Reliable consultant level data from an Acute Medical Unit: a powerful tool for improvement.

The development of a novel database interrogating the patient management system in the Acute Medical Unit at Forth Valley Royal Hospital, Scotland, has allowed, for the first time, acquisition of reliable individual consultant-level process and outcome data over a 2-year period. These data have a number of uses, including understanding the level of variation between consultant physicians in AMU across key indicators, such as direct discharge percentage (67.5-44.3%), and readmission percentage (4.0-6.8%). Looking at overnight admissions only effectively excluded case mix as a confounder to identify variation in 30-day mortality (0-2.8%). This has allowed benchmarking, and exploring of relationships between volume of work, physician experience, and patient outcomes. For example, no significant relationship was seen between direct discharge percentage and readmission percentage. Furthermore it is extremely useful for individual clinician appraisal and governance. Finally it has practical uses when designing consultant rotas in order to minimise system variation. A key consideration throughout this work has been clear provenance and local clinical ownership of these data, unlike centrally generated data that may not accurately reflect Acute Medical Unit activity.

Impact of a new daily rapid access medical clinic in a Scottish district general hospital.

BACKGROUND: Medical admissions to hospital in the UK are rising by approximately 10% per year. A Medical Assessment Unit (MAU) was opened to help deal with the rising influx of patients. The objectives of this study were to determine if a daily rapid access medical clinic could provide a safe alternative to hospital admission and aid safe discharge for medical patients. METHODS: The rapid access clinic was embedded within the MAU, utilising existing resources. Patients were allocated and reviewed by a senior acute medicine specialist registrar (SpR). Data were collected from January to September 2008. RESULTS: 74 patients seen in the clinic were analysed. 93% of these were managed in an ambulatory fashion, avoiding admission and saving a potential 280 bed days. The same day discharge rate of all patients seen and assessed in the MAU was increased from 17% to 26% (p<0.001), following institution of the clinic. The readmission rate fell from 8% to 4% (p=0.12). CONCLUSIONS: A daily rapid access medical clinic embedded within a MAU was piloted and allowed the safe management of a variety of medical complaints in an ambulatory fashion. It enabled an increase in the discharge rate of patients referred for admission by general practitioners. This seemed to be more robust than as evidenced previously by a trend towards lower readmission rates. These results were dependent on the presence of a senior clinical decision maker to facilitate safe discharges.

Improvement in time to treatment following establishment of a dedicated medical admissions unit.

The importance of medical admissions units (MAU) has been emphasised by the royal colleges and the Society for Acute Medicine. This study looked at the time to treatment of four common medical conditions before and after the establishment of a dedicated MAU. Before the development of the MAU, treatment given in the emergency department (ED; median 111 minutes) was significantly quicker than on the admitting general medical ward (median 262 minutes, p<0.001). Following the establishment of the MAU, treatment given in the ED (median 70 minutes) remained significantly quicker than on the MAU (median 180 minutes, p<0.05). Treatment was given significantly quicker on the MAU compared with the antecedent admitting medical wards (p<0.05). In addition, more patients were treated within protocol-driven time guidelines. In summary, the establishment of a MAU significantly improved time to treatment, compared with admitting directly to general medical wards. This has implications for patients who are boarded directly to medical wards when the MAU is at full capacity.

Improvement in out-of-hours outcomes following the implementation of Hospital at Night.

BACKGROUND: Hospital at Night (H@N) is a Department of Health (England) driven programme being widely implemented across UK. It aims to redefine how medical cover is provided in hospitals during the out-of-hours period. AIM: To investigate whether the implementation of H@N is associated with significant change in system or clinical outcomes. DESIGN: An observational study for 14 consecutive nights before, and 14 consecutive nights after the implementation of H@N. Data were collected from the Combined surgical and medical Assessment Unit (CAU), the 18 medical/surgical wards (The Ward Arc) and the four High Dependency Units (The Critical Care corridor) within the Royal Infirmary of Edinburgh. METHODS: Following an overnight episode of clinical concern, data were gathered on response time, seniority of reviewing staff, patient outcome and the use of Standardized Early Warning Score (SEWS). RESULTS: Two hundred and nine episodes of clinical concern were recorded before the implementation of H@N and 216 episodes afterwards. There was no significant change in response time in the CAU, Ward Arc or Critical Care corridor. However, significant inter-speciality differences in response time were eradicated, particularly in the Critical Care corridor. Following the implementation of H@N, patients were reviewed more frequently by senior medical staff in CAU (28% vs. 4%, P < 0.05) and the Critical Care corridor (50% vs. 22%, P < 0.001). Finally there was a reduction in adverse outcome (defined as unplanned transfer to critical care/cardiac arrest) in the Ward Arc and CAU from 17% to 6% of patients reviewed overnight (P < 0.01). SEWS was more frequently and accurately recorded in CAU. CONCLUSION: This is the first study that we are aware of directly comparing out-of-hours performance before and after the implementation of H@N. Significant improvements in both patient and system outcomes were observed, with no adverse effects noted.

The flavin-containing monooxygenase 2 gene (FMO2) of humans, but not of other primates, encodes a truncated, nonfunctional protein.

Flavin-containing monooxygenases (FMOs) are NADPH-dependent flavoenzymes that catalyze the oxidation of heteroatom centers in numerous drugs and xenobiotics. FMO2, or "pulmonary" FMO, one of five forms of the enzyme identified in mammals, is expressed predominantly in lung and differs from other FMOs in that it can catalyze the N-oxidation of certain primary alkylamines. We describe here the isolation and characterization of cDNAs for human FMO2. Analysis of the sequence of the cDNAs and of a section of the corresponding gene revealed that the major FMO2 allele of humans encodes a polypeptide that, compared with the orthologous protein of other mammals, lacks 64 amino acid residues from its C terminus. Heterologous expression of the cDNA revealed that the truncated polypeptide was catalytically inactive. The nonsense mutation that gave rise to the truncated polypeptide, a C --> T transition in codon 472, is not present in the FMO2 gene of closely related primates, including gorilla and chimpanzee, and must therefore have arisen in the human lineage after the divergence of the Homo and Pan clades. Possible mechanisms for the fixation of the mutation in the human population and the potential significance of the loss of functional FMO2 in humans are discussed.