Inpatient medical care

1 Inpatient medical care



Chapter Contents


Good medical practice 1

Pre- and peri-operative care and assessment 3

Specific interviews 5

Patient safety and infection control 6

Prescribing 7

Adverse drug reactions 11

Clinical trials 12

Statistical analysis 14

Do Not Attempt Resuscitate (DNAR) orders 15

Care of the dying 15

Specific clinical problems 17


Good medical practice



Providing good clinical care


Good medical care depends upon a good relationship between the doctor and the patient. The quality of care is improved with better patient communication, along with trust, honesty and openness about decisions that are made in partnership with the patient.


The General Medical Council in the UK has published guidance for doctors and outlines their duties of care (www.gmc-uk.org). National practices differ from country to country but all have similar regulatory bodies and guidance. Remember:


• Respect the views of your patients, including their ethnic and cultural background.

• Discuss their diagnosis, prognosis and treatment with them.

• Give them the necessary information to make their own decisions.

Doctors have a duty to keep up to date and to practise evidence-based medicine. Continuing professional development is necessary to achieve this. They must:


• recognize the limits of their competence

• prescribe drugs or treatment only with an adequate knowledge of the patient’s health

• provide treatments based on the best available evidence

• respect the patient’s right to ask for a second opinion

• seek consent for any procedure or treatment

• seek senior help or advice where appropriate

• respect confidentiality in practice

• respect autonomy in the treatment of vulnerable patients and those with psychiatric illness

• know the ethical and legal boundaries of the duty to protect life and health.


Clinical records


Records should be written with a pen and be dated and signed, with a printed name below the signature. They must be legible, clear and accurate. They must include clinical findings, investigations and treatment(s) prescribed, the consent given, the decisions made and the information given to the patient, with details of follow-up or referrals. Records should be updated at the time of seeing the patient or soon after. The original record should never be altered but an additional note (signed and dated) should be made alongside any mistake. Records should be kept in a secure place. Computerized records are increasingly being used in some countries.



Assessment and general management



• Take a history, including psychological and social factors.

• Examine the patient.

• Arrange appropriate investigations.

• Arrange appropriate treatment with the patient’s consent.

There are validated scoring systems that help assess how ill the patient is. An example is the Modified Early Warning Score.



Modifed Early Warning Score (MEWS)


This simple physiological scoring system (Table 1.1) can be used at the bedside in a medical admission unit. It identifies patients at risk of deterioration who will require a higher level of care in either an HDU or an ICU.



Table 1.1 Modified Early Warning Score (MEWS)

image

A nurse or healthcare worker can record six vital signs on a chart (heart rate, respiratory rate, blood pressure, conscious level, temperature and hourly urine output for the previous 2 hours). A score of between 1 and 3 is recorded for each vital sign. The sum of all the scores determines the MEWS score. A score of 4 and above will prompt the nurse to call the patient’s doctor, and scores of 5 or more are associated with an increased risk of death and immediate admission to HDU or ICU.


Communication between handing-over teams can also be a problem in busy clinical environments. A suggested proforma that covers the essential factors in transferring patient care is SBAR (situation, background, assessment, recommendation — NHS Institute for Innovation and Improvement).



SBAR


This is a mechanism by which teams can clarify what information should be communicated between members of the team. It develops better communication and teamwork, leading to increased patient safety. Standardized prompt questions in the four sections listed below are used to ensure that members of staff share concise and focused information with the correct level of detail. SBAR aids good communication and encourages prompt action on the part of the receiver.



• S Situation



• Identify yourself and the site/unit you are calling from.

• Identify the patient by name, consultant, patient location and vital signs. Give a reason for your report.

• Describe your concern.


• B Background



• Give the reason for the patient’s admission.

• Explain the significant medical history.

• Give a brief summary of the background.


• A Assessment



• Vital signs — heart rate, respiratory rate, oxygen saturations, BP, temperature, AVPU (alert, responds to voice, responds to pain, unresponsive; a patient responding to pain only is equivalent to a patient with a Glasgow coma score of <8).

• MEWS score.

• Clinical impression, severity of patient, additional concern.


• R Recommendation



• Explain what you need — be specific about the request and time frame.

• Make suggestions.

• Clarify expectations.


Pre- and peri-operative care and assessment


The aim of these assessments is to reduce the morbidity and mortality of patients undergoing surgery. Most units run pre-operative clinics prior to admission for surgery. Many procedures are performed as day cases, with local or spinal anaesthesia or short general anaesthetics.


The general condition of the patient is reviewed; cardiovascular and respiratory problems can often be addressed and treated prior to surgery. A commonly used five-point grading system has been developed by the American Society of Anesthesiologists (ASA):


• ASA I Healthy patient

• ASA II Mild systemic disease, no functional disability

• ASA III Moderate systemic disease, functional disability

• ASA IV Severe systemic disease, life-threatening

• ASA V Moribund, unlikely to survive 24 hours with or without an operation.

Anaemia, malnutrition, and electrolyte and metabolic disturbances should also all be corrected prior to surgery, if possible. Evaluation by the anaesthetist is performed in patients with chronic disorders and in those who are at high risk, e.g. the acutely ill.



History and examination


A full history with co-morbidities (particularly in the elderly) should be documented and an examination performed.



Co-morbidities



• Diabetes mellitus. Management is described on p. 595.

• Ischaemic heart disease. The incidence of myocardial infarctions in patients with previous heart attacks is >25%, compared to 0.2% in the healthy. Elective procedures should be delayed for at least 6 months (urgent surgery for 3 months) after an infarct. Unstable angina constitutes a very high risk.

• Hypertension. This should be controlled, as untreated hypertension carries a higher risk for myocardial infarctions and cerebrovascular disorders.

• Liver disorders. The risks depend on the aetiology of the disorder. Defer surgery in jaundiced patients with abnormal coagulation until the jaundice has resolved; relieve any biliary obstruction by stenting and give vitamin K (10 mg slow IV injection). The Child–Pugh classification can be used for patients with chronic liver disease to predict their operative mortality: class A (up to 10%) to class C (50–70%). Drugs that are metabolized by the liver are contraindicated in these patients and should only be prescribed if absolutely essential. The nursing and medical staff should be informed if the patient is hepatitis B- or C-positive, or HIV-positive.

• Respiratory problems. Pre-operative evaluation will require an assessment of lung function — spirometry with ABGs if the spirometry is abnormal and patients have long-term respiratory problems.

• Current medication. This should be noted and decisions made about continuation of therapy, particularly if the patient is on anticoagulants or antiplatelet therapy.

• Drug allergies/sensitivities. These should be noted with the reaction to the drug in the clinical record and a red (instead of a white) armband attached to the patient’s wrist.

• Smoking. Patients should be informed of the risks associated with smoking, and the benefits of stopping smoking prior to surgery must be emphasized. These include decreased sputum production, improved sputum clearance by cilia (often within 1–2 days of stopping smoking), increased oxygen-carrying capacity of the blood, reduced concentration of circulating nicotine (can cause vasoconstriction) and less bronchospasm.

• Alcohol. An assessment of alcohol intake should be made when taking the history. Patients may have alcohol-related chronic liver disease or develop acute alcohol withdrawal in the early post-operative period. Alcohol also causes an induction of the liver enzymes involved in the metabolism of some of anaesthetic drugs.

Elective surgery carries less risk of peri-operative problems than emergency surgery, in which there are often many co-morbidities and the patient is seriously ill.



Routine pre-operative tests


These are often not necessary in a patient undergoing minor or elective surgery.


• FBC — not unless there are co-morbidities or if more than a very small amount of blood is expected to be lost

• Coagulation tests — not necessary unless there is a bleeding disorder, the patient is on anticoagulants, or epidural anaesthesia is planned

• LFTs, biochemistry and U&E — not unless there are co-morbidities

• CXR — only for those with cardio-respiratory problems

• ECG — for the elderly or patients with a history of heart disease, or if examination revealed a cardio-respiratory problem

• Blood group and cross-matching — depending on the nature of the operation.


Prophylaxis for deep vein thrombosis


Anti-DVT/VTE measures include early ambulation, which reduces the risk of DVT/PE. Graduated compression stockings (unless patient has peripheral arterial disease) and low-molecular-weight heparin or oral anti-thrombotic agents e.g. dabigatran or rivaroxaban should be used. See p. 245 for details.



Beta-blockers


The current evidence supporting β-blocker therapy in non-cardiac surgery is poor and it should not be used, apart from in very ‘high-risk’ patients.



Post-operative care


The overall aim is to prevent complications or to detect them early, should they arise.


• Fluid and electrolyte balance — p. 369.

• Care of wounds, sutures and drains

• Pain control — p. 25.

• Early ambulation

• Physiotherapy — given particularly for chest, orthopaedic and peripheral vascular operations.

• Complications — treated as necessary, e.g. chest infections with antibiotics.

• Arrangements for discharge to home or convalescence — should be addressed early in the post-operative period so that arrangements can be made.


Specific interviews



Obtaining consent


Doctors seeking consent for a particular procedure must have proper knowledge of how the procedure is performed and its possible complications.


• Consent must be ‘informed’ to an adequate standard.

• Patients must be competent to consent to treatment.

• Patients must not be coerced into accepting treatment against their wishes.

• The doctor and patient should both sign the consent form before the procedure.

Patients need to weigh up the pros and cons of proposed treatments. They cannot do so without the basic ability to reason about information concerning what is wrong with them, what their doctors propose to do about it, and what potential benefits and risks are involved in treatment. Common and serious potential adverse events should be discussed with the patient.



Breaking bad news


These interviews are often difficult. The aim is to make sure that the patient is enabled to understand and make the best of even very bad circumstances. These interviews should always be carried out in a quiet place and without interruption; if possible, patients should have someone with them. Explain your status and your responsibility to them.


It is always best to start off by finding out how much patients know about their condition and how they feel about their illness. Some indication should then be given by the clinician that the news is bad and possibly more serious than initially thought. Pause here to allow the patient to think. It might be worthwhile going through the results of investigations and explaining how the diagnosis has been confirmed. Give information in small chunks, being honest and not hedging about the diagnosis. Avoid technical terms and check that patients understand what you are telling them. Diagrams may be helpful.


Watch for the patient’s reactions; if the patient is too upset, it may be that you will have to return to continue the interview. Talk about the treatments that are available to provide a good quality of life, e.g. dealing with pain and some other symptoms. Always provide some positive information and hope but do not be overly optimistic.


Responding to the patient’s emotions can be very difficult. The patient may become very upset but the clinician may also be upset. Empathize as much as possible. Answer their questions. The patient might ask about the time frame of the illness. This is very difficult to give so do not provide a figure.


End with a date and time for a further interview (preferably soon) to answer questions and also to see other members of the family that the patient wishes you to see. Give a contact name and number, and also supply contact addresses of good support organizations. Write what you have told the patient and the patient’s wishes clearly in the clinical records.



Patient safety and infection control


Patients admitted to hospitals are in unfamiliar surroundings, are incapacitated and are susceptible to infections due to their illness, e.g. because of poor nutrition, as well as being exposed to hospital-acquired infections.


Approximately 10% of patients contract healthcare-acquired infections (HCAIs; previously called nosocomial infections). Risk factors for HCAIs include being on mechanical ventilation, trauma, prolonged length of stay in hospital and the presence of catheters (IV, urinary, naso-gastric tubes). Cross-infection is a problem, particularly with MRSA.


A safety culture must be fostered amongst all healthcare professionals, as preventable harm in healthcare is nearly always caused by medical errors and system failures. To do this, the awareness of possible problems must be raised and a safety culture of openness and learning ensured, along with sustained good risk management.


• Infection control measures. Poor infection control practice in hospitals and other healthcare environments can cause the transfer of infection from person to person. Transfer may be airborne, via fomites, or via a direct contact route. It is essential that all healthcare workers wash or clean their hands before and after patient contact; whenever necessary, they should wear gloves, aprons and other personal protective equipment. This is particularly necessary when performing invasive procedures or manipulating indwelling devices, such as cannulae. Indwelling lines must be checked regularly for signs of infection and this observation should be documented in the notes. Alcohol-based hand washes, which are freely available in the hospital, are a quick and easy alternative to hand washing but they do not prevent the spread of Clostridium difficile, which requires formal hand washing for physical removal of spores from the hands.
• Air-borne transmission prevention again relies on hand washing and also on the use of masks by patient and healthcare worker. Positive pressure isolation is used for patients having cancer chemotherapy treatments.

• Isolation facilities should always be available, e.g. for MRSA infection.

• Antibiotics. Antibiotics, particularly broad-spectrum ones, e.g. cephalosporins, should only be used when absolutely necessary, as hospital-acquired infections (particularly C. difficile and MRSA) have been linked to hospital over-prescribing. Many hospitals have their own antibiotic prescription policies based on local sensitivities and a reduction in the use of cephalosporins.

• Reduction of medical and procedural errors. Most hospitals have guidelines and protocols to avoid errors. All new personnel should be given an induction about the procedures to maintain patient safety and this should be followed up with continuing education.

• Patient nutrition. The Malnutrition Universal Screening Tool (MUST) has been used to assess the nutrition of patients entering hospitals (p. 123). Many hospital inpatients are malnourished. Patients should be provided with protected mealtimes, good hydration and good nutritional care with fact sheets. These are outlined in the Council of Europe’s ten key characteristics of good nutritional care in hospital (www.bapen.org.uk).

• Radiation from medical imaging. The ordering of imaging procedures is increasing as technology advances. Document all exposures to ionizing radiation. For example, a patient undergoing myocardial perfusion imaging receives 15.6 millisieverts (mSv), CT abdomen 8–10 mSv and percutaneous coronary intervention 15 mSv, compared with a CXR, which is only 0.02 mSv. These doses of radiation may, in the long term, present a small risk for the development of cancer.


Prescribing


Good prescribing requires a diversity of skills. Medicines should only be prescribed if they are really necessary and if the risks of not giving the drug outweigh the side-effects/harmful effects of the drug itself.


• Drugs should only be prescribed if an accurate diagnosis has been made. Exceptions would include pain relief and ‘blind’ antibiotics for severe sepsis.

• Co-morbidities should be documented, as some diseases may have an effect on the drug itself, e.g. its elimination.

• Polypharmacy should be avoided as far as possible and drug interactions checked before a new drug is added to the regimen.

• The decisions on therapy must be made with patients and they should be told exactly which drugs they are going to be given and why. This increases the likelihood of patients taking the drugs as prescribed, as they feel they are equal partners in the decision-making (concordance).

• Always look up the drug and its dosages and effects. This can either be done online, e.g. www.bnf.org, or from information in local hospital pharmacy booklets.

• The side-effects of treatment should be explained to patients in a language they understand prior to starting the medication.

• Allergies: Always document these fully in the notes with actual clinical reaction. A red name band should replace the usual white band on the patient’s wrist.

The WHO Guide to Good Prescribing is a useful training programme to assist in prescribing medicines (http://whqlibdoc.who.int/hq/1994/WHO_DAP_94.11.pdf).



Drug metabolism



Pharmacokinetics (what the body does to the drug) and pharmacodynamics (what the drug does to the body)


Note that absorption, distribution, metabolism, and hepatic and renal elimination of drugs or their metabolites differ from person to person. Therefore the route of administration and the dose of the drug should be tailored to the patient’s needs. This may involve changing the drug, increasing/decreasing the dosage or choosing another route of administration.


Many drugs are metabolized by the liver. The metabolism varies between individuals, often because of changes in the cytochrome p450 family of enzymes. Inhibition or induction of cytochrome p450 isoenzymes is a major cause of drug interaction. Some examples are given in Box 1.1. Thus, for example, warfarin is metabolized by CYP2C9. Between 2 and 10% of people are homozygous for an allele that results in low enzyme activity and this leads to higher plasma warfarin levels.



Box 1.1 Some inducers and inhibitors of cytochrome p450



Inducers



• Carbamazepine

• Hyperforin*

• Nifedipine

• Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

• Omeprazole

• Paclitaxel

• Phenytoin

• Protease inhibitors, e.g. ritonavir


Inhibitors



• Allopurinol

• Cimetidine

• Macrolides, e.g. erythromycin, clarithromycin

• Grapefruit juice (contains flavinoids)

• Imidazoles, e.g. ketoconazole

• Quinolones, e.g. ciprofloxacin

• Quinidine

• Sulphonamides

• Clopidogrel


* Hyperforin is one of the ingredients of the herbal product known as St John’s wort, used by herbalists to treat depression. Although it is marketed as a licensed medicine, it is a reminder that drug interactions can occur with alternative, as well as conventional, medicines.


The variability of a drug’s action within the body is partly due to the drug receptor and the polymorphism of this receptor.


The interplay between pharmacokinetics and pharmacodynamics will influence drug selection and drug dosage.



Prescribing for the elderly


This may require changes in drug dosages in the presence of co-morbidities. It should be remembered that concordance diminishes as the number of prescribed drugs increases and also in the face of cognitive impairment.


• Rates of hepatic drug metabolism and renal excretion decline with age. Extrapolation of dosage regimens from younger adults could therefore lead to drug toxicity.

• Predisposition to toxicity can also occur with changes in drug distribution, a reduction of body mass, changes in body composition, and the preferential distribution of the cardiac output to the brain.

• Co-morbidity (and therefore often polypharmacy too) can lead to increased opportunities for drug interactions.

• Exaggerated pharmacodynamic effects of drugs acting on the cardiovascular system, CNS and gastrointestinal tract occur more commonly (Table 1.2).

Table 1.2 Common adverse effects of drugs in the elderly
























Drug Effect
β-Blockers (including eye drops)
Digoxin		 Bradycardia
Nitrates
α-Adrenoceptor-blockers
Diuretics		 Postural hypotension
Diuretics (thiazides) Glucose intolerance, gout
Antimuscarinic drugs
Tricyclic antidepressants
Neuroleptics
Minor tranquillizers
Anticonvulsants
Hypnotics
Opioids		 Confusion, cognitive dysfunction
Bisphosphonates (mainly alendronic acid) Oesophageal ulceration and stricture formation
NSAIDs Gastric erosions
Upper gastrointestinal bleeding
Perforated peptic ulcer
Renal impairment


Prescribing in pregnancy/breast feeding


Clinicians should be very cautious of prescribing any drug to pregnant women. Always consult the relevant literature for any drug prescribed to check its effects in women of childbearing age, in pregnancy and in nursing mothers.


Never prescribe a drug to pregnant women unless it is absolutely necessary and you have checked for possible teratogenic effects on the fetus. Appendix A gives websites for drug use. If a known teratogenic drug is required during pregnancy (e.g. an anticonvulsant), always discuss the adverse effects on the fetus with the parents, preferably prior to conception.


Most drugs can be detected in breast milk, albeit in small amounts. A few drugs, e.g. aspirin and carbimazole, can cause harm to the infant if ingested in breast milk.

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  3. Critical care
  4. Water, electrolyte and acid-base balance

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Apr 2, 2017 | Posted by in GENERAL SURGERY | Comments Off on Inpatient medical care

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