/min/1.73m2, was indicated in 9 (18%) of patients. No patient required an increase in drug dose. (Graph 1) Conclusion Over half of acute medical or cardiology patients admitted within a COVID-19 setting and taking apixaban for atrial fibrillation required at least temporary drug dose adjustment or discontinuation. Clinicians should expect that adjustment of apixaban dose may be required during acute admission.