We use cookies to improve our service and to tailor our content and advertising to you. More infoClose You can manage your cookie settings via your browser at any time. To learn more about how we use cookies, please see our cookies policyClose
Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.
The NICE guidance, recently summarised in this journal (1), is an
important initiative that consolidates the early recognition and
management of the acutely unwell hospital in-patient. The summary
document does not, however, explicitly acknowledge the significant numbers
of potentially sick patients transferring from outside hospitals to
specialist regional services, such as renal medicine. The NSF for Renal
Services (2) recommends, for instance, that patients with Acute Kidney
Injury should not just be managed in liaison with specialist renal
services, but also in the most ‘clinically appropriate setting’. Our
challenge is how this should be best determined.
The arrival of a patient on a specialist unit with unheralded
critical illness is a potential disaster. The application of the ‘in-
house’ physiological scoring system to patients prior to transfer can,
however, ‘trigger’ appropriate pre-emptive responses, including early
liaison with critical care, consultation with senior colleagues and
decision-making on the most appropriate venue for transfer. Newcastle
Renal Services now extends the radar of the local Modified Early Warning
System to all potential outside hospital transfers to ensure their most
appropriate placement. Such processes may also be applicable in other
specialist settings, where we have the luxury of being able to employ
local scoring systems at a distance.
(1) Armitage M, Eddleston J. Stokes T. Recognising and responding to
acute illness in adults in hospital: summary of NICE guidance. BMJ
2007;335:258-259
(2) DH Renal NSF team. The National Service Framework for Renal Services.
Part Two: Chronic Kidney Disease, Acute Renal Failure and End of Life
Care. Department of Health 2005.
The NICE guidelines for the ‘recognition and response to acute
illnesses in adults in hospitals’ are a welcome addition to tools designed
to protect patients from suboptimal medical practice.(1) Evidence shows
that there is delayed recognition of the acute illness and incorrect
treatment of these patients.(2)
These facts and the need for error-free medical intervention were
recognised nearly 2,500 years ago. In the Hippocratic book ‘Affections’
the writer said:
‘Generally speaking, it is the acute diseases that cause the most deaths
and that are the most painful, and with these the greatest care and the
strictest treatment are necessary. Let nothing bad be added by the person
treating – rather let the evils resulting from the diseases themselves
suffice- but only whatever good he is capable of. If, when the physician
treats correctly, the patient is overcome by the magnitude of his disease,
this is not the physician’s fault. But if, when the physician treats
either incorrectly or out of ignorance, the patient is overcome, it is his
fault.’(3)
The study of Hippocratic medicine has still a lot to give to the
modern doctor who is prepared to search.
(1) Armitage M, Eddleston J. Stokes T. Recognising and responding to
acute illness in adults in hospital: summary of NICE guidance. BMJ
2007;335:258-259
(2) National Confidential Enquiry into Patient Outcome and Death. An
acute problem? A report of the National Confidential Enquiry into Patient
Outcome and Death (NCEPOD). London: NCEPOD 2005
Recognising and responding to acute illness in adults in hospital – physiological ‘track and trigger’ systems should be applied prior to transfer of patients from outside hospitals
The NICE guidance, recently summarised in this journal (1), is an
important initiative that consolidates the early recognition and
management of the acutely unwell hospital in-patient. The summary
document does not, however, explicitly acknowledge the significant numbers
of potentially sick patients transferring from outside hospitals to
specialist regional services, such as renal medicine. The NSF for Renal
Services (2) recommends, for instance, that patients with Acute Kidney
Injury should not just be managed in liaison with specialist renal
services, but also in the most ‘clinically appropriate setting’. Our
challenge is how this should be best determined.
The arrival of a patient on a specialist unit with unheralded
critical illness is a potential disaster. The application of the ‘in-
house’ physiological scoring system to patients prior to transfer can,
however, ‘trigger’ appropriate pre-emptive responses, including early
liaison with critical care, consultation with senior colleagues and
decision-making on the most appropriate venue for transfer. Newcastle
Renal Services now extends the radar of the local Modified Early Warning
System to all potential outside hospital transfers to ensure their most
appropriate placement. Such processes may also be applicable in other
specialist settings, where we have the luxury of being able to employ
local scoring systems at a distance.
(1) Armitage M, Eddleston J. Stokes T. Recognising and responding to
acute illness in adults in hospital: summary of NICE guidance. BMJ
2007;335:258-259
(2) DH Renal NSF team. The National Service Framework for Renal Services.
Part Two: Chronic Kidney Disease, Acute Renal Failure and End of Life
Care. Department of Health 2005.
EM: suren.kanagasundaram@nuth.nhs.uk
Competing interests:
None declared
Competing interests: No competing interests