Assessment and management of patients detained under Section 136 in Northwick Park Hospital emergency department

AimsTo evaluate the role of the Emergency Medicine team (EM) within a London Emergency Department (ED) in assessing and managing patients detained under Section 136 of the Mental Health Act, 1983 (S136).BackgroundS136 allows detention and transfer of people to ED and psychiatric hospitals for further assessment. EDs are optimised for the investigation and management of the medically unwell, but attending ED may also delay access to psychiatric services if required. Minimal research has been performed to investigate the relative benefits of transferring people under S136 to ED versus psychiatric hospitals.MethodElectronic notes were searched to identify those attending under S136 between 01/04/2017 and 31/03/2018. Scanned medical notes were reviewed and data extracted regarding patient demographics, length of ED stay, reason for S136 use, investigations and interventions undertaken by EM.ResultThis identified 95 attendances by 87 patients. The mean age was 35 years (range 15-75) and 59% of attenders were male. The mean duration of stay was 7 hours 34 minutes (range 6 minutes - 25 hours 50 minutes).Reasons for S136 use were abnormal behaviour (32), expressed suicidal ideation (29), overdose (15), self-harm (13), overdose plus self-harm (4), being found wandering (1) and was unclear for 1 presentation.In 39 attendances no investigations beyond history and examination were performed by EM. Only 6 patients had investigations that were not bloods, electrocardiogram or urinalysis. These included X-radiograph trunk (4), computed tomography (CT) head (3), X-radiograph limb (3), CT cervical spine (1), Focused Assessment with Sonography for Trauma (1).No interventions were given by EM in 55 attendances. Twenty-nine different medications were prescribed and 18 patients were prescribed intravenous fluids. Three had wounds dressed, 3 glued, 3 sutured and 1 stapled.ConclusionThere were difficulties categorising the reason for S136 use, as clear documentation was often unavailable, but the vast majority of patients were detained due to abnormal behaviour, expressed suicidal ideation and self-harm.Few attending ED under S136 received investigations or interventions that could not be offered within a psychiatric hospital. There was a wide range in duration of stay within ED, however 65% of attendances were longer than the standard 4 hour target.Future research may assess the relative benefits of ED versus psychiatric hospitals in assessing those detained. This could aid services in meeting both the physical and psychiatric needs of patients whilst making efficient use of available resources.

Medical students learning on the COVID-19 frontline (Preprint)

UNSTRUCTURED This is a personal view about our perspectives, as medical students at Imperial College London, on our experiences during our infectious diseases placement at Northwick Park Hospital, touching upon other students’ experiences at other sites. These highlight some of the main drivers and barriers that motivate or dissuade medical students from seeing COVID-19 positive patients.

Global Leadership in Paediatric and Congenital Cardiac Care: “Coding our way to improved care: an interview with Rodney C. G. Franklin, MBBS, MD, FRCP, FRCPCH”

Dr Rodney Franklin is the focus of our third in a planned series of interviews in Cardiology in the Young entitled, “Global Leadership in Paediatric and Congenital Cardiac Care.” Dr Franklin was born in London, England, spending the early part of his childhood in the United States of America before coming back to England. He then attended University College London Medical School and University College Hospital in London, England, graduating in 1979. Dr Franklin would then go on to complete his general and neonatal paediatrics training in 1983 at Northwick Park Hospital and University College Hospital in London, England, followed by completing his paediatric cardiology training in 1989 at Great Ormond Street Hospital for Children in London, England. During this training, he additionally would hold the position of British Heart Foundation Junior Research Fellow from 1987 to 1989. Dr Franklin would then complete his training in 1990 as a Senior Registrar and subsequent Consultant in Paediatric and Fetal Cardiology at Wilhelmina Sick Children’s Hospital in Utrecht, the Netherlands. He subsequently obtained his research doctorate at University of London in 1997, consisting of a retrospective audit of 428 infants with functionally univentricular hearts.Dr Franklin has spent his entire career as a Consultant Paediatric Cardiologist at the Royal Brompton & Harefield Hospital NHS Foundation Trust, being appointed in 1991. He additionally holds honorary Consultant Paediatric Cardiology positions at Hillingdon Hospital, Northwick Park Hospital, and Lister Hospital in the United Kingdom, and Honorary Senior Lecturer at Imperial College, London. He has been the Clinical Lead of the National Congenital Heart Disease Audit (2013–2020), which promotes data collection within specialist paediatric centres. Dr Franklin has been a leading figure in the efforts towards creating international, pan European, and national coding systems within the multidisciplinary field of congenital cardiac care. These initiatives include but are not limited to the development and maintenance of The International Paediatric & Congenital Cardiac Code and the related International Classification of Diseases 11th Revision for CHD and related acquired terms and definitions. This article presents our interview with Dr Franklin, an interview that covers his experience in developing these important coding systems and consensus nomenclature to both improve communication and the outcomes of patients. We additionally discuss his experience in the development and implementation of strategies to assess the quality of paediatric and congenital cardiac care and publicly report outcomes.

Title: Risk factors for severe disease in patients admitted with COVID-19 to a hospital in London, England: a retrospective cohort study

COVID-19 has caused a major global pandemic and necessitated unprecedented public health restrictions in almost every country. Understanding risk factors for severe disease in hospitalized patients is critical as the pandemic progresses. This observational cohort study aimed to characterize the independent associations between the clinical outcomes of hospitalized patients and their demographics, comorbidities, blood tests and bedside observations. All patients admitted to Northwick Park Hospital, London, United Kingdom between 12 March and 15 April 2020 with COVID-19 were retrospectively identified. The primary outcome was death. Associations were explored using Cox proportional hazards modelling. The study included 981 patients. The mortality rate was 36.0%. Age (adjusted hazard ratio (aHR) 1.53), respiratory disease (aHR 1.37), immunosuppression (aHR 2.23), respiratory rate (aHR 1.28), hypoxia (aHR 1.36), Glasgow Coma Score <15 (aHR 1.92), urea (aHR 2.67), alkaline phosphatase (aHR 2.53), C-reactive protein (aHR 1.15), lactate (aHR 2.67), platelet count (aHR 0.77) and infiltrates on chest radiograph (aHR 1.89) were all associated with mortality. These important data will aid clinical risk stratification and provide direction for further research.

Risk factors for severe disease in patients admitted with COVID-19 to a hospital in London, England: a retrospective cohort study

COVID-19 has caused a major global pandemic and necessitated unprecedented public health restrictions in almost every country. Understanding risk factors for severe disease in hospitalised patients is critical as the pandemic progresses. This observational cohort study aimed to characterise the independent associations between the clinical outcomes of hospitalised patients and their demographics, comorbidities, blood tests and bedside observations. All patients admitted to Northwick Park Hospital, London, UK between 12 March and 15 April 2020 with COVID-19 were retrospectively identified. The primary outcome was death. Associations were explored using Cox proportional hazards modelling. The study included 981 patients. The mortality rate was 36.0%. Age (adjusted hazard ratio (aHR) 1.53), respiratory disease (aHR 1.37), immunosuppression (aHR 2.23), respiratory rate (aHR 1.28), hypoxia (aHR 1.36), Glasgow Coma Scale <15 (aHR 1.92), urea (aHR 2.67), alkaline phosphatase (aHR 2.53), C-reactive protein (aHR 1.15), lactate (aHR 2.67), platelet count (aHR 0.77) and infiltrates on chest radiograph (aHR 1.89) were all associated with mortality. These important data will aid clinical risk stratification and provide direction for further research.

Non-Cardiac Chest Pain

We read with interest “Non-Cardiac Chest Pain: Management in the Ambulatory Clinic setting” (Acute Med 2019;18(3)165-70). It is useful to know about the various musculoskeletal causes of chest pain, especially where specific treatment may be available. We were alarmed, however, about the discussion of pleural pain. This is a common presenting complaint to acute medical teams both on the acute medical take and on ambulatory care units. The authors do not list a differential diagnosis for pain of pleural origin, apart from pulmonary embolism. A chest radiograph is recommended, as well as either a WELL’s (sic) score or D-dimer. Furthermore, bedside lung ultrasound is recommended if the chest radiograph is normal, despite limited availability and training in the UK. Ironically, the reference provided (Aydogdu M et al, Tuberk Toraks 2014;62:12-21) is much more reflective of the modern approach to suspected pulmonary embolism. It discusses the PERC (PE rule-out criteria) which perform very well in people who present with chest pain, and reduces reliance on D-dimer testing. D-dimer testing should never be performed without determining a pre-test probability using validated scores such as the Wells score. As the authors suggest, not all chest pain that worsens with inspiration is “pleuritic”. In addition, substernal pain with a respiratory component does not increase the likelihood of PE, whereas lateral and posterior pain does (Kline J, Thomb Res 2018;163:207-20). Kind regards, Jacob F. de Wolff FRCP Katherine M. Fawcett FRCP Consultant Acute Physicians Northwick Park Hospital

Malignant features of a benign waiting list

Objective: Transurethral resection of the prostate (TURP) operations are frequently deferred. Consequently, patients awaiting TURP have multiple urology-related admissions for problems such as urinary retention. This audit aims to determine the effect of TURP deferments on the frequency and duration of urology-related admissions, as well as the financial implication in our institution over a three-month period. Patients and methods: A retrospective, electronic database review of patients who received a TURP at Northwick Park Hospital, between 1 January 2014–31 March 2014, was carried out. The following data were extracted: (a) date the patient was listed for TURP; (b) date patient underwent TURP; (c) number of deferments between a patient being listed for surgery and receiving their operation; (d) reason(s) for deferment; and (e) number, duration and indication of urology-related inpatient admissions whilst awaiting TURP. Using this data, we calculated the cost of urology-related admissions whilst awaiting surgery. Results: In total, 44 patients underwent a TURP operation. Of these, 21 patients had their TURP deferred. There were 23 urology-related admissions whilst patients awaited a TURP. Fifteen of these admissions were attributed to eight patients with deferments to surgery. They spent a total of 45 days/30 nights in hospital. The remaining eight urology-related admissions were accounted for by six patients with no deferments to surgery. They spent 12 days/3 nights in hospital. We approximate a daily cost of £250 for an NHS bed. This equates to a total cost of £11,250 (£1406 per patient) for the eight patients who had TURPs deferred versus £3000 (£500 per patient) for those six patients without deferments. Conclusion: Patients who have their TURP operations deferred have an increased frequency and duration of urology-related admissions, associated with an additional cost of at least £900 per patient.