Clinical medicine (London, England)
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Multicenter Study
Reducing inappropriate blood testing in haematology inpatients: A multicentre quality improvement project.
Haematology inpatients are subject to extensive blood testing and many of these tests could be deemed inappropriate as they are not indicated for monitoring or clinical symptoms. Unnecessary testing exposes the patient to the risks of phlebotomy and adds resources' strain to the NHS. Our aim was to reduce the number of inappropriate blood tests performed on haematology inpatient wards. ⋯ A reduction in inappropriate or overall blood testing was achieved at every site where a BTS was implemented, with a median reduction in inappropriate blood testing of 24.7% and estimated cost savings of up to £38,438 per annum. This QIP can be safely adapted to a variety of inpatient settings and is associated with cost savings. This initiative could be extended to other inpatient departments throughout the NHS.
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Pressure on acute medical services in the pandemic mandated an assertive emergency department (ED) discharge policy. Given the potential for subsequent deterioration and growing appreciation of complications relating to COVID-19 infection, this follow up study was instigated to provide clinical reassurance that discharged patients had followed a safe clinical course. 199 patients discharged from the ED of our central London hospital were identified over a 20-day period at the height of the pandemic in April 2020. 44 had already reattended ED and 12 had been admitted. At 2-week telephone follow-up, 14 patients were identified who required urgent recall for assessment. ⋯ A COVID-19 follow-up clinic was therefore established to provide multi-professional review and diagnostics. 65 patients attended for this assessment. This is the first report on outcomes in COVID-19 infected patients discharged from an ED. It highlights the importance of safety-netting after discharge, the difficulty in predicting which patients might deteriorate and the need for appropriate follow up services.
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Case Reports
Lessons of the month: A challenging presentation of hypopituitarism secondary to an intracerebral aneurysm.
A 65-year-old man presented to ambulatory care with a 10-month history of muscle weakness, weight loss, dysphagia and fatigue. Prior to presentation he had been managed in general practice for hypothyroidism with a low T4 level and normal thyroid stimulation hormone (TSH). He was commenced on levothyroxine yet, despite dose titrations, had ongoing symptoms. ⋯ This case highlights the importance of correctly interpreting TFTs as this patient's initial TFTs indicated central hypothyroidism which should have prompted urgent pituitary hormone screening. The risk of addisonian crisis with commencement of levothyroxine without steroid replacement in secondary hypothyroidism emphasises the importance of TFT interpretation. Internal carotid artery aneurysms are a rare, yet important, cause of hypopituitarism resulting in high mortality and morbidity associated with delayed diagnosis secondary to the pressure effects of the aneurysm or the effects of aneurysmal rupture.
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The COVID-19 pandemic has had many ramifications on healthcare delivery and practice. As part of this, utilising biomarkers to risk stratify patients has become increasingly popular. During the COVID-19 pandemic the use of D-dimer has increased due to the evidence of COVID-19 induced thrombo-embolic disease. ⋯ Patients without COVID-19 infection were as likely to have evidence of PE as their COVID-positive counterparts. However, the sensitivity of a D-dimer was higher in COVID-positive patients at a lower D-dimer level (>1,500 μg/L, sensitivity 81%, specificity 70%) than in those without clinical, immunological or radiological evidence of COVID-19 infection (D-dimer >2,000 μg/L, sensitivity 80%, specificity 76%). These data suggest higher D-dimer thresholds should be considered for the exclusion of pulmonary emboli.
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We sought to provide the first report of the use of NEWS2 monitoring to pre-emptively identify clinical deterioration within hospitalised COVID-19 patients. ⋯ Our results support the use of NEWS2 monitoring as a sensitive method to identify deterioration of hospitalised COVID-19 patients, albeit at the expense of a relatively high false-trigger rate.