Inpatient medical care

1 Inpatient medical care




Good medical practice





Assessment and general management







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





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):







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












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.







Specific interviews




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.





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).



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.









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.



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.



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

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