Editorial Volume 17 Issue 4 – Assessing, treating and prognosticating from the front door

In our daily working lives, acute physicians strive to provide the best holistic care to our patients from the moment they arrive in hospital. Experienced healthcare professionals develop a gut feeling (generally recognised as the nagging internal voice of professional experience) about patients who may be more unwell than appearances suggest, or who may deteriorate despite showing signs of physiologically compensating quite well. The papers in this issue challenge us to examine how we prioritise, prognosticate and risk-stratify the patients we treat in acute medicine, how we remain cognisant and skilled in treating patients with more unusual acute medical conditions, and how we allocate resources in the NHS. There are many reasons for a patient to re-attend the Emergency Department (ED) in the days following a discharge. In the UK, these unplanned re-attendances are measured as a quality indicator, implying that patient’s return to the ED is due to a deficiency in the quality of their care. In this issue, Ludwig et al challenge this simplistic view by exploring the reasons why patients to come back to the ED and describe how these re-attendances can be ascribed to factors related either to the patient, the physician or the illness itself. Is there a reliable way to predict mortality and likelihood to require critical care at the point of admission? Two papers in this issue cover the subject of prognostication in acute medicine. Most acute medics are wary of transplanting illness-severity metrics from other disciplines and installing indiscriminately them in the ED and AMU. However, Holm and Brabrand have established that the Sequential Organ Failure Assessment (SOFA) score, a longtime staple of the Intensive Care Unit (ICU), can predict deterioration and death with acceptable accuracy in acute medical patients. This suggests that the SOFA score may inform treatment escalation plans and patient prioritisation at the ‘front door’. Bindraban et al have used the haematological indices of the full blood count develop an understanding of how front line tests may predict the patient journey. Whilst common sense suggests that those with the most abnormal blood test results at admission have worse outcomes, this paper quantifies and elaborates the relationship between the results on the computer screen and the patient in the hospital bed. When Grenfell Tower blazed in June 2017, the nearby AMUs cleared their beds as best they could and stood by to receive patients suffering with smoke-related injuries. Occurrences such as this remind us that the acute physician must be up to date with rare but important medical emergencies. In their review, Björkbom and Brabrand highlight the phenomenon smoke inhalation injury, and advise us that the period of in-patient observation should be slightly longer than we realise. “The most intense spending on acute health care in a lifetime occurs in the last few months of life”; from this statement Jones and Kellett lay out their argument that local mortality rates should inform and influence local healthcare spending. In an article that should provoke debate, they suggests significant adjustments in how financial resources are allocated, and how a national death registry could impact upon how the NHS spends its money.