The evidence for assessing frailty and sarcopenia in an acute medical unit: a systematic review

BACKGROUND/OBJECTIVES

A systematic review was conducted to assess if frailty and sarcopenia were associated with poorer outcomes in older adults admitted to an acute medical unit (AMU).

METHODS

Eligible studies included older adults with an unplanned admission to an AMU and included a measure of frailty or sarcopenia, completed within 72 hours of admission. Risk of bias was assessed.

RESULTS

Of 1659 identified articles, 16 were included (4 on sarcopenia and 12 on frailty). There was significant study heterogeneity. Overall, frailty and sarcopenia were associated with worse outcomes. Targeted interventions appeared to improve outcomes.

CONCLUSION

Current evidence suggests some benefit in screening older adults admitted to an AMU for frailty and sarcopenia. However, further studies are required before clinical adoption.

Electronic-prescribing tools improve N-acetylcysteine prescription accuracy and timeliness for patients who present following a paracetamol overdose: A digital innovation quality-improvement project

Objectives

Prescription error rates and delays in treatment provision are high for N-acetylcysteine (NAC) when prescribed for paracetamol overdose (POD). We hypothesised that an electronic tool which proposed the complete NAC regimen would reduce prescription errors and improve the timeliness of NAC provision. Error rates and delays in the provision of NAC were assessed following POD, before and after the implementation of an electronic prescribing tool.

Methods

The NAC electronic prescribing tool proposed the three NAC infusions (dosed for weight) following entry of the patient's weight. All NAC prescriptions were reviewed during a three-month period prior to and after the tool's implementation. Error rates were divided into dose, infusion volume or infusion rate. Delays in NAC provision were identified using national Emergency Medicine guidelines.

Results

108 NAC prescriptions were analysed for all adult patients admitted to the emergency department of a secondary care hospital in the UK between July-September 2017 and August-October 2018, respectively. There were no differences in the demographics of patients or the seniority of the prescribing clinician before or after the introduction of the electronic tool. The electronic prescribing tool was associated with a decrease in prescribing errors (25% to 0%, p < 0.0071) and an increase in the provision of NAC within recommended times (11.1% to 47.4%, p = 0.029).

Conclusions

An electronic prescribing tool improved prescription errors and the timeliness of NAC provision following POD. Further studies will determine the effect of this on length of stay and the benefit of wider implementation in other secondary care hospitals.

Described Practices for Assessing Fluid Resuscitation in Acute Hospital Care: A Qualitative Study

Fluid resuscitation is a widely-used treatment in acute and emergency medicine, however, the process used to perform a fluid assessment has never been studied. This qualitative study explored how acute physicians describe their approach to assessing for fluid resuscitation. 18 clinicians of varying grades consented to a semi-structured interview. Transcripts were coded and analysed using thematic analysis. Participants described three subtypes of assessment; screening assessment, emergency assessment and formal assessment. Whether a patient was 'sick' was key to determining which assessment they would receive. Marked heterogeneity was noted in the assessment processes, particularly regarding the use of history-taking. Further research is required to determine how the information gathered in these assessments is used to decide when fluid resuscitation is indicated.

What is the evidence base for fluid resuscitation in acute medicine?

Intravenous fluids are commonly prescribed but uncertainty remains about how to assess when fluids are required and how much to give, particularly in our multimorbid, polymedicated and ageing population. Furthermore, studies have noted that fluid resuscitation can be harmful even if clinical evidence of hypervolaemia is not present. Two recent guidelines have acknowledged a limited evidence base to guide fluid assessment. A recommended means to assess hypovolaemia includes assessment of fluid responsiveness. Fluid responsiveness is a rise in stroke volume following an increase in preload, achieved using a fluid challenge or a passive leg raise. However, the means of defining fluid responsiveness and its ability to identify patients who would benefit from fluid resuscitation is currently unclear. This review discusses the current guidelines about, and the evidence base for the provision of, intravenous fluids in the acutely unwell medical patient. It highlights how little evidence is available to guide medical practice.

Response to: Assessment of Fluid responsiveness in the Acute Medical Patient and the Role of Echocardiography

I read the article, 'Assessment of Fluid responsiveness in the Acute Medical Patient and the Role of Echocardiography' by Dr Parulekar and Dr Harris with interest. It rightly highlights the challenges posed when assessing for fluid resuscitation in a pressured setting with limited information. This scenario is a routine one for our speciality, which is why it is a concern that the evidence-base outside of intensive care remains limited. Of particular relevance to the Acute Medical specialist, the article acknowledges that performing a focussed-echocardiogram on all acutely-unwell patients is "impractical". Developing a quick and straightforward approach to fluid resuscitation assessment should be a high research priority for Acute Medicine.