Wednesday, 2 June 2010

Consultants: a chronic problem for acutely ill patients

An editorial “Consultants: a chronic problem for acutely ill patients” in Clinical Medicine, the Journal of the Royal College of Physicians of London (Volume 10, Number 2, April 2010) by Matt Wise and Paul Frost (Consultants in intensive care medicine in Cardiff) highlights the tension between the way consultants work and the quality of care acutely unwell people receive. Matt was a clinical advisor for the National Confidential Enquiry into Patient Outcomes and Deaths report on Acute Kidney Injury: Adding Insult to Injury.

One of the key findings of Adding Insult to Injury was that nearly a quarter of patients didn’t have adequate senior review. These individuals were judged by the expert assessors to have less good care overall. The lack of consultant involvement has been a recurring message from NCEPOD, being implicated in adverse outcomes for cardiac patients, trauma patients, emergency admissions and acutely ill medical patients. Unfortunately this observation is not new. The authors of the editorial cite the latest census of consultant physicians in the UK showing that as few as 56% undertake twice daily ward rounds for acute admissions and that the majority of consultants (78%) have other duties while being responsible for acute admissions. Despite the fact that whole time consultants work in excess of the average contracted 45 hours per week. They point out that it would make no sense to an impartial observer why the sickest patient is seen by the most inexperienced clinicians first and only seen by the most experienced at the end of the admission process.

In the same issue of clinical medicine Josip Stosic (a Specialist Registrar in Acute Medicine) and colleagues from the James Paget hospital, Great Yarmouth, describe the role of the acute physician and the future of acute hospital care in the UK. This is an encouraging development. Acute physicians have been shown to be more efficient, less wasteful and speedier to respond to the needs of patients than other physicians in the hospital environment. Perhaps because they are not rostered to be doing routine activity such as outpatient clinics or endoscopy lists as well as managing the “acute take”.

Adding insult to injury” found that the overwhelming majority of people who died of AKI were under general medicine or care of the elderly physicians. Less than 2% were initially admitted under renal physicians. Improvement in the recognition of risk for AKI, early detection and prompt management will only occur when the teams managing the acutely unwell have a better understanding of AKI. Shortly after the NCEPOD report came out one medical director said to me that AKI is really the “miner’s canary” for acute physicians. Early AKI flags that the patient is more unwell than we might otherwise believe. Improving the management of AKI will improve the management of all acutely unwell patients. It is not a matter of either improve AKI or improve, for instance, the management of chest pain. The systematic changes that will improve AKI, attention to fluid balance, early treatment of sepsis, structured medicines management and prompt senior medical review will have a beneficial effect for all acutely unwell individuals. It is not possible to improve AKI without changing the way we manage acute admissions and improvements in the management of acutely unwell can’t be delivered without also improving the care and outcomes of the 20% of acute admissions that develop AKI.

Acute physicians know this – which is very encouraging. The Society for Acute Medicine held a symposium on AKI at the start of its recent Spring meeting in Yarm near Middlesborough. Vincent Connolly, Acute Physician, James Cook University Hospital, Middlesborough and local organiser opened the meeting and set the scene using a discourse on the various names that people from the towns and cities of the North East are known by – they are not all Geordies!! The plethora of titles for citizens of this region resonates with a long list of different names we have used for AKI over the years. My title was learning from mistakes – and one of those is that the nomenclature has been a recipe for disaster! The soon to be published AKI Network definition and universal adoption of an easy to use staging system will be a big advance. David Rioch, Consultant Renal Physician of the South Tees Foundation Trust walked through a week on-call taking acute referrals – the patient with a Vancomycin level of 48.2mg/l (reference range 10-15mg/l) being one of the most remarkable. Jonathan Louden, one of Dave’s colleagues, talked about the systematic approach they are taking in detection and prevention – using automatic alerts and staff training. Alistair Douglas, a friend from our days as renal trainees in Edinburgh, although Alistair saw the light and is now an acute physician at Ninewells Hospital in Dundee, spoke about the central role of the acute healthcare team in AKI – the importance of undertaking an AKI assessment in parallel with early warning scoring, the approach, skills and levels of competency of the acute team – not only doctors but also nurses and pharmacists, Phil Dyer, Consultant Acute Physician from the Heart of Birmingham Hospital and President of SAM Chaired the lively discussion and I went away convinced that acute physicians have AKI on their “to do” list. Unfortunately I left so quickly that I missed the posters, several of which were about AKI.