Medical Assessment Unit Research Articles

Frail Elderly Pilot Programme Connolly Hospital Blanchardstown 2016

Introduction: The Specialist Geriatric Services (SGS) Model of Care aims to improve quality and efficiency of care for older people with complex health care needs. The Frail Elderly Pilot Programme commenced in Connolly Hospital Blanchardstown (CHB) in January 2016 to achieve these aims. It involves the early identification of the ‘frail older person’ with confusion, falls, poor mobility, swallowing problems, communication problems, poly-pharmacy, malnutrition and social factors which may warrant a comprehensive multidisciplinary assessment. Aim: The aim of the pilot programme was to improve the experience of the 'frail older person' in the Emergency Department (ED) and onward patient flow through CHB. Methods: The Frail Elderly Team was established within the ED and the Acute Medical Assessment Unit (AMAU) in CHB. Patients 75 years and over were screened for frailty indicators during core hours. Patients who presented with frailty received a comprehensive multidisciplinary assessment in the ED with rehabilitation and discharge pathways identified from the initial assessment. Frail Elderly care pathways and guidelines were implemented to improve quality, efficiency and outcomes for this cohort. To facilitate ED discharge, a rapid access pathway to the Day Hospital was established. Close links were forged with the Patient Flow Coordinator and Community Case Managers to facilitate transition of care and safe discharge. Results: A total of 738 patients received input from the Frail Elderly Team from January to September 2016. Referral reasons included functional, cognitive, social, swallowing, communication, nutritional assessment, falls and poly-pharmacy. Patients were categorised as mildly to moderately frail on average (5.5 Rockwood Clinical Frailty Scale). From January to March 2016 a preliminary analysis of 4AT results indicated 60% were positive for acute delirium +/- cognitive impairment. 31% of those referred to the Dietitian were at high risk of malnutrition according to actual and subjective Malnutrition Universal Screening Tool scores from February to June. Results will be presented from the data gathered from January - December 2016. Conclusions: The Frail Elderly Team aims to improve the quality and efficiency of care and outcomes for the frail elderly presenting to CHB. From the success of this pilot study, hospital management are continuing with this programme into the new year. The SGS will continue to provide education and leadership in relation to the identification of the frail older person, CGA and early discharge planning where possible of identified frail older people. Lessons learned: The Frail Elderly Team members have enhanced their knowledge of each disciplines' role and referral criteria through in-services. Education has been provided by the team to the wider hospital.

National Quality Assurance & Improvement System (NQAIS) – Medicine

Introduction: Length of stay varies by hospital, admission type, diagnosis and clinical team, while waiting lists, emergency department throughput and delayed discharges generate frustration for patients and health professionals. The National Acute Medical Programme (NAMP) was established in 2010 by the Royal College of Physicians of Ireland and the Health Service Executive (HSE) to enable: - Swifter access to senior decision makers - Swifter access to investigations and interventions - Reduced overnight admissions - Shorter average length of stay (AvLOS) - Optimal use of Acute Medical Assessment Unit (AMAU) NQAIS Medicine: NQAIS Medicine supports NAMP and hospitals to re-engineer care delivery based on interdisciplinary co-operation using timely and relevant data. The system was developed by Health Intelligence, Health & Wellbeing, Health Service Executive, in collaboration with NAMP and OpenApp. It is deployed under the governance framework of the Joint NQAIS (Surgery & Medicine) Steering Group. NQAIS Medicine is a web-enabled, role-based quality assurance and improvement system providing an evidence base to inform decisions. Innovative “diamond” plots (simplified box and whisker) and trend plots in easily understood “ribbons” are displayed by hospital (or group), admission category, diagnosis and clinical team. Patient profiles (age, co-morbidity, admission day/time etc.) can be flexibly explored. Selected records can be identified for chart review. The predictive impact of meeting targets are summarised by the novel computation of the potential “number of beds freed per day” which could be made available for other patients. The Clinical Classification System (CCS) - Agency for Healthcare Research & Quality (AHRQ) - converts the principal (admission) diagnosis into clinically meaningful groups. The Charlson Index is used to convert secondary diagnoses into a “complexity” score. AvLOS and readmission rates are dynamically analysed in the context of data-driven targets: AvLOS per CCS diagnosis as achieved by top quartile (Irish) teams; 50%+ all acute medical admissions should be routed via the AMAU of whom 25% should be discharged home. AvLOS is computed for each CCS nationally in the context of its trim point - national 75%ile + 3 X (25% – 75%ile). If the target AvLOS is achieved and AMAU usage optimised, the potential impact is translated into simple summary metrics - beds used within, close to and off target. These metrics identify and prioritise processes in hospital most likely to reveal potential learning and reengineering opportunities for using beds for other patients. Implementation: A train-the-trainers approach within hospital groups, guided by a national training team, supports the national deployment of the system. NQAIS Medicine combines science and art to provide detailed but very understandable feedback to unequivocally identify areas for review. Modest meeting of targets would transform a system struggling to cope with increasing demands. The successful implementation of NAMP, using NQAIS Medicine as a continuous improvement enabler, requires sustained focus and commitment from clinicians and management alike. The system is currently being deployed to all acute hospital in Ireland, and is being extended to encompass surgery and other domains within a single system referred to as NQAIS Clinical.

A protocol to evaluate the effectiveness of a nationwide Acute Medicine programme: examining what works, for whom, how, and in what circumstances.

Introduction: To address major deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established to optimize the management of acutely ill patients in the hospital setting, and ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure timely treatment in the most appropriate setting. To meet these aims, the NAMP has established four patient pathways: 1- Ambulatory care pathway - provides access to care and avoids admission by utilizing Acute Medical Assessment Units (AMAUs) 2- Medical short stay pathway - Short Stay Units (SSUs) for assessment and treatment up to 48 hours 3- Routine specialist in-patient pathways - efficient processing of patients with stays between 3 and 14 nights 4- Pathway for frailer and older patients with complex needs after discharge - appropriate care and discharge of complex patients Methods: Study design: This mixed method study will follow a realist evaluation approach to understand how implementation of NAMP has improved patient flow across care settings. To assess its impact, data on structures (e.g., patient flow through ED and the AMAUs, access to senior medical staff), processes (e.g., patient experience time ,length of stay, readmission rates), clinical outcomes and programme sustainability will be examined. This approach involves successive phases of data collection to first establish the underlying rationale for the NAMP and to specify intervention strategies to improve patient flow, secondly generate hypotheses about how the programme is working, and thirdly test these hypotheses using data from hospital administrative systems and interviews with frontline staff. Data sources: The evaluation will draw on multiple data sources: i- Documentary analysis Documents outlining new models of care and patient pathways, and programme reports will be analyzed to develop initial programme theories, identify interventions, and refine evaluation questions. ii- Qualitative data Focus groups and interviews with NAMP programme staff will be conducted to generate hypotheses about how the programme works in different contexts. ii- Hospital administrative datasets Hospital level datasets will be analyzed to examine structural and process outcomes. ii- Comparative case studies - mix of quantitative and qualitative data Six hospital sites will be purposively sampled based on their performance on process indicators. A value stream map will be created for each site and hospital specific documents (e.g., protocols, SOPs, hospital audits and surveys, staffing levels) will be reviewed to create a profile of each hospital. Interviews with front-line staff will be conducted to identify what aspects are working, for whom, how, and in what circumstances. Data analysis: Data will be analyzed using an explanatory sequential design. Quantitative data will firstly be analyzed to assess variation across hospitals, and qualitative research conducted to explain these results. Findings will be synthesised using analytic induction to develop middle range theory on how the programme leads to specific outcomes. Discussion: Evaluation of this large national programme will enable us to generate practical theory about how specific adaptations in hospital acute care pathways can promote effective patient flow through the continuum of care from presentation at the emergency department through safe discharge home.

015Deep Venous Thrombosis in Irish Older Adults Attending an Acute Medical Assessment Unit

015Deep Venous Thrombosis in Irish Older Adults Attending an Acute Medical Assessment Unit

Integrated Care for Emergency Medical Patients - Irish Acute Medicine Programme

Background: GPs experiencing access difficulties for medical patients in all hospitals. Hospitals only accepted admission referrals to ED Department, long waits experienced , admitted patients waited lengthy periods on trolleys. Patients most affected were older patients with co morbidities, delays resulting in unsafe practice and poor outcomes. Description of Programme: National Acute Medicine Programme established with the Royal College of Physicians. Objective to integrate Primary and Secondary care for emergency medical patients. Programme linked local General Practitioners and local hospital, redesigned medical flow, streamed acute patients away from ED to Acute Medical Assessment Units, to improve access. The programme also focussed on intense early treatment, shortening LOS, enabling early discharge. This resulted in more beds available to meet access demand and reduce trolley waits. Aim and theory of change: Triple Aim; Quality – patients were seen by senior doctor within 1 hour, direct access by GP. Patient Experience – patient journey shortened, trolley waits reduced. Value – increased ambulatory care, reduced admissions, shortened LOS, bed savings. Strategy for change; Governance Group; Local General Practitioners, specialists, managers formed. GPs referred directly to Acute Medical Assessment Unit (AMAU). Rapid assessment by senior clinicians in AMAU, “investigate to discharge” not “admit to investigate”. Detailed analysis of GP demand, hospital flows, capacity, discharge to general practice, rapid diagnostics, access to rapid OPD. Performance improvement cycles, monthly performance feedback workshops, coaching. Targeted population and stakeholders: Targeted population 250,000 medical admissions to the 33 Irish Hospitals. Stakeholders; GPs, medical consultants and hospital managers. Timeline: Programme designed 2010, ramped up over 7 years, now operational in each of the hospitals. Highlights: - Patient experience time reduced, 67% of hospitals now meeting target. - LOS reduced 1.6 days, freeing over 1000 medical beds. - Trolley waits reduced 17%. - GPs report improved access, GPs and patients report improved experience. - Improvements against a background of 30% increase in demand. Sustainability and Transferability: Programme ramped up to each hospital. Hospitals implementing the programme reliably achieved improvements, which were transferable to other hospitals. Discussion: The Programme demonstrated a national evidence based programme implemented across a whole health system, beneficial results aligning to the triple aim; improved quality, improved patient experience and improved value. Efficiencies gained allowed Irish Health Service to cope with the austerity measures successfully between 2010 and 2016 (34% reduction in hospital resources) and large increase in demand. Conclusion: Redesigned model between General Practitioners and acute services resulted in reorientation to ambulatory care and early discharge. This has allowed improved access for patients, improved patient experienced times, improved quality of service and improved value. Lessons Learned: - Importance of clinical leadership. - Critical local health network governance by General Practitioners, hospital clinicians, managers. - Analysis of each eco system flow model and capacity requirement. - Demonstration of power of data to change practice, regular feedback and coaching.

37 A weighty issue: nutritional screening in the amau

Background IrSPEN states that malnutrition affects ~145 000 adults at any time in Ireland, especially in chronic illness with >95% of malnourished being community based. HIQA’s Report “Review of Nutrition and Hydration Care in Public Acute Hospitals” suggests nutritional assessment within 24 hours of hospitalisation to identify high risk or malnourished patients. In 2011, The Acute Medical Assessment Unit (AMAU), CUH reviewed 5560 patients. Nutritional screening is routinely completed on admitted patients however it was unclear what nutrition details were being recorded on day patients. Aim To assess if nutritional screening is currently being performed in AMAU day patients. Method A chart review of 52 consecutive day patient discharges was undertaken examining recording of nutritional screening and weight loss history. Results 52 consecutive patient charts (19 males, 33 females) were examined with an average age of 53.4 years with an average of 1.46 co-morbidities. Weight was recorded on 36.5% of patients with 26.9% having a hydration status measured. A weight loss history was taken in 19.2% of patients, 40% of which listed weight loss as their presenting complaint. One patient had a BMI completed. A nursing pro-forma in relation to diet consumed was completed in 55.8% of patients. Conclusions Currently full nutritional screening is not being performed on AMAU day patients. An AMAU patient visit could represent a unique opportunity to nutritionally screen and intervene in high risk multimorbid ill community dwelling day patients. Current barriers to implementation of full nutritional screening include staff shortages, staff training and access to dietetics input if found to be at high risk.

Older persons who re-present to the Emergency Department: An observational study

BackgroundModels of emergent care evolve in response to an ageing population. The Medical Assessment Unit (MAU) receives patients from the Emergency Department (ED) for up to 48h to facilitate assessment, care and treatment before discharge home or to another inpatient unit. AimTo describe the clinical and social characteristics of older people who had a stay in the MAU and then re-present to the ED within 28days of discharge from hospital. MethodsA retrospective observational study design was used. Data were extracted from electronic medical records of older people who re-presented to two public teaching hospital EDs in Queensland, Australia, over a two-week period in 2014. FindingsThere were 78 older people who made 84 re-presentations. The average age was 79 years; average number of co-morbidities was seven (range 1–18); almost one-quarter (23%) lived alone; more (63%) were female; half (58%) were married; and one-fifth (20%) had some form of cognitive impairment. Of those who re-presented with the same diagnosis, 46% had cardio-respiratory conditions. One-quarter (28%) of the re-presenters had a discharge summary from the last admission. DiscussionMost of the re-presenters in this study had cardio-respiratory conditions. While a discharge summary was available, it was not consistently completed, raising the importance of discharge summaries as part of continuity across services for older people. ConclusionHow the ED, MAU and primary health services are coordinated bears further investigation. Research into the value of coordination roles, such as nurse navigators, for older people re-presenting to ED is recommended.

Recreational drug use and chemsex among HIV-infected in-patients: a unique screening opportunity.

While a high rate of recreational drug use (RDU) has been documented among HIV-infected out-patients, particularly in men who have sex with men (MSM), there is a distinct lack of data for HIV-infected in-patients. Hospital admission offers a unique opportunity to engage drug users. We aimed to establish and characterize RDU among new admissions to a large dedicated London HIV in-patient unit and compare it to RDU among general medical admissions to inform clinical pathways. A prospective opt-out survey was administered to all new HIV-positive admissions over a 10-week period (cases) and all medical Acute Assessment Unit admissions over two 24-h periods (controls). All provided consent for urine toxicology upon admission. Data were collected in 59 of 65 (91%) newly admitted HIV-positive individuals and in 48 of 54 (89%) non-HIV-positive medical admissions. HIV-infected in-patients were more likely than non-HIV-positive medical admissions to be male (P < 0.0001) (71% MSM), to be younger (P < 0.0001), to report current RDU (41 vs. 10%, respectively; P = 0.0001), to have a positive urine toxicology screen (19 vs. 2%, respectively; P = 0.0091) and to be a drug-related admission (15% vs. none; P = 0.004). Thirteen of 26 HIV-infected current recreational drug users admitted to sexualized drug taking and nine to injecting drugs. Twenty-seven per cent (seven of 26) were known to drug services. Crystal methamphetamine, mephedrone, gamma butyrolactone/gamma hydroxybutyrate and ketamine were exclusively taken by MSM. In total, 13 of 59 HIV-infected in-patients had current or past infection with hepatitis C virus, of whom 92% reported lifetime drug use. These data strongly support the use of formal screening and drug service referral pathways at the time of admission to hospital to engage HIV-positive drug users.

The Sydney Triage to Admission Risk Tool (START) to predict Emergency Department Disposition: A derivation and internal validation study using retrospective state-wide data from New South Wales, Australia.

BackgroundDisposition decisions are critical to the functioning of Emergency Departments. The objectives of the present study were to derive and internally validate a prediction model for inpatient admission from the Emergency Department to assist with triage, patient flow and clinical decision making.MethodsThis was a retrospective analysis of State-wide Emergency Department data in New South Wales, Australia. Adult patients (age ≥ 16 years) were included if they presented to a Level five or six (tertiary level) Emergency Department in New South Wales, Australia between 2013 and 2014. The outcome of interest was in-patient admission from the Emergency Department. This included all admissions to short stay and medical assessment units and being transferred out to another hospital. Analyses were performed using logistic regression. Discrimination was assessed using area under curve and derived risk scores were plotted to assess calibration.Results1,721,294 presentations from twenty three Level five or six hospitals were analysed. Of these 49.38% were male and the mean (sd) age was 49.85 years (22.13). Level 6 hospitals accounted for 47.70% of cases and 40.74% of cases were classified as an in-patient admission based on their mode of separation. The final multivariable model including age, arrival by ambulance, triage category, previous admission and presenting problem had an AUC of 0.82 (95% CI 0.81, 0.82).ConclusionBy deriving and internally validating a risk score model to predict the need for in-patient admission based on basic demographic and triage characteristics, patient flow in ED, clinical decision making and overall quality of care may be improved. Further studies are now required to establish clinical effectiveness of this risk score model.

Ensuring timely thromboprophylaxis on a Medical Assessment Unit

The Department of Health has defined hospital acquired venous thromboembolism (VTE) as any VTE event occurring within 90 days of hospital admission or surgery.1 Hospital acquired thrombosis (HAT) is common...

Managing risk during care transitions when approaching end of life: A qualitative study of patients’ and health care professionals’ decision making

Background: Increasing importance is being placed on the coordination of services at the end of life. Aim: To describe decision-making processes that influence transitions in care when approaching the end of life. Design: Qualitative study using field observations and longitudinal semi-structured interviews. Setting/participants: Field observations were undertaken in three sites: a residential care home, a medical assessment unit and a general medical unit in New Zealand. The Supportive and Palliative Care Indicators Tool was used to identify participants with advanced and progressive illness. Patients and family members were interviewed on recruitment and 3–4 months later. Four weeks of fieldwork were conducted in each site. A total of 40 interviews were conducted: 29 initial interviews and 11 follow-up interviews. Thematic analysis was undertaken. Findings: Managing risk was an important factor that influenced transitions in care. Patients and health care staff held different perspectives on how such risks were managed. At home, patients tolerated increasing risk and used specific support measures to manage often escalating health and social problems. In contrast, decisions about discharge in hospital were driven by hospital staff who were risk-adverse. Availability of community and carer services supported risk management while a perceived need for early discharge decision making in hospital and making ‘safe’ discharge options informed hospital discharge decisions. Conclusion: While managing risk is an important factor during care transitions, patients should be able to make choices on how to live with risk at the end of life. This requires reconsideration of transitional care and current discharge planning processes at the end of life.

Scoping review of medical assessment units and older people with complex health needs.

To explore current knowledge of medical assessment units (MAUs) with specific reference to older people with complex needs and to stimulate new topics and questions for future policy, research and practice. A scoping review was conducted using an integrated-latent thematic approach. This review provides a unique perspective on MAUs and older people which is framed using four themes: efficiency, effectiveness, equity and time. Eighteen articles were reviewed. Most (14) articles reported on efficiency and effectiveness while none reported explicitly on equity. Time was identified as a fourth, latent theme within the literature. Findings from this review indicate that future policy, research and practice relating to MAUs should focus on older people with complex needs, patient-centred metrics and those MAU characteristics most likely to deliver positive health outcomes to this particular cohort of patients.

Outcomes for family carers of a nurse-delivered hospital discharge intervention for older people (the Further Enabling Care at Home Program): Single blind randomised controlled trial

BackgroundHospital discharge of older people receiving care at home offers a salient opportunity to identify and address their family caregivers’ self-identified support needs. ObjectivesThis study tested the hypothesis that the extent to which family caregivers of older people discharged home from hospital felt prepared to provide care at home would be positively influenced by their inclusion in the new Further Enabling Care at Home program. DesignThis single-blind randomised controlled trial compared outcomes from usual care alone with those from usual care plus the new program. The program, delivered by a specially trained nurse over the telephone, included: support to facilitate understanding of the patient’s discharge letter; caregiver support needs assessment; caregiver prioritisation of urgent needs; and collaborative guidance, from the nurse, regarding accessing supports. Setting and participantsDyads were recruited from the medical assessment unit of a Western Australian metropolitan public hospital. Each dyad comprised a patient aged 70 years or older plus an English speaking family caregiver. MethodsThe primary outcome was the caregiver’s self-reported preparedness to provide care for the patient. Data collection time points were designated as: Time 1, within four days of discharge; Time 2, 15–21days after discharge; Time 3, six weeks after discharge. Other measures included caregivers’ ratings of: their health, patients’ symptoms and independence, caregiver strain, family well-being, caregiver stress, and positive appraisals of caregiving. Data were collected by telephone. ResultsComplete data sets were obtained from 62 intervention group caregivers and 79 controls. Groups were equivalent at baseline. Needs prioritised most often by caregivers were: to know whom to contact and what to expect in the future and to access practical help at home. Support guidance included how to: access help, information, and resources; develop crisis plans; obtain referrals and services; and organise legal requirements.Compared to controls, preparedness to care improved in the intervention group from Time 1 to Time 2 (effect size=0.52; p=0.006) and from Time 1 to Time 3 (effect size=0.43; p=0.019). These improvements corresponded to a change of approximately 2 points on the Preparedness for Caregiving instrument. Small but significant positive impacts were also observed in other outcomes, including caregiver strain. ConclusionsThese unequivocal findings provide a basis for considering the Furthering Enabling Care at Home program’s implementation in this and other similar settings. Further testing is required to determine the generalisability of results.

Isolated thrombosis of the vein of Labbe – Clinical and imaging features

Abstract We report the case of a normally fit and well 27 year old female, who presented to the Medical Assessment Unit with ongoing headaches, photophobia nausea and one episode of vomiting. Cranial Computed Tomography identified a wedge shape low density area in the right temporal lobe consistent with a venous infarct, which contained areas of acute haemorrhage. Further cranial magnetic resonance imaging confirmed the diagnosis of a thrombosed vein of labbe. This is a rare clinical finding. Her only risk factor was the recent commencement of the combined oral contraceptive pill. She was commenced on low molecular weight heparin and warfarin. Serial six month imaging revealed complete resolution of the thrombus.

Do daily ward interviews improve measurement of hospital quality and safety indicators? A prospective observational study.

The aim of this study was to determine if the addition of daily ward interview data improves the capture of hospital quality and safety indicators compared with incident reporting systems alone. An additional aim was to determine the potential characteristics influencing under-reporting of hospital quality and safety indicators in incident reporting systems. A prospective, observational study was performed at two tertiary metropolitan public hospitals. Research assistants from allied health backgrounds met daily with the nurse in charge of the ward and discussed the occurrence of any falls, pressure injuries and rapid response medical team calls. Data were collected from four general medical wards, four surgical wards, an orthopaedic, neurosciences, plastics, respiratory, renal, sub-acute and acute medical assessment unit. An estimated total of 303 falls, 221 pressure injuries and 884 rapid response medical team calls occurred between 15 wards across two hospitals, over a period of 6 months. Hospital incident reporting systems underestimated falls by 30.0%, pressure injuries by 59.3% and rapid response medical team calls by 17.0%. The use of ward interview data collection in addition to hospital incident reporting systems improved data capture of falls by 23.8% (n = 72), pressure injuries by 21.7% (n = 48) and rapid response medical team calls by 12.7% (n = 112). Falls events were significantly less likely to be reported if they occurred on a Monday (P = 0.04) and pressure injuries significantly more likely to be reported if they occurred on a Wednesday (P = 0.01). Hospital quality and safety indicators (falls, pressure injuries and rapid response medical team calls) were under-reported in incident reporting systems, with variability in under-reporting between wards and the day of event occurrence. The use of ward interview data collection in addition to hospital incident reporting systems improved reporting of hospital quality and safety indicators.

Redefining the patient-carer model at end of life.

While the patient-carer dyad has been broadly described, there is little exploration of patient-carer models in use. To explore types of patient-carer models in use for those with advanced and progressive disease. Qualitative interviews were undertaken with patients at risk of dying in the next year and their carers across three sites (residential care home, medical assessment unit, general medical unit). Thematic analysis was undertaken. Four patient-carer models were identified. In these, the provision of care and of coordination of care services were important areas and organised differently across the patient, the carer, and alternative sources of support. A 'one size fits all' patient-carer model is outdated and a new understanding of different types of patient-carer models are required to fully inform care delivered at end of life.

Side rooms on the medical assessment unit – safety versus privacy and dignity

To assess if patients have been appropriately allocated to side rooms on the acute medical unit (AMU), along with how this impacted the workings of the AMU with a 25% side room capacity, in contradiction to current Derpartment of Health guidance of having 50–100% side room capacity. A sequential

PWE-127 The Extended Effect of An Alcohol Liaison Nurse Service on Attendance at A County’s Emergency Departments: A 3 Year Retrospective Cohort Study

Introduction Worcestershire Acute Hospitals NHS Trust has an Alcohol Liaison Nurse Service (ALNS) across two hospital sites, with two full-time ALNs providing screening, case management support, brief interventions (BI) and referrals into community treatment services. We performed a retrospective cohort study to assess the impact of the ALNS on emergency departement (ED) re-attendance over a 3 year period and estimated the cost saving using the 2012/3 reference costs. Methods All patients who had attended the ED, surgical or medical assessment units and received a BI delivered by the ALNS over a 3 month period, between January to March 2012, was identified via hospital records (Patient First ED computer system and OASIS). Patient attendances to ED for the preceding 12 month period were compared with the 12 month periods after the BI over the following 3 years. Patients were excluded if they lived outside the trust catchment area or were imprisoned or died during the study period. Costs of attendances to ED over the period were estimated as £114 per visit. Statistical analysis was by paired t-test. Results 192 patients (123 males & 69 females) identified as having a BI were included in the cohort. 36 were excluded due to death within the study period and 4 due to incarceration. The median age of the cohort was 44 years (range 17–87 years). The most common reason for presentation related to mental health issues including deliberate self harm and overdose. During the 12 month period before ALNS intervention there were 464 qualifying ED attendances with an average of 2.42 attendances per patient. In the first 12 months following BI, the ED attendance rate fell to 327 (1.7 attendances/patient), and then to 255 in the second 12 months (1.33 attendances/patient), and finally 225 in the third 12 months following BI (1.17 attendances/patient). The reduction in attendance was statistically significant 12 months after intervention compared with the preceding year (p For this 3 month cohort of 192 patients, the cost of ED attendance in the year before BI was estimated at £52, 896. By the end of the study period this had been reduced by 51.5% (twelve monthly cost estimates £37,278, £29,070 and £25,650). Conclusion This pragmatic study suggests that an ALNS may have a sustained effect upon the number and cost of ED attendances. Reference 1 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/261154/nhs_reference_costs_2012-13_acc.pdf Disclosure of Interest None Declared

Mucosal erosions as the presenting symptom in erythema multiforme: a case report

Erythema multiforme (EM) is an acute and self-limiting hypersensitivity reaction. This article describes the case of a patient who suffered from a chest infection and later presented with the mucosal manifestations of EM. This condition manifests as skin lesions, most commonly in reaction to herpes simplex virus (HSV) 1 and 2, Mycoplasma pneumoniae , or certain medications.1 A 31-year-old male patient presented to his GP with cough and fever, sores in his mouth, and itchy eyes. He had not received any medical attention prior to this appointment, nor had he taken any recent medications. He was initially prescribed aciclovir to treat oral herpes simplex infection, amoxicillin for chest infection, and chloramphenicol for conjunctivitis. Two weeks later he was seen by the medical assessment unit. In addition to blisters on his mouth and lips (Figure 1), he developed pruritic blisters on his penis and foreskin (Figure 2), small lesions acrally, and red eyes. On this basis the consultant medical physician referred the patient to the genitourinary medicine (GUM) clinic to rule out sexually-acquired reactive arthritis (SARA) secondary to chlamydia infection. Figure 1. Erosions of the oral mucosa in a case of erythema multiforme. Figure 2. Erythema multiforme-associated …

Current Practice of Hospital Acquired Thrombosis (HAT) Prevention in an Acute Hospital (a single centre cross sectional study)

BackgroundEvidence based consensus guidelines for venous thromboembolism (VTE) prevention are broadly accepted to be effective and safe for more than three decades (Clagett GP et al, 1992). However VTE continues to be associated with a major global burden of disease with 3.9 million cases of HAT during one year among 1.1 billion citizens of high income countries (Jha AK et al, 2013). Therefore prevention is the key to reduce death and disability resulting from VTE (Kahn S et al, Gould MK et al & Falck-Yitter Y et al, 2012). Ireland like many other countries has yet to implement a mandatory risk assessment tool and thromboprophylaxis (TP) policy nationally.AimsThe aim of this study was to calculate the proportion of inpatients who had a VTE risk assessment performed and received appropriate TP in a large tertiary referral hospital. This information will be vital for baseline data for implementation of a new national policy for prevention of HAT.MethodsThis audit was performed at Cork University Hospital on 4 pre specified days between November 2014 to February 2015. All adult inpatients (Medical and Surgical) excluding maternity and psychiatric were included. Patients on therapeutic anticoagulation were also excluded. The patients' medical chart and drug prescription chart were reviewed to determine whether or not a VTE risk assessment was documented for each patient and if they had received appropriate TP. If no risk assessment had been performed, trained researchers applied the National Institute for health and Care Excellence (NICE) guidelines 92 (Jan 2010) for VTE risk assessment and prevention.Following the risk assessment patients were divided into three categories, high risk of VTE with low risk of bleeding; high risk of VTE with significant risk of bleeding and low risk of VTE. From this the proportion of patients in each group that received appropriate TP were calculated.ResultsA total of 1019 patients were enrolled the majority were medical patients 63.5% (n=648). The mean age of patients was 69 years. Females accounted for 52% of patients. Average length of hospitalisation for each patient at the time of the audit was 6 days (range 1-664 days).Overall, a formal TP risk assessment was documented in only 24% (n=244) of all charts reviewed however TP was prescribed in 43.2% (n=441) of patients. See table. Table 1High Risk of VTE low risk of bleedingHigh risk of VTE significant risk of bleedingLow risk of VTENo. of pts80.3% (n=819)16.6% (n=170)2.9% (n=30)VTE risk assessment documented21.9% (n=180)28.2% (n=55)30% (n=9)Received TP46.3% (n=380)28.8% (n=49)40% (n=12)Within the high risk category patients, 64.3% (n=526) medical. TP was only administered to 46.3% (n=380) of patients in the high risk category. This was almost evenly distributed between surgical 50.1% (n=147) and medical 43.4% (n=233) patients.ConclusionThis audit was done as the initial step to develop a national policy to prevent HAT. As suspected, this audit highlights that a large proportion of hospitalised patients, both surgical and medical, continue to be at high risk for VTE despite the availability of preventative measures.There is clear illustration of under prescription of safe, effective and recommended means of VTE prevention. The current overall figure of less than 50% prescription of VTE thromboprophylaxis in high risk patients is a major patient safety concern. There are numerous recognised international guidelines for prevention of VTE, and an efficient method to implement these guidelines needs to be developed. Beyond developing national guidelines for TP, we need a co-ordinated approach to implement and monitor compliance with guidelines.Once the preliminary results of this audit were available to us in March 2015, urgent measures were taken to reduce the identified risk such as the establishment of a Hospital Thrombosis Group which developed a user friendly VTE risk assessment tool and TP policy. The VTE risk assessment tool was incorporated into the patients drug prescription chart and included a pre printed prescription for TP. It is now mandatory for the all patients to have a VTE risk assessment tool and TP prescribed if appropriate within 24hrs of admission. This was successfully piloted for four weeks in the acute medical assessment unit and is now incorporated into each patients drug chart throughout the hospital. This audit will be replicated in 6 months from introduction of this initiative, with an aim of >90% compliance. DisclosuresNo relevant conflicts of interest to declare.