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Strategies to reduce antibiotic overuse in hospitals depend on prescribers taking decisions to stop unnecessary antibiotic use. There is scarce evidence for how to support these decisions. We evaluated a multifaceted behaviour change intervention (ie, the antibiotic review kit) designed to reduce antibiotic use among adult acute general medical inpatients by increasing appropriate decisions to stop antibiotics at clinical review.We performed a stepped-wedge, cluster (hospital)-randomised controlled trial using computer-generated sequence randomisation of eligible hospitals in seven calendar-time blocks in the UK. Hospitals were eligible for inclusion if they admitted adult non-elective general or medical inpatients, had a local representative to champion the intervention, and could provide the required study data. Hospital clusters were randomised to an implementation date occurring at 1-2 week intervals, and the date was concealed until 12 weeks before implementation, when local preparations were designed to start. The intervention effect was assessed using data from pseudonymised routine electronic health records, ward-level antibiotic dispensing, Clostridioides difficile tests, prescription audits, and an implementation process evaluation. Co-primary outcomes were monthly antibiotic defined daily doses per adult acute general medical admission (hospital-level, superiority) and all-cause mortality within 30 days of admission (patient level, non-inferiority margin of 5%). Outcomes were assessed in the modified intention-to-treat population (ie, excluding sites that withdrew before implementation). Intervention effects were assessed by use of interrupted time series analyses within each site, estimating overall effects through random-effects meta-analysis, with heterogeneity across prespecified potential modifiers assessed by use of meta-regression. This trial is completed and is registered with ISRCTN, ISRCTN12674243.58 hospital organisations expressed an interest in participating. Three pilot sites implemented the intervention between Sept 25 and Nov 20, 2017. 43 further sites were randomised to implement the intervention between Feb 12, 2018, and July 1, 2019, and seven sites withdrew before implementation. 39 sites were followed up for at least 14 months. Adjusted estimates showed reductions in total antibiotic defined daily doses per acute general medical admission (-4·8% per year, 95% CI -9·1 to -0·2) following the intervention. Among 7 160 421 acute general medical admissions, the ARK intervention was associated with an immediate change of -2·7% (95% CI -5·7 to 0·3) and sustained change of 3·0% (-0·1 to 6·2) in adjusted 30-day mortality.The antibiotic review kit intervention resulted in sustained reductions in antibiotic use among adult acute general medical inpatients. The weak, inconsistent intervention effects on mortality are probably explained by the onset of the COVID-19 pandemic. Hospitals should use the antibiotic review kit to reduce antibiotic overuse.UK National Institute for Health and Care Research.

BackgroundThe increasing number of older, complex patients who require emergency admission to hospital has prompted calls for better models of medical generalist care, especially for smaller hospitals, whose size constrains resources and staffing.ObjectiveTo investigate the strengths and weaknesses of the current models of medical generalism used in smaller hospitals from patient, professional and service perspectives.MethodsThe design was a mixed-methods study. Phase 1 was a scoping and mapping exercise to create a typology of models of care, which was then explored further through 11 case studies. Phase 2 created a classification using the Hospital Episode Statistics of acute medical ‘generalist’ and ‘specialist’ work and described differences in workload and explored the links between case mix, typology and length of stay and between case mix and skill mix. Phase 3 analysed the relationships between models of care and patient-level costs. Phase 4 examined the strengths and weaknesses of the models of care through focus groups, a discrete choice experiment and an exploration of the impact of typology on other outcomes.ResultsIn total, 50 models of care were explored through 48 interviews. A typology was constructed around generalist versus specialist patterns of consultant working. Twenty-five models were deployed by 48 hospitals, and no more than four hospitals used any one model of care. From the patient perspective, analysis of Hospital Episode Statistics data of 1.9 million care episodes found that the differences in case mix between hospitals were relatively small, with 65–70% of episodes accounted for by 20 case types. The skill mix of hospital staff varied widely; there were no relationships with case mix. Patients exhibited a preference for specialist care in the discrete choice experiment but indicated in focus groups that overall hospital quality was more important. From a service perspective, qualitative work found that models of care were contingent on complex constellations of factors, including staffing, the local hospital environment and policy imperatives. Neither the model of care nor the case mix accounted for variability in the length of stay (no associations were significant atp LimitationsSmaller hospitals in multisite trusts were excluded, potentially leading to sample bias. The rapidly changing nature of the models limited the analysis of typology against outcomes.ConclusionsThe case mix of smaller hospitals was dominated by patients with presentations amenable to generalist approaches to care; however, there was no evidence to support any particular pattern of consultant working. Matching hospital staff to better meet local need and the creation of more collaborative working environments appear more likely to improve care in smaller hospitals than changing models.Future workThe exploration of the relationships between workforce, measures of hospital culture, models of care, costs and outcomes in both smaller and larger hospitals is urgently required to underpin service reforms.Study registrationThis study is registered as Integrated Research Application System project ID 191393.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.

Smaller hospitals internationally are under threat. The narratives around the closure of smaller hospitals, regardless of size and location, are all constructed around three common problems – cost, quality and workforce. The literature is reviewed, demonstrating that there is little hard evidence to support the contention that hospital merger/closure solves these problems. The disbenefits of mergers and closures, including loss of resources, increased pressure on neighbouring organisations, shifting risk from the healthcare system to patients and their families, and the threat hospital closure represents to communities, are explored. Alternative structures, policies and funding mechanisms, based on the evidence, are urgently needed to support smaller hospitals in the UK and elsewhere.

One of the current obsessions of the NHS is with economies of scale – the notion that healthcare would be safer, faster, cheaper and more efficient if services were provided by larger teams in bigger hospitals or across ever-enlarging networks of organisations. This could be seen as an extension, albeit in a mutated form, of the decades-long drive towards centralisation and specialisation of hospital services.1,2 To these ends, over half of all hospitals in England have been closed or merged in the last 20 years, while one of the purposes of sustainability and transformation partnerships (STPs) is to create unprecedented economies of scale at regional level across every type of NHS organisation.2–4 One of the consequences of this trend has been to make the smaller hospital seem a near irrelevance in the NHS landscape. Yet smaller hospitals provide care to nearly half the …

Biomarkers represent a major technological innovation in medicine. This article discusses the definition and uses of biomarkers, particularly their role in diagnosis, risk stratification and management of disease. It reviews the current roles of the seven most commonly used biomarkers in the acute setting (troponin, creatine kinase, myoglobin, brain natriuretic peptide, d-dimer, C-reactive protein, procalcitonin). The article looks briefly at the utility of point-of-care testing, which, despite concerns about accuracy, can help to risk-stratify patients more efficiently at the point of presentation. Biomarkers currently in development for diagnosis and prognostication across a spectrum of disease are surveyed.

Background: To ensure patients continue to get early access to antibiotics at admission, while also safely reducing antibiotic use in hospitals, one needs to target the continued need for antibiotics as more diagnostic information becomes available. UK Department of Health guidance promotes an initiative called ‘Start Smart then Focus’: early effective antibiotics followed by active ‘review and revision’ 24–72 h later. However in 2017, Methods/design: Antibiotic Review Kit for Hospitals (ARK-Hospital) is a complex ‘review and revise’ behavioural intervention targeting healthcare professionals involved in antibiotic prescribing or administration in inpatients admitted to acute/general medicine (the largest consumers of non-prophylactic antibiotics in hospitals). The primary study objective is to evaluate whether ARK-Hospital can safely reduce the total antibiotic burden in acute/general medical inpatients by at least 15%. The primary hypotheses are therefore that the introduction of the behavioural intervention will be non-inferior in terms of 30-day mortality post-admission (relative margin 5%) for an acute/general medical inpatient, and superior in terms of defined daily doses of antibiotics per acute/general medical admission (co-primary outcomes). The unit of observation is a hospital organisation, a single hospital or group of hospitals organised with one executive board and governance framework (National Health Service trusts in England; health boards in Northern Ireland, Wales and Scotland). The study comprises a feasibility study in one organisation (phase I), an internal pilot trial in three organisations (phase II) and a cluster (organisation)-randomised stepped-wedge trial (phase III) targeting a minimum of 36 organisations in total. Randomisation will occur over 18 months from November 2017 with a further 12 months follow-up to assess sustainability. The behavioural intervention will be delivered to healthcare professionals involved in antibiotic prescribing or administration in adult inpatients admitted to acute/general medicine. Outcomes will be assessed in adult inpatients admitted to acute/general medicine, collected through routine electronic health records in all patients.Discussion: ARK-Hospital aims to provide a feasible, sustainable and generalisable mechanism for increasing antibiotic stopping in patients who no longer need to receive them at ‘review and revise’.Trial registration: ISRCTN Current Controlled Trials, ISRCTN12674243. Registered on 10 April 2017.

Reduced kidney function, whether acute or chronic, is a highly significant biomarker of in most clinical settings. This is particularly true on the acute medical take where altered renal function is associated with a worse prognosis, and may also impact on immediate management strategies such as drug choice, dosing and suspension, and the use of contrast agents for imaging. In this edition of the Acute Medical Journal, Yang et al present the results of their study describing the renal function and associated characteristics in 2,070 consecutive patients presenting on the unselected medical take at their hospital over a 40 day period. In this study, the authors provide a wealth of information on the general characteristics of acute medical patients admitted with altered kidney function, be it CKD or AKI. Importantly, both chronic kidney disease (CKD) and acute kidney injury (AKI) are very highly prevalent. Indeed, in this study more than 5% of all medical admissions actually demonstrated evidence of both.

Conducting research on the Acute Medical Unit (AMU) poses unique challenges; the environment is one that sees a diverse range of patient groups and pathologies and holds the potential for easy patient recruitment to research studies, however is geared towards a specific set of triage and discharge goals. We conducted a study into Stress Hyperglycaemia (SH) on a busy AMU, which involved profiling glycaemic changes using specialist equipment and interventions in patients with unscheduled medical admissions, and experienced a number of challenges. This article discusses these challenges and proposes potential solutions. Conducting research on a busy AMU was complicated by factors including rapid patient and staff turnover, the differing goals of the AMU system and suboptimal staff engagement in labour intensive research. We endeavored to follow patients up in further visits after discharge but found they lacked engagement after the resolution of the acute illness requiring initial admission. In this article, we discuss these issues in more detail and suggest approaches for future AMU researchers.

A structured online survey was used to establish the views of 2,684 practising clinicians of all ages in multiple countries about the value of the physical examination in the contemporary practice of internal medicine. 70% felt that physical examination was 'almost always valuable' in acute general medical referrals. 66% of trainees felt that they were never observed by a consultant when undertaking physical examination and 31% that consultants never demonstrated their use of the physical examination to them. Auscultation for pulmonary wheezes and crackles were the two signs most likely to be rated as frequently used and useful, with the character of the jugular venous waveform most likely to be rated as -infrequently used and not useful. Physicians in contemporary hospital general medical practice continue to value the contribution of the physical examination to assessment of outpatients and inpatients, but, in the opinion of trainees, teaching and demonstration could be improved.

Overcrowding in the emergency department (ED) has become an increasingly significant worldwide public health problem in the last decade. It is a consequence of simultaneous increasing demand for health care and a deficit in available hospital beds and ED beds, as for example it occurs in mass casualty incidents, but also in other conditions causing a shortage of hospital beds. In Italy in the last 12-15 years, there has been a huge increase in the activity of the ED, and several possible interventions, with specific organizational procedures, have been proposed. In 2004 in the United Kingdom, the rule that 98 % of ED patients should be seen and then admitted or discharged within 4ho f presentation to the ED ('4 hr ule') was intro- duced, and it has been shown to be very effective in decreasing ED crowding, and has led to the development of further acute care clinical indicators. This manuscript represents a synopsis of the lectures on overcrowding problems in the ED of the Third Italian GREAT Network Congress, held in Rome, 15-19 October 2012, and hope- fully, they may provide valuable contributions in the understanding of ED crowding solutions.

It is a common perception that young people do not become ill and do not pose a challenge in the unscheduled healthcare setting. The research, however, increasingly suggests that young adults and adolescents (YAAs) are a highly vulnerable group, with poorer outcomes than either older adults or children, and distinct healthcare needs. The acute medical unit (AMU) setting poses particular challenges to the care of this patient group. To improve care and patient experience, adult clinicians need to look critically at their services and seek to adapt them to meet the needs of YAAs. This requires cooperation and linkage with local paediatric and emergency services, as well as the input of other relevant stakeholder groups. Staff on AMUs also need to develop the knowledge, skills and attitudes to communicate effectively and address the developmental and health needs of YAAs and their parents/carers at times of high risk and stress.

Patient safety in hospital is dependent on a multitude of factors. Recent reports into the failings of healthcare organisations in the UK have highlighted low staffing levels as a significant factor. There is research into the impact of nurse-to-patient ratios on patient safety, but our literature search found little published data that would allow healthcare providers to define a minimum number of physician staff and skills mix that would assure safety in the largest hospital specialty: unscheduled (acute) medicine. Future work should focus on the evaluation of existing data on hospital mortality rates and physician staffing levels as well as on empirical time and motion studies to ascertain the resources required to undertake safe medical care at times of peak demand.

Chapter 10 covers endocrinology and metabolic disorders, including diabetes and diabetic coma, abnormalities of sodium and potassium, calcium, magnesium, and phosphate, metabolism, acid-base balance, thyroid emergencies, pituitary emergencies, adrenal emergencies, and toxin-induced hyperthermic syndromes.

Objectives Reliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process at an acute hospital with the aim of improving the provision of information and documentation of reliable medication lists to enable clear, timely communications on discharge. Setting An acute 400-bedded teaching hospital in London, UK. Participants The effects of change were measured in a simple random sample of 10 adult patients a week on the acute admissions unit over 18 months. Interventions Quality improvement methods were used throughout. Interventions included education and training of staff involved at ward level and in the pharmacy department, introduction of medication documentation templates for electronic prescribing and for communicating information on medicines in discharge summaries co-designed with patient representatives. Results Statistical process control analysis showed reliable documentation (complete, verified and intentional changes clarified) of current medication on 49.2% of patients' discharge summaries. This appears to have improved (to 85.2%) according to a poststudy audit the year after the project end. Pharmacist involvement in discharge reconciliation increased significantly, and improvements in the numbers of medicines prescribed in error, or omitted from the discharge prescription, are demonstrated. Variation in weekly measures is seen throughout but particularly at periods of changeover of new doctors and introduction of new systems. Conclusions New processes led to a sustained increase in reconciled medications and, thereby, an improvement in the number of patients discharged from hospital with unintentional discrepancies (errors or omissions) on their discharge prescription. The initiatives were pharmacist-led but involved close working and shared understanding about roles and responsibilities between doctors, nurses, therapists, patients and their carers.

Our study reviewed policies in 8 high-income countries (Australia, Canada, United States, Italy, Spain, United Kingdom, Croatia and Estonia) in Europe, Australasia and North America with regard to hospitals in rural or remote areas. We explored whether any specific policies on hospitals in rural or remote areas are in place, and, if not, how countries made sure that the population in remote or rural areas has access to acute inpatient services. We found that only one of the eight countries (Italy) had drawn up a national policy on hospitals in rural or remote areas. In the United States, although there is no singular comprehensive national plan or vision, federal levers have been used to promote access in rural or remote areas and provide context for state and local policy decisions. In Australia and Canada, intermittent policies have been developed at the sub-national level of states and provinces respectively. In those countries where access to hospital services in rural or remote areas is a concern, common challenges can be identified, including the financial sustainability of services, the importance of medical education and telemedicine and the provision of quick transport to more specialized services.

Background Several triage systems have been developed for use in the emergency department (ED), however they are not designed to detect deterioration in patients. Deteriorating patients may be at risk of going undetected during their ED stay and are therefore vulnerable to develop serious adverse events (SAEs). The National Early Warning Score (NEWS) has a good ability to discriminate ward patients at risk of SAEs. The utility of NEWS had not yet been studied in an ED. Objective To explore the performance of the NEWS in an ED with regard to predicting adverse outcomes. Design A prospective observational study. Patients Eligible patients were those presenting to the ED during the 6 week study period with an Emergency Severity Index (ESI) of 2 and 3 not triaged to the resuscitation room. Intervention NEWS was documented at three time points: on arrival (T0), hour after arrival (T1) and at transfer to the general ward/ICU (T2). The outcomes of interest were: hospital admission, ICU admission, length of stay and 30 day mortality. Results A total of 300 patients were assessed for eligibility. Complete data was able to be collected for 274 patients on arrival at the ED. NEWS was significantly correlated with patient outcomes, including 30 day mortality, hospital admission, and length of stay at all-time points. Conclusion The NEWS measured at different time points was a good predictor of patient outcomes and can be of additional value in the ED to longitudinally monitor patients throughout their stay in the ED and in the hospital.

Objective To find out what questions the public ask of pharmacists on a hospital medicines information helpline, and to assess the potential for improving individuals' management of medicines through telephone helpline support. Methods We analysed consecutive phone calls made by members of the public over 6 months to a hospital pharmacy medicines information helpline. Calls were coded for type of medicine, reason for phoning and any error revealed in the call. We also looked at which medicines were associated with harm and/or potential for harm had the caller not enquired about appropriate action to take. Key findings Five hundred of the 923 consecutive calls to the helpline were from members of the public (including discharged hospital patients). Antimicrobial agents, analgesics and cardiovascular medicines accounted for approximately half of all calls. The reason for phoning was most often to ask about interactions (22%), directions for use (21%) or advice on adverse effects (15%). In a third of calls it is possible an error had occurred (including patient error and directions missing from a dispensed item). Forty-eight per cent of calls were concerned with harm or judged to have potential for harm had professional information not been available. Four of these cases (0.8%), one of which was patient error and three of which were adverse effects reported by the caller, were categorised as Harm Index category F, defined as requiring intervention and referral. Conclusions Our medicines information helpline appears to be a valuable resource for discharged patients and public and the advice given may be expected to improve safety with medicines and reduce harm. Our results reveal gaps in patient education about their medicines, some of which could be addressed by dispensing staff or the pharmacist at discharge. The data provide a baseline for measuring improvements in medicines management and will be useful in identifying patients who may benefit from follow-up call support from pharmacists.

Purpose To assess the effectiveness of acute medical units (AMUs) in hospitals. Data sources (i) Controlled and observational studies in peer-reviewed journals retrieved from PubMed, EPOC, CINAHL and ERIC databases published between January 1990 and July 2008; and (ii) reports from non-peer-reviewed websites combined with Google search. Study selection Articles reporting effects of the introduction of an AMU on mortality, length of stay, discharge disposition, readmissions, resource use and patient and/or staff satisfaction. Data extraction Data on unit operations and outcome measures were extracted by a single author and confirmed by a second author, with disagreement settled by consensus. Results of data synthesis Nine peer-reviewed reports of before–after analyses of seven units introduced into the UK and Ireland were analysed. Two studies, one prospective, reported significant reductions in in-patient mortality between 0.6 and 5.6% points following commencement of AMU. Four studies reported significant reductions in the length of stay between 1.5 and 2.5 days. Waiting times for patient transfer from emergency departments to medical beds decreased by 30% in one study. In three studies, the proportion of medical patients discharged directly home from the AMU increased by 8–25% points. Three studies noted no increase in 30-day readmission rates following unit commencement. Two studies described significant improvements in patient and staff satisfaction with care. Eight non-peer-reviewed reports relating to 48 units confirmed reductions in the length of stay. Conclusion Limited observational data suggest AMUs reduce in-patient mortality, length of stay and emergency department access block without increasing readmission rates, and improve patient and staff satisfaction.