Acute Tertiary Hospital Research Articles

Prevalence and Outcomes of Multi-Drug Resistant Blood Stream Infections Among Nursing Home Residents Admitted to an Acute Care Hospital.

The prevalence of multi-drug resistant organism (MDRO) colonization in nursing home residents has been well documented, but little is known about the impact of MDRO bloodstream infections (BSIs). The aim of this study was to assess the prevalence, cost, and outcomes of MDRO-BSI vs. non-MDRO-BSI among nursing home residents. Retrospective cohort study. 960 bed tertiary academic medical center. Persons ≥18 years old admitted to an acute care tertiary hospital from Skilled Nursing Facilities with a diagnosis of sepsis between 2015 and 2018. Retrospective analysis of prevalence and outcomes. Among patients admitted to the study hospital with a diagnosis of sepsis during the study period, 7% were from nursing homes. The prevalence of MDRO-BSI was 47%. We identified 54 (50%) gram positive BSIs, 48 (45%) gram negative BSI and 5 (5%) fungal BSI. Thirty-one (57%) of the gram-positive infections and 14 (30%) of the gram-negative infections were with MDROs. The prevalence of BSI organisms were Staphylococcus aureus in 24%, Escherichia coli in 14%, Proteus mirabilis in 13%, Staphylococcus epidermidis in 8%, Enterococcus faecalis in 7%, and Klebsiella pneumoniae in 6%. We found that intensive care unit length of stay (7 days vs 5 days, P = .009), direct cost ($13,639 vs $9,922, P = .027), and total cost ($23,752 vs $17,900 P = .032) were significantly higher in patients with MDRO-BSI vs. non-MDRO-BSI. Patients with MDRO-BSI were twice as likely to receive inappropriate empiric antiinfective therapy (31% vs 16%, P = .006) and were more likely to die (49.1% vs 29.6%, P = .049). Nursing home residents have a high prevalence of MDRO-BSI, which is associated with higher risk of receiving inappropriate initial anti-infective therapy, higher cost, higher ICU LOS, and higher mortality. Our research adds new information about the prevalence of fungemia in this population.

Interprofessional and Intraprofessional Communication about Older People's Medications across Transitions of Care.

Communication breakdowns contribute to medication incidents involving older people across transitions of care. The purpose of this paper is to examine how interprofessional and intraprofessional communication occurs in managing older patients’ medications across transitions of care in acute and geriatric rehabilitation settings. An ethnographic design was used with semi-structured interviews, observations and focus groups undertaken in an acute tertiary referral hospital and a geriatric rehabilitation facility. Communication to manage medications was influenced by the clinical context comprising the transferring setting (preparing for transfer), receiving setting (setting after transfer) and ‘real-time’ (simultaneous communication). Three themes reflected these clinical contexts: dissemination of medication information, safe continuation of medications and barriers to collaborative communication. In transferring settings, nurses and pharmacists anticipated communication breakdowns and initiated additional communication activities to ensure safe information transfer. In receiving settings, all health professionals contributed to facilitating safe continuation of medications. Although health professionals of different disciplines sometimes communicated with each other, communication mostly occurred between health professionals of the same discipline. Lack of communication with pharmacists occurred despite all health professionals acknowledging their important role. Greater levels of proactive preparation by health professionals prior to transfers would reduce opportunities for errors relating to continuation of medications.

Employing serious game for assessing knowledge of blood transfusion procedure among nurses: A qualitative evaluation and feedback improvement study

BackgroundEmploying serious game for assessing nurses' blood transfusion knowledge and skill competency has gained interest among nurse educators worldwide. However, its acceptance by nurses has not been fully explored. AimTo explore the registered nurses' experiences using serious game for nursing skills competency and gather feedback to improve the quality of learning using serious game. SettingAcute tertiary hospital in Singapore. ParticipantsRegistered nurses in inpatient settings. MethodsThis qualitative evaluation and feedback improvement study was conducted in an acute tertiary hospital in Singapore between September 2019 and November 2019. Registered nurses who had completed the blood transfusion knowledge and skills competency via the serious game platform were invited to participate in this study. Individual face-to-face interviews using a semi-structured questionnaire were conducted. All interviews were audio-recorded and transcribed verbatim. Data analysis was performed inductively using the Braun and Clarke's six-step of thematic analysis. ResultsA total of 11 registered nurses were interviewed from a variety of clinical areas including medical and surgical wards, and intensive care units. The mean age of the participants was 28 years old. The majority of participants were females (81.8%), with their years of experience ranging from 1 to 13 years. Each interview took between 20 and 30 min. Three themes were identified: (1) novel learning experience; (2) varying levels of appreciation towards the serious game; and (3) navigating the interface and technical issues. ConclusionEmploying serious game for nursing skills competency is considered acceptable by the nurses in this sample population. Compared to the traditional modes of competency assessment, the serious game is innovative and stimulates learning. Nevertheless, more rigorous efforts are needed to improve the interface and technical issues to enhance the user learning experience. Future versions of the serious game will need to be more accessible and intuitive for all levels of nursing staffs.

Developing a model of bereavement care in an adult tertiary hospital.

Objectives Hospitals are the most common place of death in Australia. Bereavement care is recognised by national standards as being central to providing high-quality care at the end of life, and has significant health implications on morbidity, mortality and health service usage. Despite this, bereavement care is not routinely or systematically provided in most Australian hospitals. This study aimed to develop a comprehensive, evidence-based model of bereavement care specific to the needs of an acute Australian adult tertiary hospital. Methods This study used a multiple-methods design, which included a scoping literature review, a survey of current institutional bereavement practices, interviews with bereaved family members and staff focus groups and the development of a model of bereavement care for the acute hospital service through advisory group and expert consensus. Results Staff and bereaved family members strongly supported a systematic approach to bereavement, perceiving the need for greater support, training, coordination and follow-up. In all, 10 core elements were developed to support a structured model of bereavement care provision and follow-up for the acute hospital organisation. Conclusions This evidence-generated model of care promotes the provision of quality and systematic bereavement care in the acute hospital setting. What is known about the topic? Acute hospitals are the most common place to die in Australia, yet there is a lack of understanding of how bereavement care is or should be provided in these environments. The bereavement period is associated with increased use of health services and worse morbidity and mortality, and thus has significant implications for public health. The provision of bereavement care in acute hospitals is often sporadic, often involving untrained staff who may not provide evidence-based care. What does this paper add? This paper describes the development of a comprehensive, evidence-based model of bereavement care specific to the needs of an Australian acute hospital. What are the implications for practitioners? Developing a consistent approach to bereavement for the acute care sector has the potential to support staff, minimise conflict at the end of life, facilitate recognition of those suffering from difficult bereavement and proactively engage services for these people. It is hoped that such a model of care can find relevance across acute hospitals in Australia, to improve the quality and consistency of bereavement care.

Carbapenemase screening in an Irish tertiary referral hospital: Best practice, or can we do better?

SummaryBackgroundCarbapenems are a family of end line antibiotics with increasing levels of resistance that are a cause for concern.AimTo ascertain whether the CPE screening programme employed in an acute tertiary hospital is fit for purpose.MethodWe outlined the current working algorithm employed using a universal screening programme over a 26-month screening period. Rectal swabs are cultured on arrival. Those with suspicious growth are further investigated using NG-Carba 5 lateral flow tests and Vitek 2.0 sensitivity cards. These practices were compared with NHS guidelines.Findings & ConclusionsIn all, 53 true positives were detected from 45 patients since the screening was implemented in early 2018 (46 OXA-48, 6 KPC, 1 NDM). As the rate of screening increased, the number of positive screens decreased over time. There were a lot of similarities between the HSE guidelines and the published NHS CPE toolkit. It was evident that there is no standard practice being employed across all hospitals. Comparing the MUH to national guidelines it appears to be quicker and more effective with universal screening in place at reducing the potential contacts and identifying carriers. Cost analysis indicates that the need to confirm all positive strains in a reference lab is costly, unnecessary and time consuming. There are adequate confirmatory tests available in-house for routine positive screens. It was concluded that infection prevention and control are key to identifying and controlling possible outbreaks in a hospital setting.

Containment of COVID-19 and reduction in healthcare-associated respiratory viral infections through a multi-tiered infection control strategy.

BackgroundDuring the ongoing COVID-19 pandemic, healthcare-associated transmission of respiratory viral infections (RVI) is a concern. To reduce the impact of SARS-CoV-2 and other respiratory viruses on patients and healthcare workers (HCWs) we devised and evaluated a multi-tiered infection control strategy with the goal of preventing nosocomial transmission of SARS-CoV2 and other RVIs across a large healthcare campus.MethodsFrom January–June 2020, a multi-tiered infection control strategy was implemented across a healthcare campus in Singapore, comprising the largest acute tertiary hospital as well as four other subspecialty centres, with more than 10,000 HCWs. Drawing on our institution's experience with an outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003, this strategy included improved patient segregation and distancing, and heightened infection prevention and control (IPC) measures including universal masking. All symptomatic patients were tested for COVID-19 and common RVIs.ResultsA total of 16,162 admissions campus-wide were screened; 7.1% (1155/16,162) tested positive for COVID-19. Less than 5% of COVID-19 cases (39/1155) were initially detected outside of isolation wards in multi-bedded cohorted wards. Improved distancing and enhanced IPC measures successfully mitigated onward spread even amongst COVID-19 cases detected outside of isolation. COVID-19 rates amongst HCWs were kept low (0.13%, 17/13,066) and reflected community acquisition rather than nosocomial spread. Rates of healthcare-associated-RVI amongst inpatients fell to zero and this decrease was sustained even after the lifting of visitor restrictions.ConclusionThis multi-tiered infection control strategies can be implemented at-scale to successfully mitigate healthcare-associated transmission of respiratory viral pathogens.

TIMING OF INTUBATION AND OUTCOME IN THE COVID-19 PANDEMIC: CHALLENGING THE CONCEPT OF PERMISSIVE HYPOXEMIA

SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: After the novel coronavirus disease (COVID-19), was declared a pandemic, New York quickly became the new epicenter of the disease, with Queens County reporting the most confirmed cases in the United States. This study was conducted during the peak of COVID-19 in Queens. Due to the severity of the disease and limited resources, patients were intubated at varying degrees of oxygenation. This study examines the preoxygenation state of COVID-19 ARDS patients prior to intubation and its implication on clinical outcomes. METHODS: At a single acute tertiary care hospital located in Queens, New York, all patients admitted between March 15 and April 15, 2020 were screened. Active COVID-19 status was confirmed with reverse transcriptase-polymerase chain reaction assay on nasopharyngeal samples. All COVID-19 patients who were intubated with documented pre-intubation oxygen saturation (PreO2) were included. All data were collected from the electronic health record, including laboratory data, ventilator settings, and hospital course. Peri-intubation cardiac arrest events up to 24 hours post-intubation and mortality during the study period were examined as outcomes. Data was analyzed with SPSS (version 25). Continuous variables were tested using independent T-tests. All tests of significance were two-tailed, and a p-value of 0.05 was considered significant. RESULTS: A total of 192 patients were included in the study. They had a mean age of 61.2 ± 12.2 years, and 130 (64.1%) were men. The mean preO2 of all patients was 71.3 ± 13.6, and the mean peri-intubation PF ratio was 120.84 ± 58.6. 32 out of 192 patients (16.7%) with peri-intubation cardiac arrest demonstrated significantly lower preO2 (p=0.03) compared to those without. These 32 patients also demonstrated more days with symptoms prior to intubation (p=0.004). 121 patients who expired during the clinical course demonstrated lower PreO2 (p=0.60) and PF Ratios (p=0.48) compared to the 71 patients who did not, but these comparisons were not statistically significant. Patients who expired demonstrated fewer symptomatic days prior to intubation than those who did not, but this was not statistically significant (p=0.06). CONCLUSIONS: At the time of intubation, the patients had significant hypoxemia and severe ARDS by PF ratio. Lower oxygenation prior to intubation is associated with an increase in peri-intubation complications. CLINICAL IMPLICATIONS: Due to unclear pathophysiology of ARDS in COVID-19, the optimal timing of intubation continues to be debated. Physicians should consider intubation earlier in the disease course prior to significant hypoxemia, which may have a negative impact on peri-intubation complications. Clinical outcome was further impacted by the restriction on preoxygenation of the patients prior to intubation, given its risk of viral aerosolization. Means of preoxygenating with minimal risk of disease spread should continue to be explored. DISCLOSURES: Advisory Committee Member relationship with Ambu Please note: $1-$1000 by Olumayowa Abe, source=Admin input, value=Honoraria No relevant relationships by Ahmed Al-Ghrairi, source=Web Response No relevant relationships by Christian Castaneda, source=Web Response No relevant relationships by Ettaib El Marabti, source=Web Response No relevant relationships by Hadya Elshakh, source=Web Response No relevant relationships by Teressa Ju, source=Web Response No relevant relationships by Michael Karass, source=Admin input No relevant relationships by Miri Kim, source=Web Response No relevant relationships by Jack Mann, source=Web Response No relevant relationships by Christina Jee Ah Rhee, source=Web Response No relevant relationships by Fizza Sajid, source=Web Response No relevant relationships by Angelina Voronina, source=Web Response

Burden of scrub typhus among patients with acute febrile illness attending tertiary care hospital in Chitwan, Nepal

ObjectivesScrub typhus is an emerging neglected tropical disease, reported from many parts of Asia including Nepal. This study aims to determine the seroepidemiology of scrub typhus among febrile patients attending...

Specialist Palliative Care Activity at an Acute Care Tertiary Hospital and Its Representation in Administrative Data.

To quantify and examine specialist palliative care (SPC) in-hospital activity and compare it to routinely collected administrative data on palliative care (PC). All patients discharged from a large acute care tertiary hospital in New South Wales, Australia, between July 1 and December 31, 2017, were identified from the hospital's data warehouse. Administrative data were supplemented with information from the electronic medical record for hospital stays which were assigned the PC additional diagnosis code (Z51.5); had a "palliative care" care type; or included SPC consultation. Of 34 653 hospital stays, 524 were coded as receiving PC-based on care type (43%) and/or diagnosis code Z51.5 (100%). Specialist palliative care provided 1717 consultations over 507 hospital stays. Patients had 2 (median; interquartile range: 1-4) consultations during an average stay of 15.3 days (SD 15.78; median 10); the first occurred 7.0 days (SD 12.13; median 3) after admission. Of patient stays with an SPC consultation, 70% were assigned the PC Z51.5 code; 60% were referred for symptom management; 68% had cancer. One hundred forty-one patients were under a palliative specialist-either from initial hospital admission (49.6%) or later in their stay. Palliative care specialists provide expert input into patient management, benefitting patients and other clinicians. Administrative data inadequately capture their involvement in patient care, especially consultations, and are therefore inappropriate for reporting SPC activity. Exclusion of information related to SPC activity results in an incomplete and distorted representation of PC services and fails to acknowledge the valuable contribution made by SPC.

Nurses’ ability to timely activate rapid response systems for deteriorating patients: A comparative case scenario study between Finnish and British nurses

BackgroundFailure or delay in using rapid response system is associated with adverse patient outcomes. ObjectivesTo assess nurses’ ability to timely activate the rapid response system in case scenarios and to assess nurses’ perceptions of the rapid response system. Methodology/designA comparative cross-sectional study was conducted using a modified rapid response team survey. SettingsA sample of medical/surgical registered nurses were recruited from one acute tertiary care hospital in Finland and one National Health Service acute care hospital in United Kingdom (N = 180; UK: n = 86; Finland: n = 94). ResultsThe results demonstrated that in half of the case scenarios, nurses failed to activate the rapid response system on time, with no significant difference between countries. Nurses did not perceive doctor’s disagreement with activation of the rapid response system to be a strong barrier for activating the rapid response system. Finnish nurses found doctor’s disagreement in activating the rapid response system less important compared to British nurses. ConclusionsThe study identified gaps in nurses’ knowledge in management of deteriorating patients. Nurses’ management of the case scenarios was suboptimal. The findings suggest that nurses need education for timely activation of the rapid response system. Case scenarios could be beneficial for nurses’ training.

Interprofessional barriers in patient flow management: an interview study of the views of emergency department staff involved in patient admissions

ABSTRACT Patient flow in emergency departments (EDs) is notoriously difficult to manage efficiently. While much of the attention has focused on the procedures, protocols and pathways in which patients receive their first hours of care, less attention has been paid to the relational factors that make it happen. Our study is the first, to our knowledge, to consider the role of interprofessional barriers, defined as suboptimal ways of working, as perceived by ED staff in patient flow management. Drawing on 19 interviews with hospital staff in an acute tertiary trauma center hospital in England, we established three flow-related types of interprofessional barriers: ED teamwork barriers, performance-driven coordination barriers, and referral-related collaborative barriers. Knotworking was recognized as a form of interactions and asset to teamworking, coordination, and collaboration. Identifying processes such as chasing, escalating, and advocating enabled our investigation to highlight a very complex set of interprofessional interactions, and signpost what the suboptimal practices of flow management are. Our analysis holds promise for hospitals beyond the National Health Service in England.

Characteristics and Outcomes of Patients Referred to an Emergency Department-Based End-of-Life Care Service in Hong Kong: A Retrospective Cohort Study.

This study describes the characteristics and outcomes of patients referred to an emergency department (ED)-based end-of-life (EOL) service in a tertiary acute hospital in Hong Kong. We examine how emergency physicians (EPs) perform in recognizing and managing dying patients. From September 2010 to April 2018, patients referred to this EOL service in this hospital were included. A group of 5 EPs assessed whether the referred patient would die within a few days. Dying patients (EOL group) were admitted to ED-based EOL service whereas those not likely dying within few days (non-EOL group) would continue management in respective specialty wards. Baseline characteristics of these 2 groups were compared. The time-to-death and use of opioids and anticholinergics were compared. In total, 783 of 830 patients assessed were recognized as being in dying phase, with 688 admitted under ED-based EOL care. Their demographics and characteristics were described. Mean time from assessment to death (time-to-death) was significantly less in EOL group (38.93 hours) than in non-EOL group (250.36 hours; P = .004). Mean time-to-death was not significantly different between those under EP-based EOL service or not. The ED-based EOL care had significantly more patients receiving symptomatic treatment. The characteristics of patients under an ED-based EOL service are described. Emergency physicians are capable of recognizing dying patients. Emergency department-based EOL service does not alter the dying process and offers adequate palliation of symptoms. Emergency physician should assume a more active role in providing adequate EOL care to suitable patients.

Designing, Implementing, and Evaluating a Practice Tutor Internship Model during an Acute Care Clinical Internship.

Purpose: The purpose of this study was to implement and evaluate a novel internship model that incorporates a practice tutor in physiotherapy clinical education during an acute care cardiorespiratory internship at a large acute tertiary care teaching hospital in Canada. Method: A prospective evaluation of this model was conducted by means of a mixed-methods approach using surveys and focus groups. The participants were students and clinical instructors (CIs) who were taking part in the internship. Results: Half of the CIs agreed that the practice tutor model gave them more time to manage their caseload and work with the student than did the traditional model, and 63% would recommend the model for future internships. In reviewing the focus group and open-ended data, we identified four themes: benefits, tensions, critical logistics, and unforeseen blind spots. There was a trend for patient attendance to increase with the practice tutor model compared with the previous year's internship session and with the 5 weeks immediately preceding the internship. Conclusions: On the basis of CIs' and students' self-reports, the piloted practice tutor model was perceived to facilitate students' clinical reasoning and collaborative learning skills. In addition, during the 5-week internship, the number of patients seen each day by the individual CIs and their students was not reduced, with a trend toward increased patient attendance. There was also a trend toward CIs having the same or more time to manage their caseload and work with the students compared with a non-practice tutor internship model. Recommendations to improve this model in future implementations are made.

A Descriptive Study of enteral tube feeding among adults in an acute care tertiary hospital-patient selection, characteristics and complications

It is vital to develop a better understanding of the use of different modalities for enteral feeding and its associated complications, given differences in funding support, community resources and infrastructure available to support home enteral feeding in an acute care tertiary hospital. To provide a description of the clinical characteristics of patients on long-term enteral feeding and incidence of associated complications. A retrospective case records review study design was adopted. Medical records of patients discharged from a tertiary hospital with long-term nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG) feeding for the first time during the period of January 2010 to June 2017 were reviewed. Data collected include patient's demographics, reason for enteral feeding, morbidity and nutritional status upon initiation of NGT and PEG feeding, readmission episodes and documented complications (associated with enteral feeding) within one-year post discharge. Records of 120 NGT and 118 PEG patients were analysed. Significant age and gender differences were found with older patients being more likely to be placed on NGT [NGT (Mean 79.1, SD 11.3) vs. PEG (Mean 67.1, SD 12.6)] and higher number of females in the NGT group as compared to the PEG group (NGT 59.2% vs. PEG 31.4%). Majority of patients were fed by caregivers in the NGT (99.2%) as compared to the PEG (51.7%) group. Patients with cancer were more likely to be on PEG feeding (NGT 5%, PEG 70.3%), whereas patients with stroke-related diagnoses were more likely to be on NGT feeding (NGT 48% vs. PEG 8.5%). The total Charlson Comorbidity score was also significantly different between the NGT (mean=5.7; SD=1.5) and PEG (mean=4.5; SD=2.0) groups. A higher number of patients with PEG feeding had no complications (47.5%) as compared to the NGT group (8.3%). Patients who received NGT feeding were more likely experience tube blockage [OR 0.03, 95% CI (0.001-0.72), p=0.03], secondary displacement of tube [OR 0.04, 95% CI (0.002-0.72), p=0.03] and accidental tube removal [OR 0.03, 95% CI (0.004-0.21), p< 0.001]. Overall, patients who received NGT feeding experienced more complications than those who had PEG feeding. The choice for NGT or PEG feeding may be influenced by patient related factors as well as the presence of caregivers, which need to be considered in the improvement of enteral nutrition services in the local context.

Promotion of mobility among hospitalised older adults: An exploratory study on perceptions of patients, carers and nurses

BackgroundHospitalisation of an older adult due to acute medical illness can result in adverse events and accelerate loss of independence despite recovery from the illness. Promoting mobility during hospitalisation can help to mitigate the risks of functional decline. Understanding the perspectives on the barriers and the maintenance of mobility is essential in the development of effective strategies. AimsTo explore the perceptions of patients and their carers, as well as the nurses on promotion of mobility among hospitalised adult older patients. MethodsA qualitative descriptive study design with purposive and convenience sampling approach was undertaken. A total of fourteen patients, six carers and ten nurses from a general medical ward of an acute care tertiary public hospital in Singapore were recruited over the period of November 2017 to February 2018. Face to face semi-structured interviews were conducted and audio-recorded. The interview transcripts were coded and an inductive content analysis approach was adopted to generate categories of sub-themes and themes through the open coding process. ResultsFour main themes were generated: (1) perceived and induced fear of falling; (2) challenges in initiation of mobility; (3) influence of premorbid status and physical condition on activity level; and (4) strategies to promote mobility. ConclusionRecognition of the importance of mobility as well as the detrimental effects of prolonged bed rest during hospitalization is an essential first step toward developing successful interventions to promote mobility in the Asian context. Improvements need to be made to help overcome the various barriers and challenges in the mobilization of the older patients in the acute care settings. Nurses and other members of the care team can help to increase the confidence of patients and among family carers (in providing assistance during mobility) by role modelling and provision of walking aids as well as risk-based education.

Preventing Intra-hospital Infection and Transmission of Coronavirus Disease 2019 in Health-care Workers.

Coronavirus disease 2019 poses an occupational health risk to health-care workers. Several thousand health-care workers have already been infected, mainly in China. Preventing intra-hospital transmission of the communicable disease is therefore a priority. Based on the Systems Engineering Initiative for Patient Safety model, the strategies and measures to protect health-care workers in an acute tertiary hospital are described along the domains of work task, technologies and tools, work environmental factors, and organizational conditions. The principle of zero occupational infection remains an achievable goal that all health-care systems need to strive for in the face of a potential pandemic.

Abstract TP359: Rapid Access Stroke Unit - A Virtual Clinic to Assess Minor Stroke Admissions, Expedite Investigations and Implement Timely Treatments

Background: The current Stroke service is seeing more than 200 patients per month admitted to our acute tertiary hospital. Acute major stroke patients are admitted to the stroke ward but many of the minor strokes or mimics are admitted to an acute medical assessment unit (AMAU) waiting on average 3 days for completion of investigations. TIA clinics are an established element of a stroke service in other countries. We established a similar service, the Rapid Access Stroke Unit (RASU), opened daily in July 2018 aiming to reduce admission rates by expediting investigations and treatments for patients presenting with minor or resolved symptoms. The referral criteria for RASU is a CT scan with no evidence of hyperacute stroke and the Patient is independent in ADL’s. If the patient is in hospital the clinical nurse specialist will triage patients for suitability for transfer to RASU. Out of hours suitable patients can be discharged from ED with instructions to attend RASU the following morning. The clinical nurse specialist, supported by the Stroke Consultant, will coordinate the investigations, track results, organise reviews and ensure the patients are fully educated of diagnosis, treatment and risk factor management. Results: The first year’s figures show a decrease in the inpatient admissions with 496 patients attending RASU, saving 1749 bed days. There is also an increase in the number of patients discharged directly home from the Emergency Department (ED), with the option of attending RASU if required. The diagnosis of patients admitted to RASU are 102 ischemic, 145 TIA, 247 Mimics and 1 ICH. Conclusion: One-year results have shown a significant benefit in patient care, early discharge and improved use of the hospital resources. One unexpected result was the increase in discharges from ED and this may be attributed to the ED physicians discharging patients confident that there is a rapid access service available. Another consequence of the service is that patients will ‘walk in’ to RASU if they have any further concerns or require clarification of treatments.

To study the epidemiology and clinical profile of adult patients with acute abdominal pain attending tertiary care hospital

Introduction: Acute abdomen is a very common problem in emergency department. Aims and Objectives: This study aims to find out the clinical and epidemiology profile of acute abdominal pain among patients attending emergency department of Santosh Medical College Ghaziabad. Materials and Methods: A tertiary care hospital based, cross-sectional study was conducted from January 2018- April 2019 2018, among patients presenting with acute abdominal pain to Santosh Medical College Ghaziabad, India. Data was entered on a standard data collection sheet after obtaining a written informed consent. Results: Out of 1200 patients admitted via the Emergency Department at the Hospital, 200 (16.6%) were admitted with atraumatic acute abdominal pain. Out of 200, 120(60%) were due to Surgical causes and 80 due to non-surgical causes. Most consistent symptom and sign were pain abdomen and abdominal tenderness respectively. Acute cholecystitis was the most common etiology of acute abdominal pain (35.8% cases), followed by, Renal Stones (30.5%), Acute Appendicitis (17.5%) and Intestinal Obstruction (16.67%) respectively. Conclusion: About 16.60% of all emergency admissions were due to acute abdominal pain and about 60.0% of all atraumatic acute abdominal pain was due to surgical cause. Acute cholecystitis was the most common cause of surgical abdominal pain. Keywords: Acute abdominal pain (AAP), Right hypochondrium (RHC), Epigastrium, Hypochondrium.

The opioid epidemic and headache: Experience of a general neurology consult service

Background: Headaches represent a significant proportion of referrals to any neurology consult service, of which many are migrainous. Regular use of opioids can lead to medication overuse headache in these patients and in some cases, dependence. The epidemic of opioid abuse represents a serious public health concern, with long term use of opioids associated with risk of misuse, abuse, addiction and even overdose. Methods: We audited headache referrals to the neurology consult service in an acute tertiary hospital over three 6-month periods between 2012 and 2019. Appropriateness of referrals with respect to NICE guidelines and initial treatments strategies were assessed. Results: The majority of headache disorders seen were migrainous and we found an alarming and repeated trend of early opioid prescribing in the initial acute setting (up to 56%). Conclusions: Further education of healthcare professionals and patients is urgently required to prevent this group becoming victims of the growing global opioid epidemic.

Streamlining an existing hip fracture patient pathway in an acute tertiary adult Irish hospital to improve patient experience and outcomes.

ObjectiveTo improve access for hip fracture patients to surgery within 48 h of presentation to the Emergency Department, and to increase the number of patients receiving pre-operative orthogeriatric review, through streamlining an existing hip fracture patient pathway.DesignA pre–post design involving a multi-disciplinary team use of the Define, Measure, Analyse, Improve and Control framework integral to Lean Six Sigma (LSS) methodology, to assess and adapt the existing hip fracture pathway from presentation to Emergency Department to the initiation of surgery.SettingA 600-bed teaching hospital in Ireland.ParticipantsNursing, medical, administrative and physiotherapy staff working across Emergency Medicine, Orthogeriatrics and Orthopaedic Specialities and Project management.InterventionsLSS methodology was used to redesign an existing pathway, improving patient access to ortho-geriatrician assessment, pain relief and surgery in line with the Irish Hip Fracture Data Base Key performance indicators.Main Outcome MeasuresAccess to pain relief, access to surgery and volume of patients receiving ortho-geriatric assessment.ResultsThe percentage of patients undergoing surgery within 48 h of presentation to Emergency Department increased from 55% to 79% at 3 months, and to 85% at 6 months. Improvements were also achieved in the secondary performance metrics relevant to quality of patient care. All care pathway changes were cost neutral.ConclusionsHip fracture surgery within 48 h of presentation to hospital is a recognized standard of hip fracture care associated with decreased length of stay and decreased mortality. With respect to this performance metric, this intervention has contributed to improved patient outcomes.