Editorial – Evolve, Adapt, Innovate and Deliver: Acute Medicine post COVID pandemic

2021 ◽  
Vol 20 (2) ◽  
pp. 90-91
Author(s):  
Ben Lovell ◽  
Keyword(s):  
Acute Care ◽  
Winter Period ◽  
Medical Patients ◽  
Patient Journey ◽  
Acute Medicine ◽  
Care Systems ◽  
Innovative Work ◽  
A Prospective Study ◽  
The Impact

Predictions for acute care in the upcoming months are difficult. There will be challenges: there always are and that to a degree is what makes working in acute care so fulfilling. However, even the most adaptive and innovative acute care systems will toil when these challenges become overwhelming. Back in 2015, the then SAM President Mark Holland described a “perfect storm” of events that could lead to a challenging winter period. It was as predicted; but this storm continues to evolve and has not yet reached its perfected chaotic peak. A picture of the COVID pandemic without the brilliant and innovative work of Acute Medicine teams is even darker. As a specialty we should and must remain proud of the impact we are having in delivering safe and sustainable care despite immense pressures. There is an escalating sense of desperation to reach a post-pandemic phase. Increasingly the sense of community unity and spirit at the beginning of the pandemic is being replaced by fear and disgruntlement. A toxic mix of emotions permeates and increasingly hostile divisions as to how manage the next stage of the pandemic grow. Opposing viewpoints are entrenched and neither wants to countenance a brief reflection on any deviation from their position. Meanwhile many people simply observe with bafflement and a sense of betrayal desperate for their lives to return to “normal”. Delivering acute medical care on this background is a challenge that none of us have faced. The skills and resilience of our teams will face its sternest test yet. As a specialty we will continue to do what we have always done since its inception: evolve, adapt, innovate and deliver. This issue of the journal reflects the fantastic work in Acute Medicine that continues to be delivered internationally despite the current challenges. Chris Subbe and the SAM Quality Improvement team have written a review considering frameworks for measuring quality in Acute Medicine.1 Quantifying the impact that Acute Medicine has on the patient journey with defined measurable metrics is key to embedding high quality acute care. The recognition and evaluation of abnormal physiology remains core to the practice of Acute Medicine. International Acute Medicine colleagues from Denmark and Hong Kong present some innovative work on the potential use of thermography in predicting prognosis in acute care.2 In a prospective study of 726 patients they demonstrated that the temperature gradient between nose and eye could help identify variations in skin perfusion and was predictive of all cause 30 day mortality.3 This requires further study but may become a further useful tool in the assessment of physiology of acute unwell medical patients. Dutch colleagues prospectively studied 1328 patients presenting acutely with infective illnesses. Their results reaffirmed the superiority of NEWS to SIRS and qSOFA in predicting mortality and outcomes in this cohort.4 The evolving nature and clinical characteristics of COVID19 are described by Cat Atkin and her colleagues from Birmingham.5 This important paper provides robust data on which to benchmark the severity of future variants of the virus and can support complex service provision planning adapted to the pandemic. Once again, SAM and the editorial board of Acute Medicine thank all colleagues for their amazing and diligent work during the pandemic, which we know will continue long after it. We hope that all friends and colleagues are able to have some well deserved rest and relaxation during a summer break.

scholarly journals Editorial Volume 19 Issue 1 – “Eternal Winter”: Acute Medicine the key to providing longer periods of summer

2020 ◽  
Vol 19 (1) ◽  
pp. 2-3
Author(s):  
Tim Cooksley ◽  
Keyword(s):  
Respiratory Rate ◽  
Ambulatory Care ◽  
Acute Care ◽  
Point Of Care ◽  
Point Of Care Ultrasound ◽  
Point Of Care Testing ◽  
Acute Medicine ◽  
Care Services ◽  
Acute Care Services ◽  
The Impact

As another winter season passes, many colleagues will continue to be working under immense pressures striving to provide high quality care for increasingly larger numbers of patients. The work of Acute Medicine teams to keep the “front door” safe are fundamental to the delivery and sustainability of acute care services. The challenges of innovating and enacting positive changes at times of such high service demand are not insignificant; but the specialty is blessed with rapidly expanding driven and dedicated international, national and local leaders. The first winter SAMBA has recently been performed. SAMBA is an increasingly rich data source that will serve both nationally and locally to help improve performance and ultimately patient outcomes.1 Higher quality Acute Medicine is being produced. Acute Physicians are leading in many acute sub-specialties. Pleasingly, there has a been a significant rise in the number of trainees applying to train in Acute Medicine in the UK reflecting the traction the specialty is achieving. Ambulatory care remains a fundamental tenet to the sustainability of acute care services. Point of care testing is a key element in driving efficient performance in this setting and in this issue Verbakel et al. perform an important analysis on the reliability of point of care testing to support community based ambulatory care.2 This work should field the way for further research defining the impact of point of care testing and how it should be implemented in ambulatory clinical practice. The performance of respiratory rate observation remains poorly performed in acute care settings despite its well validated predictive value. Nakitende et al. describe an app that allows respiratory rate to calculated more quickly and accurately by using a touch screen method.3 Technological innovations to improve the recording and accuracy of physiological parameters in acute care, which can also be used in resource poor settings, will be a focus of large quantities of research in the upcoming years. Blessing et al. describe an important modelling study on the impact of integrated radiology units.4 Co-ordination between Acute Medicine and Radiology departments is essential in a high functioning AMU, especially as increasingly Acute Physicians are trained in point of care ultrasound. Lees-Deutsch et al. provide a fascinating insight into the patient’s perspective of discharge lounges.5 Often used to help maintain flow through the hospital, they elucidate that patients and caregivers transferred from AMU do not find this aspect of their journey a positive one. In times of significant organisational pressures, it is important that clinicians continue to examine the impact of flow measures on the quality of patient care and experience.

EDITORIAL VOLUME 19 ISSUE 4: COVID-19: Exemplifying the importance and challenges of Acute Medicine

2020 ◽  
Vol 19 (4) ◽  
pp. 174-175
Author(s):  
Timothy Cooksley ◽  
Keyword(s):  
Medical Care ◽  
Acute Care ◽  
Quality Indicators ◽  
Acute Medicine ◽  
Care Services ◽  
Senior Clinician ◽  
Acute Care Services ◽  
The Impact ◽  
Second Wave ◽  
Acute Medical Care

COVID-19 has challenged healthcare providers and systems. It has dominated the international news agenda for the majority of 2020; arguably opinion becoming more fractured and disparate as the pandemic has evolved. The changing tone of discourse is concerning, although perhaps not surprising. As the majority of the population become increasingly baffled, bored and betrayed desperate for their lives return to “normal”, progressively binary, toxically expressed and opposing scientific views as to how to manage the “second wave” of the pandemic permeate. The initial failings of personal protective equipment (PPE) and a lack of preparedness to face a viral pandemic against the background of a strained acute care sector must not be forgotten and lessons learned. In the UK, COVID-19 has highlighted both the challenges and importance of Acute Medicine. Acute Medicine teams have provided innovative and rapidly adaptive models of care in response to the pandemic. The fundamental tenets of Acute Medicine – MDT working, rapid initiation of treatment, sound use of diagnostics, early senior clinician input and recognition of those in whom ambulatory care is appropriate – are essential components in the management of all acute medical care and demonstrably equally apply to COVID-19. Our increasing global community of Acute Physicians and Acute Medicine teams have once again demonstrated the importance of our specialty. The innovative practice of Acute Medicine teams and the impact of COVID-19 features prominently in this issue of Acute Medicine. There has been wide commentary regarding the impact of COVID-19 on both mental health issues and non-COVID-19 presentations. Riley et al. report an important analysis of presentations to AMU during the first wave of COVID-19 demonstrating a significant change in patient case mix.1 There were increased numbers of presentations potentially associated with social isolation such as falls, alcohol-related pathologies and overdoses alongside smaller numbers of traditionally lower risk presentations, such as non-cardiac chest pain. Ambulatory management of low risk patients with suspected COVID-19 is fundamental to the safety and sustainability of acute care services during the “second wave” and moving forward. Nunan et al. report the experience of the TICC-19 – a virtual ward monitoring oxygen saturations for COVID-19 triaged using a 30 metre rapid walk test.2 This strategy appears safe and feasible with high levels of patient satisfaction and similar models are being utilised across many organisations. The role of POCUS in the diagnosis and management of COVID-19 is increasingly recognised.4 Knight et al. describe a simple aggregated score formed by summating the degree of pleural and interstitial change within six anatomical lung zones showing good discriminatory performance in predicting a range of adverse outcomes in patients with suspected COVID-19.4 This may form an important addition to COVID-19 ambulatory pathways. SAMBA, the Society for Acute Medicine’s Benchmarking Audit, initially focused on the Society’s key quality indicators, continues to flourish and grow. It now not only benchmarks performance but is being used to guide the development of UK clinical quality measures. Colleagues in the Netherlands are commencing similar work and describing international standards of acute medical care, an iterative process, is one of the ultimate goals of this work. SAMBA 19 continues to demonstrate the evolving complexity of acute medical pathways and highlights the need to define optimal quality indicators for acute medical care.5 The inaugural winter SAMBA adds further evidence to the concerns that during this period there is an unfortunate cocktail of both sicker patients and poorer performance.6 Adapting acute medical services to meet this challenge requires innovation and investment. Those working in Acute Medicine should feel proud of their continued contribution to managing the acutely unwell patient and their impact on the sustainability of acute care services, particularly during this most challenging of years. The Society for Acute Medicine has tremendous pride in representing this brilliant workforce. Alongside, the fantastic work of teams this year, there have been multiple emotional and physical stressors. Many AMUs have experienced large numbers of patient deaths, often having to support their loved ones by telephone. The seroprevalence of SARS-CoV-2 was greatest among colleagues working in Acute Medicine.7 Tragically, some AMUs have lost valued colleagues from COVID-19. We remember these friends for their fantastic work they have done, thank them for their contributions to Acute Medicine and on behalf of all the patients they served, we express thanks; their dedication resulted in the ultimate personal sacrifice. They will never be forgotten.

scholarly journals A multistage mixed methods study protocol to evaluate the implementation and impact of a reconfiguration of acute medicine in Ireland’s hospitals

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
E. Hurley ◽  
S. McHugh ◽  
J. Browne ◽  
L. Vaughan ◽  
C. Normand
Keyword(s):  
Mixed Methods ◽  
Hospital Stay ◽  
Patient Care ◽  
Hospital Admissions ◽  
Hospital Setting ◽  
Length Of Hospital Stay ◽  
Comparative Case Study ◽  
Medical Patients ◽  
Acute Medicine ◽  
The Impact

Abstract Background To address deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established in 2010 to optimise the management of acutely ill medical patients in the hospital setting, and to ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure patients receive timely treatment in the most appropriate setting. It does so primarily via the development of Acute Medical Assessment Units (AMAUs) for the rapid assessment and management of medical patients presenting to hospitals, as well as streamlining the care of those admitted for further care. This study will examine the impact of this programme on patient care and identify the factors influencing its implementation and operation. Methods We will use a multistage mixed methods evaluation with an explanatory sequential design. Firstly, we will develop a logic model to describe the programme’s outcomes, its components and the mechanisms of change by which it expects to achieve these outcomes. Then we will assess implementation by measuring utilisation of the Units and comparing the organisational functions implemented to that recommended by the NAMP model of care. Using comparative case study research, we will identify the factors which have influenced the programme’s implementation and its operation using the Consolidated Framework for Implementation Research to guide data collection and analysis. This will be followed by an estimation of the impact of the programme on reducing overnight emergency admissions for potentially avoidable medical conditions, and reducing length of hospital stay of acute medical patients. Lastly, data from each stage will be integrated to examine how the programme’s outcomes can be explained by the level of implementation. Discussion This formative evaluation will enable us to examine whether the NAMP is improving patient care and importantly draw conclusions on how it is doing so. It will identify the factors that contribute to how well the programme is being implemented in the real-world. Lessons learnt will be instrumental in sustaining this programme as well as planning, implementing, and assessing other transformative programmes, especially in the acute care setting.

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

2018 ◽  
Vol 17 (4) ◽  
pp. 174-176
Author(s):  
Ben Lovell ◽  
◽  
Timothy Cooksley ◽  
Keyword(s):  
Sofa Score ◽  
Healthcare Spending ◽  
Inhalation Injury ◽  
Smoke Inhalation ◽  
Full Blood Count ◽  
Medical Patients ◽  
Patient Journey ◽  
Smoke Inhalation Injury ◽  
Acute Medicine ◽  
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.

Improving Patient Safety and Patient–Provider Communication

2019 ◽  
Vol 4 (5) ◽  
pp. 1017-1027 ◽  
Author(s):  
Richard R. Hurtig ◽  
Rebecca M. Alper ◽  
Karen N. T. Bryant ◽  
Krista R. Davidson ◽  
Chelsea Bilskemper
Keyword(s):  
Acute Care ◽  
Augmentative And Alternative Communication ◽  
Health Care Team ◽  
Provider Communication ◽  
Alternative Communication ◽  
Patient Provider Communication ◽  
Acute Care Settings ◽  
Nurses Perceptions ◽  
Communication Needs ◽  
The Impact

Purpose Many hospitalized patients experience barriers to effective patient–provider communication that can negatively impact their care. These barriers include difficulty physically accessing the nurse call system, communicating about pain and other needs, or both. For many patients, these barriers are a result of their admitting condition and not of an underlying chronic disability. Speech-language pathologists have begun to address patients' short-term communication needs with an array of augmentative and alternative communication (AAC) strategies. Method This study used a between-groups experimental design to evaluate the impact of providing patients with AAC systems so that they could summon help and communicate with their nurses. The study examined patients' and nurses' perceptions of the patients' ability to summon help and effectively communicate with caregivers. Results Patients who could summon their nurses and effectively communicate—with or without AAC—had significantly more favorable perceptions than those who could not. Conclusions This study suggests that AAC can be successfully used in acute care settings to help patients overcome access and communication barriers. Working with other members of the health care team is essential to building a “culture of communication” in acute care settings. Supplemental Material https://doi.org/10.23641/asha.9990962

HOW CLIMATE CHANGE CAN INFLUENCE THE AGRICULTURE IN UKRAINE: A REVIEW

2020 ◽  
Author(s):  
N. Maidanovych ◽  
Keyword(s):  
Climate Change ◽  
Crop Yields ◽  
Soil Surface ◽  
Winter Period ◽  
Negative Consequences ◽  
Resource Saving ◽  
Impact Of Climate Change ◽  
Positive Effects ◽  
Average Annual Temperature ◽  
The Impact

The purpose of this work is to review and analyze the main results of modern research on the impact of climate change on the agro-sphere of Ukraine. Results. Analysis of research has shown that the effects of climate change on the agro-sphere are already being felt today and will continue in the future. The observed climate changes in recent decades have already significantly affected the shift in the northern direction of all agro-climatic zones of Europe, including Ukraine. From the point of view of productivity of the agro-sphere of Ukraine, climate change will have both positive and negative consequences. The positives include: improving the conditions of formation and reducing the harvesting time of crop yields; the possibility of effective introduction of late varieties (hybrids), which require more thermal resources; improving the conditions for overwintering crops; increase the efficiency of fertilizer application. Model estimates of the impact of climate change on wheat yields in Ukraine mainly indicate the positive effects of global warming on yields in the medium term, but with an increase in the average annual temperature by 2 ° C above normal, grain yields are expected to decrease. The negative consequences of the impact of climate change on the agrosphere include: increased drought during the growing season; acceleration of humus decomposition in soils; deterioration of soil moisture in the southern regions; deterioration of grain quality and failure to ensure full vernalization of grain; increase in the number of pests, the spread of pathogens of plants and weeds due to favorable conditions for their overwintering; increase in wind and water erosion of the soil caused by an increase in droughts and extreme rainfall; increasing risks of freezing of winter crops due to lack of stable snow cover. Conclusions. Resource-saving agricultural technologies are of particular importance in the context of climate change. They include technologies such as no-till, strip-till, ridge-till, which make it possible to partially store and accumulate mulch on the soil surface, reduce the speed of the surface layer of air and contribute to better preservation of moisture accumulated during the autumn-winter period. And in determining the most effective ways and mechanisms to reduce weather risks for Ukrainian farmers, it is necessary to take into account the world practice of climate-smart technologies.

Predictors of nonroutine discharge among patients undergoing surgery for grade I spondylolisthesis: insights from the Quality Outcomes Database

2020 ◽  
Vol 32 (4) ◽  
pp. 523-532 ◽  
Author(s):  
Praveen V. Mummaneni ◽  
Mohamad Bydon ◽  
John Knightly ◽  
Mohammed Ali Alvi ◽  
Anshit Goyal ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Acute Care ◽  
Body Mass ◽  
Care Facility ◽  
Older Age ◽  
Quality Outcomes ◽  
Acute Care Facility ◽  
Factors Associated ◽  
Patient Reported ◽  
The Impact

OBJECTIVEDischarge to an inpatient rehabilitation facility or another acute-care facility not only constitutes a postoperative challenge for patients and their care team but also contributes significantly to healthcare costs. In this era of changing dynamics of healthcare payment models in which cost overruns are being increasingly shifted to surgeons and hospitals, it is important to better understand outcomes such as discharge disposition. In the current article, the authors sought to develop a predictive model for factors associated with nonroutine discharge after surgery for grade I spondylolisthesis.METHODSThe authors queried the Quality Outcomes Database for patients with grade I lumbar degenerative spondylolisthesis who underwent a surgical intervention between July 2014 and June 2016. Only those patients enrolled in a multisite study investigating the impact of fusion on clinical and patient-reported outcomes among patients with grade I spondylolisthesis were evaluated. Nonroutine discharge was defined as those who were discharged to a postacute or nonacute-care setting in the same hospital or transferred to another acute-care facility.RESULTSOf the 608 patients eligible for inclusion, 9.4% (n = 57) had a nonroutine discharge (8.7%, n = 53 discharged to inpatient postacute or nonacute care in the same hospital and 0.7%, n = 4 transferred to another acute-care facility). Compared to patients who were discharged to home, patients who had a nonroutine discharge were more likely to have diabetes (26.3%, n = 15 vs 15.7%, n = 86, p = 0.039); impaired ambulation (26.3%, n = 15 vs 10.2%, n = 56, p < 0.001); higher Oswestry Disability Index at baseline (51 [IQR 42–62.12] vs 46 [IQR 34.4–58], p = 0.014); lower EuroQol-5D scores (0.437 [IQR 0.308–0.708] vs 0.597 [IQR 0.358–0.708], p = 0.010); higher American Society of Anesthesiologists score (3 or 4: 63.2%, n = 36 vs 36.7%, n = 201, p = 0.002); and longer length of stay (4 days [IQR 3–5] vs 2 days [IQR 1–3], p < 0.001); and were more likely to suffer a complication (14%, n = 8 vs 5.6%, n = 31, p = 0.014). On multivariable logistic regression, factors found to be independently associated with higher odds of nonroutine discharge included older age (interquartile OR 9.14, 95% CI 3.79–22.1, p < 0.001), higher body mass index (interquartile OR 2.04, 95% CI 1.31–3.25, p < 0.001), presence of depression (OR 4.28, 95% CI 1.96–9.35, p < 0.001), fusion surgery compared with decompression alone (OR 1.3, 95% CI 1.1–1.6, p < 0.001), and any complication (OR 3.9, 95% CI 1.4–10.9, p < 0.001).CONCLUSIONSIn this multisite study of a defined cohort of patients undergoing surgery for grade I spondylolisthesis, factors associated with higher odds of nonroutine discharge included older age, higher body mass index, presence of depression, and occurrence of any complication.

scholarly journals Treatment of HIV-associated facial lipoatrophy: impact on infection progression assessed by viral load and CD4 count

2013 ◽  
Vol 88 (4) ◽  
pp. 570-577 ◽  
Author(s):  
Flávia Machado Gonçalves Soares ◽  
Izelda Maria Carvalho Costa
Keyword(s):  
Viral Load ◽  
Disease Progression ◽  
Statistical Significance ◽  
Undetectable Viral Load ◽  
Fat Distribution ◽  
Cd4 Count ◽  
Before And After ◽  
Facial Lipoatrophy ◽  
A Prospective Study ◽  
The Impact

BACKGROUND: HIV/AIDS-Associated Lipodystrophy Syndrome includes changes in body fat distribution, with or without metabolic changes. The loss of fat from the face, called facial lipoatrophy, is one of the most stigmatizing signs of the syndrome.OBJECTIVES:To evaluate the effect of FL treatment using polymethylmethacrylate (PMMA) implants on disease progression, assessed by viral load and CD4 cell count.METHODS: This was a prospective study of 44 patients treated from July 2009 to December 2010. Male and female patients, aged over 18 years, with clinically detectable FL and who had never been treated were included in the study. PMMA implantation was done to fill atrophic areas. Laboratory tests were conducted to measure viral load and CD4 count before and after treatment.RESULTS: Of the 44 patients, 72.72% were male and 27.27% female, mean age of 44.38 years. Before treatment, 82% of patients had undetectable viral load, which increased to 88.6% after treatment, but without statistical significance (p = 0.67). CD4 count before treatment ranged from 209 to 1293, averaging 493.97. After treatment, the average increased to 548.61. The increase in CD4 count after treatment was statistically significant with p = 0.02.CONCLUSION: The treatment of FL with PMMA implants showed a statistically significant increase in CD4 count after treatment, revealing the impact of FL treatment on disease progression. Viral load before and after treatment did not vary significantly.

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