Download Acute Medicine How to avoid Hospital Admission

Acute Medicine - How to
Avoid Hospital Admissions
Dr Kevin Jones FRCP MD
Royal Bolton Hospital
Acute Medical Unit







Assessment and Short Stay Beds
D1 Ward - female (26 beds)
D2 Ward - male (22 beds )
GP Assessment Unit
Emergency Department
Rapid access Clinics
Bolton Community Unit (BCU)
Admissions
(Sept 09 – Aug 10)

D1
D2

Mean 41 per day ( 48 beds )

8519 ( includes GPAU)
6510
Time of Admission to AMU
100%
90%
80%
70%
60%
50%
Approximately
24% total
admissions come
direct from GPs
40%
30%
20%
10%
0%
0000-0400 0400-0800 0800-1200 1200-1600 1600-2000 2000-0000
Do our rotas reflect our demand and support
senior review?
Lengths of Stay for AMU
discharges
100%
45% discharged
home
55% admitted to
specialist ward
90%
80%
70%
60%
50%
D1
40%
D2
30%
20%
10%
0%
2hrs
4hrs
6hrs
12hrs
24hrs
24+ hrs
75% of patients kept on Acute Medical Unit
are discharged within 24 hours
How to Reduce
Pressure on Beds






Maintain 85% bed occupancy
Reduce Lengths of Stay
Consultant-held Triage Bleep
Early senior decision maker review
Capacity for Short Stay in AMU
Ambulatory Care
Rapid Access Clinic
Consultant Physician
Every weekday afternoon
8 slots per day
Reduces need for GPAU
Not a follow-up clinic
Not a specialist clinic
Consultant held Triage
Bleep for GP Direct







Results
Mean number of calls dealt with per day between
0800 and 1600: 13 (range 8 – 23)
On average the consultant is able to divert or
deflect 4 – 6 admissions per day.
Giving advice to the GP
Advising referral to a specialist clinic
Giving the patient an appointment in Rapid Access
Clinic
Asking the hospital Referral and Assessment Team
to assess patients with social problems.
Rapid Access Clinic
Main Referrals
Headaches
Chest pain
Shortness of breath
Blackouts and collapses
Generally unwell
Emerg Med J 2010 27: 530-532
Consultant held Triage Bleep
Rapid Access Clinics

Any Questions ?
Hyperthyroidism



Carbimazole 40 mg daily
Propranolol 40 mg tds
Endocrine Outpatients
Primary Pneumothorax

Only needs aspirating if 2 cm rim

10x10x10 = 1000
8 x 8 x 8 = 512

Temporal Arteritis




Usually aged above 50 years
ESR usually above 80 mm/hr
Start prednisolone 60 mg daily
Temporal artery biopsy within a week
Bell’s Palsy





Diagnose lower motor neurone palsy
Imaging not required unless atypical or not
recovering after 8 weeks
Give prednisolone 60 mg for 1 week
Protect the eye
Primary care – not acute medicine
Pleural effusion
Unilateral Pleural Effusion




Bilateral effusions do not require drainage
Simple aspiration first
Diagnostic tests
CT thorax prior to biopsy
Pneumonia – BTS Guidelines



Can be a clinical diagnosis
Chest X-ray not essential
CRB-65 score of 0-1 may be treated in the
community
Pneumonia – CURB 65 score





Confusion – new onset
Urea > 7.0 mmol/l
Respiratory rate > 30 / min
BP - < 90 syst or < 60 diast
Age > 65 yrs
Haematemesis
Stanley et al, Lancet, 373, Jan
3rd 2009. Glasgow-Blatchford
Anaemia
British Society of
Gastroenterology
May 2005
Guidelines on the Management of
Iron Deficiency Anaemia
Iron Deficiency Anaemia
without symptoms
Screen for coeliac disease
Upper and lower GI investigation should
be considered for female patients who are
post-menopausal, aged over 50 years
or have a strong family history
of colorectal cancer
Iron Deficiency Anaemia
Blood transfusions should
be reserved for patients
with, or at risk of,
cardiovascular instability
due to their degree of
anaemia particularly if they
are due to have endoscopic
investigations before a
response from iron
treatment is expected
Iron Deficiency Anaemia
Unless cardiopulmonary or cerebrovascular
disease is present, transfusion is rarely
needed in patients who have chronic anaemia
with an Hb greater than 7 g/dL.
Atrial Fibrillation
Atrial Fibrillation
A frequent reason for admission is to "rule out"
an acute myocardial infarction.
AF is rarely the
only manifestation of an acute coronary syndrome,
although AF with a rapid ventricular rate and hypotension
can provoke angina. As a result, there is no reason to
admit the patient unless there are other
clinical reasons to consider an acute coronary syndrome such as
ST segment elevation or major (>2 mm) ST segment depression
Indications for Hospitalisation
in new onset AF




To treat the medical condition causing the AF
Elderly patients more safely treated in
hospital
Patients with underlying heart disease and
haemodynamic consequences of AF
Patients known to have been in AF for less
than 48 hours
CHADS(2) SCORE FOR AF

Cardiac Failure
Hypertension
Age > 75yrs
Diabetes
Stroke, TIA or DVT/PE

Warfarin for score of 2 or more




1
1
1
1
2
CHA2DS2-VASc score
Congestive Heart Failure
Hypertension
Age >75 years
Age 65 to 74 years
Stroke/TIA/VTE
Vascular disease
Diabetes mellitus
Female
0=Low 1=Mod 2=High
1
1
2
1
2
1
1
1
Transient Ischaemic Attack
Is it a TIA or not?





Are the neurological symptoms focal rather than non
focal?
Are the neurological symptoms negative rather than
positive?
Was the onset of the focal neurological symptoms
sudden?
Were the focal symptoms maximal at onset?
Syncope does not occur with TIA
TIA – ABCD2 Score



Age > 60 yrs
BP > 140/90
Clinical


Duration


Diabetes
Weakness
Speech
< 1 hour
> 1 hour
1
1
2
1
1
2
1
TIA – ABCD2 Score



Start aspirin 300mg
Score 4 or more – clinic within 24 hours
Score less than 4 – clinic within 1 week
Hypertension
Hypertensive Urgency
Systolic > 200 mmHg
Diastolic > 120 mmHg
No symptoms ( headache )
No end-organ damage
Usually poorly compliant
Pulmonary Embolism and d-dimer
Importance of History in
diagnosis of PE
Importance of History in
diagnosis of PE
Headache
Subarachnoid haemorrhage



Suddeness of onset more important than
severity
Comes on to maximum intensity within a
minute
Lasts for at least an hour
Renal Failure
Rapid Lowering of Serum
Potassium
1.Patients with hyperkalaemia and electrocardiographic changes.
2.Patients with a serum potassium greater than
7.0 mmol/L who have no clinical or electrocardiographic
signs of hyperkalaemia.
3.A lesser degree of hyperkalemia in patients with
a serum potassium that is rapidly increasing.
Nursing Home Residents
< Many nursing home residents find acute admission distressing,
many hospital admissions are ‘inappropriate’, and advance
care planning can improve patients’ end of life care.
< Nursing home residents were significantly less likely to survive
acute medical admission than elderly people living in the
community.
< The results show one third of nursing home residents did not
survive the admission and over a half had died within 6 weeks
of admission.
< Patients with a higher level of comorbidity are less likely to
survive the admission or to 6 weeks than those with lower
levels.
< Advance care planning should be considered in all nursing
home residents, especially those with the greatest level of
comorbidity.
Postgrad Med J 2010;86:131e135. doi:10.1136/pgmj.2008.076430
Artificial Feeding does not
Prolong Survival in Patients
with Dementia
Discussion
Other Conditions








Temporal arteritis
Deterioration in CKD
Worsening of chronic heart failure
Small pneumothorax
Late presentation of stroke with good function
Painless jaundice
Hyperthyroidism
Nursing home patients and palliative care