Observational
Medicine
Observational medicine units are an expansion of traditional Emergency Department activity. Patients who are likely to be fit for discharge within 24 hours are held in a unit managed by the Emergency Department.
The reason for the rise of
observational medicine is the pressure to better use hospital beds in the main
part of the hospital, together with a better appreciation of the risks of
hospitalisation. Emergency physicians are less inclined to hold onto patients
than other specialties and are motivated to ensure rapid discharge wherever
possible.
Features that differentiate
an observational medicine ward from other wards in the hospital are:
• Frequent consultant-led ward rounds, e.g. three times a day, to ensure
rapid progress and decision making.
•
A discharge plan is necessary for entry to the unit.
• Ready availability of other health professionals, e.g. physiotherapists,
occupational therapists, social workers.
The observation unit should
not be used as an alternative to making a decision. There should be rapid
turnover of patients: bed occupancy is often 200–300% per day.
Minor injury in elderly patient
A relatively minor injury in
an older patient may have a disproportionate effect on their ability to cope
safely at home. Common injuries, often the result of a fall, that may
incapacitate patients include fracture of the neck of the humerus, Colles’ fracture
and fractured pubic rami. There are a vast number of potential causes for
elderly patients to fall, but common medical causes that can be diagnosed and
treated within the Emergency Department include:
•
Arrhythmias: ECG.
•
Postural hypotension: lying and standing blood pressure.
•
Infections: urine dipstick, chest X-ray.
•
Medication: polypharmacy increases the risk of drug interactions and
adverse effects.
Review in the observation
unit by a multidisciplinary team, which includes occupational therapy, physiotherapy
and social workers as well as medical and nursing staff, can ensure a rapid,
safe discharge from hospital.
Homelessness
The Emergency Department is
sometimes the only medical contact that homeless people have. Appropriate
emergency medical care is given but it is not the job of the Emergency
Department to resolve the multiple chronic and social problems these patients
often have. Mental illness and drug and alcohol dependence are common in this
group, but there is a limited amount that the Emergency Department can do
unless there is ongoing community support.
‘Frequent flyers’
There is a small group of
patients who come to the Emergency Department very often. This is usually due
to a combination of factors, which may include personality disorders, drug and
alcohol problems, self-harm, loneliness, homelessness and mental illness. These
are difficult patients to manage as they are often very experienced at
manipulating healthcare staff. It is best if they are looked after by the most
senior staff available, to avoid one group of health professionals being played
off against another.
Domestic violence and elder abuse
An Emergency Department
visit is an opportunity for intervention: staff need to be alert to the
possibility of non-accidental injury in vulnerable people. Drug and alcohol
problems often coexist with domestic violence. Emergency Department staff
cannot force someone to seek help, but can provide contact details and a quiet
area with a telephone. Elder abuse may be particularly difficult to diagnose
due to the high rate of natural falls and bruising, together with poor memory.
Drugs and alcohol
Although drug and alcohol
dependence are often managed by psychiatrically trained doctors, they are not
mental illnesses per se. However, drug and alcohol use often coexists with
mental illness; this could be viewed as the patient’s self-medicating.
Patients sometimes present
to the Emergency Department seeking ‘a detox’. A detoxification is a (usually
temporary) drug-free period. The Emergency Department is not the place for
elective management of withdrawal of drugs or alcohol: this can be safely
managed in the community.
Patients who are dependent
on drugs or alcohol often end up in the Emergency Department as a result of
falls, fights, and so on. These patients may experience withdrawal in the
Emergency Department, and this must be identified and managed, otherwise they
may have seizures or the patient will leave, compromising their medical care.
Withdrawal symptoms do not respect class or educational attainment, and one
must be alert to symptoms in unexpected patients.
If alcohol problems are
suspected, use the CAGE questionnaire (Chapter 29) and, if positive, expect to
have to manage with-drawal, and ensure the patient is aware of community
support on discharge.
Alcohol and benzodiazepine withdrawal
Withdrawal from alcohol and
benzodiazepines is potentially dangerous, as fits may occur. Thiamine,
usually combined with other B and C vitamins, is given to prevent Wernicke’s
encephalopathy (characterised by confusion, ataxia, ophthalmoplegia and
nystagmus) and Korsakoff’s psychosis, the disastrous irreversible consequences
of chronic thiamine deficiency common in alcoholics.
Alcohol withdrawal is
generally best managed using front- loaded oral diazepam, which has
active metabolites with a long half-life (2–4 days). Large doses of diazepam,
e.g. 20 mg every one to two hours, are given according to symptoms; multiple
doses are often required.
Once the patient’s symptoms
have been controlled, the patient does not have to stay in hospital, and does
not need diazepam on discharge, as its pharmacokinetics will ensure a tapering
dose of benzodiazepines.
Opiate withdrawal
Opiate withdrawal is
unpleasant, but not dangerous. Musculo- skeletal symptoms respond to NSAIDs;
high-dose diazepam helps with agitation and nausea. Clonidine, an alpha
antagonist with mild opiate agonist properties, can also be used.
Other patient groups
Other patient groups who
often end up in the observation ward include:
•
Overdose (Chapters 24 and 25).
•
First fit (Chapter 43).
•
Minor head injury (Chapter 11).
•
Post-sedation (Chapter 6).
