Inpatient Treatment – Getting the dose right

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Dr Richard Genever, consultant geriatrician and physician and ECIST clinical associate, discusses the NEWS Flow Chart – Decision Support Tool. The tool has been designed by patient facing clinicians to support ‘balanced risk’ discharge decision making on a ‘day-to-day’ basis. 

Tony was admitted to hospital after finding himself wedged between his bed and the radiator when trying to make a night-time trip to the bathroom. His daughter found him in the place he had fallen, some 6 hours earlier. Admission to hospital led to a diagnosis of rhabdomyolysis and 48 hours of intravenous fluid. The episode had taken its toll on Tony. Usually, he would explore his bungalow with an occasional steadying hand on a wall. Now, a short walk with a frame seemed to require all his energy. His family were kept up to date with his progress. He seemed to be getting a little stronger but was still some way off his baseline. With each conversation, new information emerged. Tony had lost weight in the last 6 months. Everyone seemed worried, including the doctors. A scan was requested. Two days later, 10 days after his initial admission, Tony was sitting in a chair next to his bed. He started to shiver. Within minutes he was shaking all over and sweating profusely. A Chest X-Ray and blood tests led to the conclusion that Tony had pneumonia. Antibiotics and oxygen were given but the die was cast. The day before he died, Tony was wheeled to the CT department on his bed. The only major abnormality on the scan was the chest infection that would soon take his life.

Being sick enough to require hospital admission means that you are in a high-risk situation. In 2017, long before COVID-19 even existed, 230,428 people died in England’s hospitals. Risk factors for dying include older age, social deprivation, and longer length of stay. More than half of over 75s who died had been in hospital for 8 days or more and for most of them, the cause of death was different to the primary diagnosis on admission.

In hospital deconditioning is a well-recognised complication of admission in frail, older people as is delirium. I remember being astonished during a lecture by Liz Sampson, Professor of Dementia and Palliative Care, when she forced us to reflect on the impact of environmental factors, such as sleep deprivation, limited access to exercise and control of heat and light. I was even more astonished when she pointed out that those words actually came from a critical report on conditions for detainees of Guantanamo Bay.

Tony’s story is a sad but common scenario. One problem leads to another, like a bowling ball clattering through pins. Some will be knocked over by the ball itself, while others will be dislodged by their neighbours falling. The outcome was determined the moment the ball left the bowler’s hand; or was it? Could he have been discharged when he had completed his intravenous fluid. He was mobile, but not at his baseline. A CT scan was a reasonable test, but one that could have been arranged urgently as an outpatient. We cannot know what would have happened if he had been discharged but we do know what followed when he wasn’t.

Decision-making requires the recognition of all the risks. Whatever plan is made will lead to a chance of a poor outcome. Some people that are discharged will deteriorate. It is important to acknowledge this as part of a realistic options assessment.

One way to help with this evaluation is to think about time spent in hospital is if it is a drug treatment. The Length of Stay is the dose. Drugs tend to have a dose-response curve, which means the additional benefit starts to tail off with increasing dose. The risk of side effects remains.

RG Blog 1

 

We need to identify the appropriate dose of inpatient care to allow us to discharge them. We also need to develop the ability to act quickly when they have reached this point. This can be difficult. Discussions can get caught up on issues such as whether the person is back to their baseline mobility, or if additional investigations should be arranged during the spell.

 

The ECIST NEWS Decision Support Tool helps with this. It uses a NEWS score of 3 or less as a starting point for discussion and leads to a series of questions that potentially open doors to other ways of managing a problem. For example, asking the question whether you would admit this person as they are now is a very simple way of checking if you should keep them in hospital.

RG Blog 2

 

In reality, a person’s course during an admission is more undulating. Sadly, some people’s level of recovery will never reach the threshold for possible discharge, but for those that do, it is essential to recognise it, understand what must be done and act quickly enough to discharge them before a life-changing or fatal dose of the treatment is given.

Lucy was 78 when she was admitted following a stroke. She received thrombolysis and started to improve quickly. She was able to stand with assistance when she suffered a setback with aspiration pneumonia. Further improvement followed but an outbreak of norovirus meant that intravenous fluid was required for a few days. Things started to get better and, after 2 more weeks, Lucy was walking short distances with a frame. She was very enthusiastic, and the team was keen to get her walking as well as possible. There was talk of stair practice and trying to sit in the passenger seat of her nephew’s car. One day Lucy seemed strangely argumentative. Later that day, her NEWS score had risen to 6 and she was agitated. Antibiotics and oxygen were given, but the die was cast.

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Unplanned admissions are complicated. It can be difficult to predict the outcomes. However, thinking about time spent as an inpatient as an increasing medication dose can help healthcare professionals to recognise that risks are ever present in hospital, but benefits may not be. Combining this approach with the NEWS Decision Support Tool will help teams to identify when there are other options available, and how to put the necessary plans into action. You will never know when discharging someone has saved their life but that is a small price to pay.

[Both cases are composites and are not based on any individual people]

References

Older People who Died in Hospital: 2017. Public Health England 2019

International Committee of the Red Cross report following visits to 14 ‘High Value Detainees’, Guantanamo, 2006 

ESIST NEWS2 Decision Support Tool https://future.nhs.uk/ECISTnetwork/view?objectId=89020869

In the video below Dr Richard Genever, Dr Ben Owens & Dr Ian Sturgess discuss the NEWS Decision Support Tool.

NEWS Decision Support Tool

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