• Acute hospital medicine--a new sub-speciality or internal medicine re-born?

      Kellett, John; Nenagh Hospital, Department of Medicine, Nenagh, Co. Tipperary, Ireland. jgkellett@eircom.net (2011-08)
    • Assessing the need for hospital admission by the Cape Triage discriminator presentations and the simple clinical score.

      Emmanuel, Andrew; Ismail, Asyik; Kellett, John; Nenagh Hospital, Nenagh, Ireland. (2010-11)
      There is uncertainty about how to assess unselected acutely ill medical patients at the time of their admission to hospital. This study examined the use of the Simple Clinical Score (SCS) and the medically relevant Cape Triage discriminator clinical presentations to determine the need for admission to an acute medical unit.
    • An assessment tool for acutely ill medical patients.

      Gleeson, Margaret; Kellett, John; Cowan, Mairead; Casey, Marie; Mid-Western Regional Hospital, Nenagh, County Tipperary, Ireland. (2012-01-26)
      This article reports the implementation and impact of a standardized systematic evidence-based predictive score for the initial assessment of acutely ill medical patients. The Simple Clinical Score (SCS) was introduced in the A&E department and the medical floor of the authors' hospital between June 2007 and July 2008. The SCS was well received by the staff - 67% felt it greatly improved patient assessment and was very valuable for ensuring appropriate placement of the patient after admission and improved the quality of care. This article describes the change process, the pilot evaluation and the training programme undertaken during the implementation of the SCS. It is hoped that this experience will be of value to other project teams who are undertaking similar initiatives.
    • Hospital Medicine (Part 1): what is wrong with acute hospital care?

      Kellett, John; Department of Medicine, Nenagh Hospital, Nenagh, County Tipperary, Ireland. jgkellett@eircom.net (2009-09)
      Modern hospitals are facing several challenges and, over the last decade in particular, many of these institutions have become dysfunctional. Paradoxically as medicine has become more successful the demand for acute hospital care has increased, yet there is no consensus on what conditions or complaints require hospital admission and there is wide variation in the mortality rates, length of stay and possibly standards of care between different units. Most acutely ill patients are elderly and instead of one straightforward diagnosis are more likely to have a complex combination of multiple co-morbid conditions. Any elderly patient admitted to hospital is at considerable risk which must be balanced against the possible benefits. Although most of the patients in hospital die from only approximately ten diagnoses, obvious life saving treatment is often delayed by a junior doctor in-training first performing an exhaustive complete history and physical, and then ordering a number of investigations before consulting a senior colleague. Following this traditional hierarchy delays care with several "futile cycles" of clinical activity thoughtlessly directed at the patient without any benefit being delivered. If acute hospital medicine is to be improved changes in traditional assumptions, attitudes, beliefs and practices are needed.
    • Hospital medicine (Part 2): what would improve acute hospital care?

      Kellett, John; Department of Medicine, Nenagh Hospital, Nenagh, County Tipperary, Ireland. jgkellett@eircom.net (2009-09)
      There are so many obvious delays and inefficiencies in our traditional system of acute hospital care; it is clear that if outcomes are to be improved prompt accurate assessment immediately followed by competent and efficient treatment is essential. Early warning scores (EWS) help detect acutely ill patients who are seriously ill and likely to deteriorate. However, it is not known if any EWS has universal applicability to all patient populations. The benefit of Rapid Response Systems (RRS) such as Medical Emergency Teams has yet to be proven, possibly because doctors and nurses are reluctant to call the RRS for help. Reconfiguration of care delivery in an Acute Medical Assessment Unit has been suggested as a "proactive" alternative to the "reactive" approach of RRS. This method ensures every patient is in an appropriate and safe environment from the moment of first contact with the hospital. Further research is needed into what interventions are most effective in preventing the deterioration and/or resuscitating seriously ill patients. Although physicians expert in hospital care decrease the cost and length of hospitalization without compromising outcomes hospital care will continue to be both expensive and potentially dangerous.
    • The prediction of the in-hospital mortality of acutely ill medical patients by electrocardiogram (ECG) dispersion mapping compared with established risk factors and predictive scores--a pilot study.

      Kellett, John; Rasool, Shahzeb; Department of Medicine, Nenagh Hospital, Nenagh, County Tipperary, Ireland. jgkellett@eircom.net (2011-08)
      ECG dispersion mapping (ECG-DM) is a novel technique that analyzes low amplitude ECG oscillations and reports them as the myocardial micro-alternation index (MMI). This study compared the ability of ECG-DM to predict in-hospital mortality with traditional risk factors such as age, vital signs and co-morbid diagnoses, as well as three predictive scores: the Simple Clinical Score (SCS)--based on clinical and ECG findings, and two Medical Admission Risk System scores--one based on vital signs and laboratory data (MARS), and one only on laboratory data (LD).
    • READS: the rapid electronic assessment documentation system.

      Hickey, Ann; Gleeson, Margaret; Kellett, John; Nenagh Hospital, Nenagh, Ireland. (2012-12-13)
      Patient documentation is time consuming and can detract from care. The authors report a novel computer programme that manipulates routinely collected information to quantify nursing workload, along with the reason for admission, functional status, estimates of in-hospital mortality and life expectancy. The programme stores information in a database, and produces a print-out in a situation/background/assessment/recommendation (SBAR) format. The average time taken to enter 629 patient encounters was 6.6 minutes. Pain was the most common presentation for low workload patients, while high workload patients often presented with altered mental status and reduced mobility. There was only a modest correlation between the risk of death and nursing workload. The programme measures nursing workload without further paperwork, and improves routine documentation with a legible brief report that is automatically generated. This report can be shared and provides data that is immediately available for day-to-day care, audit, quality control and service planning.
    • Should systematic risk assessment and immediate intervention of the acutely ill patient replace the traditional management paradigm?

      Kellett, John; Department of Medicine, Nenagh Hospital, Nenagh, County Tipperary, Ireland. jgkellett@eircom.net (2012)
      The outcome of the traditional diagnostic history and physical depends entirely on the availability, ability and diligence of an individual doctor. An alternative is a team-based approach that performs the following tasks: a focused assessment, monitoring of the response to initial treatment, and then determining what further management is appropriate (calling for urgent help if it is required). This concept is based on risk prediction rather than diagnosis, and is captured by the mnemonic FAITH3 (Focused Assessment, Initial Treatment, hAssessing response, calling for Help and Handing over care).
    • Validation of an abbreviated Vitalpac™ Early Warning Score (ViEWS) in 75,419 consecutive admissions to a Canadian regional hospital.

      Kellett, John; Kim, Arnold; Department of Medicine, Nenagh Hospital, Nenagh, County Tipperary, Ireland. jgkellett@eircom.net (2012-03)
      The early warning score derived from 198,755 vital sign sets in the Vitalpac™ database (ViEWS) has an area under the receiver operator characteristic curve (AUROC) for death of acute unselected medical patients within 24h of 88%.
    • What diagnoses may make patients more seriously ill than they first appear? Mortality according to the Simple Clinical Score Risk Class at the time of admission compared to the observed mortality of different ICD9 codes identified on death or discharge.

      Kellett, John; Deane, Breda; Department of Medicine, Nenagh Hospital, Nenagh, County Tipperary, Ireland. jgkellett@eircom.net (2009-01)
      The Simple Clinical Score (SCS) determined at the time of admission places acutely ill general medical patients into one of five risk classes associated with an increasing risk of death within 30 days. The cohort of acute medical patient that the SCS was derived from had, on average, four combinations of 74 groupings of ICD9 codes. This paper reports the ICD9 codes associated with the different SCS risk classes and identifies those ICD9 codes with a greater observed mortality than that of other patients in the same SCS risk class.
    • Who will be sicker in the morning? Changes in the Simple Clinical Score the day after admission and the subsequent outcomes of acutely ill unselected medical patients.

      Kellett, John; Emmanuel, Andrew; Deane, Breda; Department of Medicine, Nenagh Hospital, Nenagh, County Tipperary, Ireland. jgkellett@eircom.net (2011-08)
      All doctors are haunted by the possibility that a patient they reassured yesterday will return seriously ill tomorrow. We examined changes in the Simple Clinical Score (SCS) the day after admission, factors that might influence these changes and the relationship of these changes to subsequent clinical outcome.