Summary of presentation day 2015 - PowerPoint Presentation

1. Summary of presentation day 2015

2. By David SparksmanAn Unusual PresentationACCS Presentation Day

3. SymptomsFatigue and weaknessAnorexiaNauseaVomitingWeight lossAbdominal painDiarrhoeaConstipationSyncopeDizzinessConfusionPersonality changeIrritabilityAmenorrhoeaSalt craving

4. ConclusionAddison’s disease is a rare condition presenting insidiously. Misdiagnosis occurs frequently.Symptoms include syncope, gastrointestinal disturbance, weight loss, signs include hyperpigmentation.Salt improves clinical symptoms.A dietary history should be sought.

5. An HIV Positive Puzzle

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7. Opportunistic Infections & HIVCD4 <350

8. Opportunistic Infections & HIVCD4 <200

9. Opportunistic Infections & HIVCD4 <100

10. Back To The Case…Deteriorated over weekend; SBP 70Ultimately BAL showed Candida & antifungal therapy was commenced.No MAI, No AAFB on smear Blood Cultures x 3 negativeTB Culture: MTB - sensitive

11. ConclusionHIV must be considered in all with unexplained immunodeficiency symptomsKnowledge of what infections to expect at what degree of immunodeficiency can aid diagnostic and treatment plans

12. Head Injury Audit : Current Practice Project Lead: Dr Tanveer Afridi : Dr Serjevan Kalsi Audit Supervisor: Mr Nafis

13. IntroductionHead injury is the commonest cause of death and disability in people aged 1–40 years in the UKHead injury is defined as any trauma to the head other than superficial injuries to the face.Annually, about 200,000 people are admitted to hospital with head injuryMost patients recover without specific or specialist interventionOthers experience long-term disability or even die from the effects of complications that could potentially be minimised or avoided with early detection and appropriate treatment

14. Nice GuidelinesTriage TimesWithin 15 minutes to allow for early identification for CT HeadAnalgesiaPain should be managed effectively because it can lead to a rise in intracranial pressure.Essential History & ExaminationTo accurately weigh up clinical indication for CTCorrect Discharge PlanningVerbal & printed advice to be given to a responsible adult in all cases

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16. ConclusionsVast majority of patients did not go through triageInappropriate use of CTLack of documentationMostly negative findingsShould we have a checklist?

17. RecommendationsImproved focus on triage within 15 minutes and stratification of high risk and low risk patientsProposed departmental screening tools Revised proforma for undertaking CT head Appropriate use of CT scanning according to NICE guidelinesDoctor’s Checklist?A small tick-box to be placed in the clinical notes to improve documentation

18. Assessment of Suspected C-Spine Injury in the Emergency DepartmentColchester General Hospital – January 2015Dr Clare Bird – ACCS CT1A Pain in the Neck?

19. Why?You don’t want to miss a c-spine fractureYou don’t want to scan everyone with neck painSpinal immobilisation isn’t a benign procedureDistracting injuries are distractingDocumentation is important!

20. Findings (2)

21. Opportunities for improvementConsider C-spine in all head injuriesDocument clinical “rule out”Examination not just XRsMore liberal use of CT c-spinePrompt review of pre-hospital immobilisation

22. Other thoughts…Immobilisation & Cervical collars - A risky interventionIncreased ICPAirway compromisePressure soresPivot point?AnatomicalThe aggressive/agitated patient

23. Developing the Addenbrooke’s Vascular Frailty ScoreDavid BrooksACCS (Anaesthetics) CT1 (Peterborough City Hospital)Honorary clinical fellow (Addenbrooke’s hospital)

24. AimsTo determine whether frailty predicts adverse short- and mid-term outcomesTo determine the frailty characteristics that are most predictive of poorer outcomesTo develop a simple tool that predicts outcomes by incorporating information from a small number of these frailty characteristics

25. Results – 12 month mortalityUnivariable and multivariable predictors of increased 12 month mortality shown in table:Multivariable Cox regression showed these 6 variables were independent discriminators of increased mortality:Anaemia (Hb < 119)Lack of independent mobilityPolypharmacy (> 8 drugs)Raised waterlow score (> 13 on admission)DepressionEmergency admission

26. Results6 features used to create the addative Addenbrooke’s Vascular Frailty Score (AVFS), each scoring 1 point:AnaemiaLack of independent mobilityPolypharmacyRaised waterlow scoreDepressionEmergency admission

27. DiscussionAn ageing population requires a way to stratify the effect of frailtyThe frailty characteristics we collected were easily accessible from routine medical and nursing documentationWe have shown that a small number of frailty characteristics combined with admission mode can create a powerful predictor for mortality and morbidity in a broad vascular cohortRobust statistical analysis and modelling has produced a novel frailty score which is a powerful predictor for multiple adverse outcomes

28. DiscussionNegating the effect of just one of the adverse factors before or at admission could lead to significant long-term improvements in mortalityThere is great potential to identify ‘at risk’ patients in a pre-operative settings as part of their work upCurrently all vascular admissions to Addenbrooke’s are having their AVFS calculatedA further validation study using this new data is plannedThis supports the ‘Peri-operative Medicine’ strategy currently being developed by the Royal College of Anaesthetists

29. ITU Case PresentationDr Fiona MendesACCS-EM10th June 2015

30. Bickerstaff's EncephalitisAtaxiaOphthalmoplegia+ Drowsiness, coma, hyperreflexia+/- limb/face weakness, abnormal pupils, absent reflexes

31. SummaryRare autoimmune disease secondary to infectionAtaxia + Ophthalmoplegia + Drowsiness, coma, hyperreflexiaGood prognosis – MDT approachSerial neurological examinationConsider a wider differentialEthical issues – on information sharing

32. A baseline audit examining the management of patients with subarachnoid haemorrhage presenting to BTUHBy Dr F. Ali, Dr H. Reihani, Dr R. English, Dr S. Aneke, Dr C. Davies, Dr M. Tomek and Dr G. Simon

33. STANDARDS 95% of patients presenting with suspected SAH should have a full neurological examination with GCS documented 95% of patients with suspected SAH should have CT/MRI within 24 hours of onset95% of patients with suspected SAH, not confirmed on CT/MRI should have LP>12 hours after onset

34. A baseline audit examining the management of patients with subarachnoid haemorrhage presenting to BTUH By Dr F. Ali, Dr H. Reihani, Dr R. English, Dr S. Aneke, Dr C. Davies, Dr M. Tomek and Dr G. Simon. Basildon and Thurrock University Hospitals Aims To develop a minimum dataset to capture information on patient characteristic, management and outcome of patients with SAH presenting to BTUH.To establish whether BTUH is compliant with the European Stroke Organisation (ESO) guidelines which recommend that: The initial assessment of SAH patient's should include Glasgow Coma Scale (GCS) as a way of grading the clinical conditionCT/CTA/MRI should be performed within 24 hLumbar puncture (LP) must be performed in a case of clinically suspected SAH if CT or MRI does not confirm the diagnosisTo establish recommendations to improve the early assessment and management of patients presenting with SAH, reducing delays in investigations and improving patient outcome. 2. Introduction SAH accounts for <5% of all strokes, with approximately 4,800 cases diagnosed annually in the UK, and an incidence of 8-12 per 100,000. There is a 60% mortality rate within 6 months, and 15% of cases are fatal before reaching hospital. 50% of patients are <60 years old. 1,2,3,4 Causes include rupture of a cerebral aneurysm (70%), vascular malformations (10%), head trauma, hypertension and coagulation abnormalities. Clinical features may include hyperacute onset of severe headache, neck stiffness, reduced GCS, seizures and neurological impairment.1,2,3,4 GCS has been shown to be a valid tool in assessing disability and predicting outcome from SAH, as it widely used and understood, and has good inter-observer agreement. It is important to document GCS at initial assessment and at intervals, to monitor for deterioration.3For the majority of patients, SAH can be identified on CT with a sensitivity of 98% at 12 hours. This drops to 93% at 24 hours, demonstrating the need for urgent scans in these patients. In those patients with a negative CT, LP for xanthochromia is the next investigation recommended for diagnosis. As xanthochromia is only detectable after 12 hours, it is necessary to delay LP until after this time. LP can detect SAH up to two weeks after thunderclap headache. If both CT and LP are negative at this time, SAH can be ruled out.5Outcomes for patients with SAH are influenced by medical management and timing of surgical interventions. A multidisciplinary approach is a necessity for an optimal outcome, and efficient referral to a tertiary neurosurgical unit is critical.1,2,3,4This audit is designed to assess whether BTUH is following the ESO guidelines for the management of SAH, and to implement recommendations to improve patient outcome.3. Methods The audit is of all BTUH patients with confirmed diagnosis of non-traumatic SAH presenting between 01/01/14 – 31/12/14. Symphony v2.27.1.8, EDH v1.7.6.2 and EMR v1.1.4.8B were used to collect data. An NCEPOD proforma was used to collate and analyse all anonymised patient data.9. Recommendations A formal Trust guideline on the assessment pathway of suspected SAH to be drafted and made easily accessible online via the Clinical Hub. This should outline the main ESO recommendations, with a particular focus on the need to clearly document initial GCS. The guidelines should also be incorporated into the teaching curriculum for junior and middle-grade staff based in A&E and AMU. Re-audit annually to complete the audit cycle and reassess performance.5. Results Between 01/01/14-31/12/14, there were 32 confirmed cases of SAH at BTUH. Of these 10 had a traumatic SAH, 3 were repatriations or readmissions, and 1 presented directly to the Essex Cardiothoracic Centre. These were excluded, leaving 18 patients included in the analysis. 50% patients were female, 50% male The average age was 63 38.8% (7) had at least 2 risk factors 83.3% (15) of patients had a GCS recorded on initial assessment. 93% (14) of these patients had a GCS >12/15 on admission. 1 patient had a GCS of 3/15 on admission 27.7% (5) of patients had imaging within 1 hour of presentation to BTUH, 66.6% (12) had imaging within 12 hours, and 0.5% (1) had imaging within 24 hours. 88.9% (16) had SAH confirmed on CT. 11.1% (2) required LP to confirm diagnosis. 100% (2) of the LP's were performed >12 hours after onset 100% (18) of patients were discussed with neurosurgical teams. 27.7% (5) of patients were treated conservatively. 72.2% (13) were accepted for transfer to neurosurgical centre 40% (2) of the patients treated conservatively, died during admission. Mortality rates for those transferred to the Neurosurgical Unit (NSU), were not available for analysis8. Discussion This audit evaluated the performance of BTUH with regards to the initial management of patients with SAH, as assessed against the ESO recommendations. Specifically, we focused on the documentation of GCS on presentation, imaging within the first 24 hours, and the use of LP in cases not diagnosed on CT/MRI. In total, we identified 18 cases of spontaneous SAH presenting to BTUH during a 12-month period. No sex preponderance was observed, and 39% of the patients had two or more risk factors.On initial assessment, GCS was recorded in only 83% of cases, which is significantly lower than the recommended 95% target. The reason for this discrepancy is unclear, especially given the ease of use and rapidity of determining GCS in an acute setting. It may simply reflect a documentation omission in cases where the patient presents without any neurological impairment and the clinician may deem the recording of GCS irrelevant or unnecessary. Nevertheless, GCS is not only a important prognostic indicator, and serves as a useful baseline measure for further clinical monitoring, so must be recorded.Regarding imaging, all patients underwent either CT or MRI brain within 24 hours, exceeding the 95% target. In fact, almost a third of patients had imaging within one hour of presentation, and only one patient had imaging after more than 12 hours. The radiology pathway for assessment of SAH currently in place therefore appears to be effective.SAH was diagnosed by lumbar puncture in only 2 cases. In these cases, no SAH had been detected on imaging. 100% of the LP's were performed >12 hours after onset, therefore meeting the outlined standard. With regards to further data collected, the following observations are of note: i) 2 patients died during their admission; one had GCS 3/15 on first assessment, the second had initial GCS 12/15, which dropped to GCS 3/15. This again underscores the prognostic significance of GCS monitoring. ii) In one case the diagnosis of SAH was delayed due to CSF results not being chased over night. Such instances may occur due to inadequate handover, but also due to failure to inform the biochemistry laboratory by phone.References: 1) NCEPOD (2013) Managing the flow? [online]. Available from http://www.ncepod.org.uk/2013report2/downloads/Managing%20the%20Flow_SummaryReport.pdf [Accessed 26th May 2015] 2) Clinical Effectiveness Unit (2006) National Study of subarachnoid Haemorrhage, Final Report. [online]. Available from http://www.rcseng.ac.uk/publications/docs/nat_study_subarachnoid_haem_feb2006.html [Accessed 26th May 2015] 3) Steiner T. et al. European Stroke Organisation Guidelines for the Management of Intracranial Aneurysms and Subarachnoid Haemorrhage. Cerebrovasc Dis. 2013; 35: 93-112. 4) Sander Connelly E. Guidelines for the Management of Aneurysmal Subarachnoid Haemorrhage. Stroke. 2012; 43; 1711-1737. 5) Scottish Intercollegiate Guidelines Network (2008) Diagnosis and management of headache in adults, a national clinical guideline. [online]. Available from http://www.sign.ac.uk/pdf/qrg107.pdf [Accessed 26th May 2015] 7. TablesAcknowledgements: We would like to thank the AMU team for all of their help and continued support.4. Standards 95% of patients presenting with suspected SAH should have a full neurological examination with GCS documented 95% of patients with suspected SAH should have CT/MRI within 24 hours of onset 95% of patients with suspected SAH, not confirmed on CT/MRI should have LP>12 hours after onset6. Figures 10. Limitations This is a baseline audit so it is not possible to compare it to earlier results. The sample size was small.AGEn 40-495 50-594 60-693 70-792 80-894RISK FACTORSn n Diabetes2 COPD/Asthma1 Ischaemic stroke/TIA2 Smoking4 Hypertension 5 Hyercholeserolaemia1 Cancer1 Hyperthyroidism0 Arthritis3 Depression/Anxiety2 IHD1 Migraine1 CKD1 None of the above6GLASGOW COMA SCALE EYESSpontaneous4Open to voice3Open to pain2None1 VERBALOriented5Confused4Inappropriate words3Incomprehensible 2None1 MOTORObeys command6Localises to pain5Withdraws from pain4Abnormal flexion3Abnormal extension2None1