How do you assess acutely ill patients? John Kellett MD Nenagh Ireland

Why assess patients? Immediate Risk – Death – Falls – Bedsores – DVT/PE – Contagion Prognosis – Short term – Long term – End of life decisions Triage – Red – Orange – Yellow – Green Actions – Sepsis – CT brain Workload – Right persons – Right place

Resuscitation 2013;84:

Eur Geriatric Med 2014;5:92-96

Increase the risk of death * >50 years of age and no alcohol or OD QJM 2006;99:

Decrease the risk of death QJM 2006;99:

Simple Clinical Score QJM 2006;99:

Simple Clinical Score AUROC 90%AUROC 85% 30 days QJM 2006;99:

Simple Clinical Score comparisons Intern Med J 2012:42: 160–165 Clinical Medicine 2010;10:352-7

Severity Illness Comorbidity Functional Capacity Predictors of Prognosis Pompei P. et al. J. Clin. Epidemiol. 1988;41:

17 Top ICD9 Codes Associated with increased 30- day mortality

Mortality Rates of 17 Top ICD9 Codes Associated with increased 30-day mortality ¶ significantly reduced mortality* significantly increased mortality

Risk Class as Percentage of Total Admissions

p <.03

Access block

Time to see “junior” doctor in UK: 6 hrs 55 min (range 3 hrs 13 min to 12 hrs 30 min)

Documentation Overload In the UK, nurses spend approximately 20% of their time on documentation [1] and in the US, every hour of patient care requires from 30 to 60 minutes of paperwork [2]. Nurses Spend less and less time with a patient!

Current Problems Nurses Spend Less and Less Time with a Patient Due to Documentation Overload Same Information is Recorded Multiple Times Causing Major Duplication. Completing Assessment Documentation is a Lengthy Process: 30 – 50% of Time Patient Information is not Used Proactively in Treatment Decisions & Planning Information is Often Recorded Incorrectly, Difficult to Find or Misplaced Interrogating the Recorded Information is Difficult and Next Steps are Unclear

Current Problems Nurses Spend Less and Less Time with a Patient Due to Documentation Overload Same Information is Recorded Multiple Times Causing Major Duplication. Completing Assessment Documentation is a Lengthy Process: 30 – 50% of Time Patient Information is not Used Proactively in Treatment Decisions & Planning Information is Often Recorded Incorrectly, Difficult to Find or Misplaced Interrogating the Recorded Information is Difficult and Next Steps are Unclear Is it of any value?

READS Rapid Electronic Assessment and Documentation System “The Rapid Electronic Assessment Documentation System (READS) is a novel IT System that prospectively records and manipulates clinical information in order to assess the patient's clinical predicament and risks and then drives care tailored to each individual patient’s needs.”

Tasks Less urgent Less frequent More stable Done by best Actions Urgent Frequent Volatile Done at bedside

READS Solution R R apid Functionality Progressively Builds a Clinical Patient Profile E E lectronic Solution Provides Consistent Processing and Display of Information and Trends S S ystem Allows Users to Operate Across a Hospital Network in Parallel and Beside the Patient A A ssessment Models Integration of Proprietary and Standard D D ocumentation Repository for ALL Assessments

Issues What justifies hospital admission? Does severity of illness and functional capacity TRUMP presenting complaint/suspected diagnosis? What needs to be assessed? How long should assessment take? What needs to be documented? Which patients is it SAFE to send home?

Why does this patient need to be in hospital? How likely is he to die? What needs to be done NOW to prevent death? Who should provide the REST of his treatment and where should they do it? A new paradigm? How long should this take?

Thank you