A&E tipping points
248 British Journal of Healthcare Management 2015 Vol 21 No 5 © 2 01 5 M A H ea lth ca re L td Figure 2 clearly shows the impact of the last two of these tipping points on AE 2013). No sane health care administration would ever expect to run hospitals at the level of occupancy common in the UK—but sanity appears to be sadly lacking in this case, and the consequences are entirely predictable. The reasons for the sudden jumps in AE Jones and Beauchant, 2015)—although politicians appear determined to avoid any discussion of the real issues for fear of jeopardising their own pet policies. There will be Rod Jones A&E tipping points
Small area spread of a new type of infectious condition across Berkshire in England between June 2011 and March 2013: effect on medical emergency admissions.
Aims: This study aims to investigate the small area spread of a presumed infectious agent, and to determine which factors determined the point of initiation, speed of the spread and the resulting increase in emergency medical admissions. Study Design: Analysis of a monthly time series of medical admissions using small area population aggregates of around 7,000 population contained within the census spatial unit called a Mid Super Output Area (MSOA). Place and Duration of Study: Emergency medical group admissions for residents of the six unitary authority locations in Berkshire, southern England between January 2008 and March 2013. Methodology: A running twelve month total of admissions was used to determine the point of Original Research Article Jones and Beauchant; BJMMR, 6(1): 126-148, 2015; Article no.BJMMR.2015.190 127 initiation and the extent of a step-like increase in medical admissions. Results: Analysis shows evidence for spatial spread initiating around June 2011 through to March 2013. At onset, medical admissions increase and stay high for 12 to 18 months before beginning to abate. This spread commenced earlier among mainly Asian small areas (clustered from July 2011 onward) and later (clustered around March 2012) in predominantly affluent white areas. The observed percentage increase in admissions within the unitary authority areas varied from 25% to 51% (median value), however the average increase was highest as the geographic area became smaller, and this is suggested to arise from the aggregation of smaller social networks where the point of initiation of infectious spread occurs over time. The percentage increase in admissions displayed high single-year-of-age specificity suggestive of the immune phenomena called antigenic original sin, and is therefore suggestive of a different strain of an agent with previous outbreaks. The increase in emergency admissions showed a month-of-year pattern which appeared to follow the seasonal pattern of vitamin D levels in the blood. The presence of nursing homes, deprivation and ethnicity also has an effect on the average increase in admissions. Conclusion: It is suggested that all the above point to an outbreak of a previously uncharacterized type of infectious agent. There are profound implications regarding the use of standard five year age bands for the standardization of medical admission rates.
Influenza A(H1N1) infection and severe cardiac dysfunction in adults: A case series
ZusammenfassungHINTERGRUND: Während die virale Myokarditis und das Herzversagen anerkannte und gefürchtete Komplikationen einer saisonalen Influenza A Infektion sind, liegen bislang nur wenig Informationen über ein durch das 2009 Influenza A(H1N1) Virus induziertes Herzversagen vor. METHODEN UND HAUPTERGEBNISSE: Diese Fallsammlung fasst den Krankheitsverlauf von vier Patienten mit 2009 Influenza A(H1N1) Infektion zusammen, welche an unserer Klinik im Zeitraum von November 2009 bis September 2010 behandelt wurden. Alle Patienten präsentierten sich mit einer schweren kardialen Funktionsstörung (akutes Herzversagen, kardiogener Schock oder Herzkreislaufstillstand im Rahmen eines Kammerflimmerns) als das führende Symptom einer Influenza A(H1N1) Infektion. Zwei Patienten waren mit hoher Wahrscheinlichkeit kardial vorerkrankt, und drei benötigten eine Katecholamintherapie, um die hämodynamische Funktion zu stabilisieren. Mit Ausnahme eines Patienten der vor der Diagnosestellung der Influenza A(H1N1) Infektion verstarb, wurden alle Patienten mit einer antiviralen Therapie mit Oseltamivir und supportiver Intensivtherapie behandelt. Ein Acute Respiratory Distress Syndrom infolge der Influenza A(H1N1) Infektion trat bei einem Patienten auf. Die Herzfunktion normalisierte sich bei zwei Patienten und war bei einem Patienten noch bei Krankenhausentlassung eingeschränkt. SCHLUSSFOLGERUNG: Eine Influenza A(H1N1) Infektion kann mit einer schweren kardialen Funktionseinschränkung assoziiert sein. Diese kann sich sogar als führendes klinisches Symptom darstellen. Während einer Influenza Pandemie kann eine genaue Anamneseerhebung Grippeähnliche Symptome hervorbringen und sollte auch bei kritisch kranken Patienten mit akutem Herzversagen eine Diagnostik auf H1N1 Infektion veranlassen.SummaryBACKGROUND: While viral myocarditis and heart failure are recognized and feared complications of seasonal influenza A infection, only limited information is available for 2009 influenza A(H1N1)-induced heart failure. METHODS AND MAIN FINDINGS: This case series summarizes the disease course of four patients with 2009 influenza A(H1N1) infection who were treated at our institution from November 2009 until September 2010. All patients presented with severe cardiac dysfunction (acute heart failure, cardiogenic shock or cardiac arrest due to ventricular fibrillation) as the leading symptom of influenza A(H1N1) infection. Two patients most likely had pre-existent cardiac pathologies, and three required catecholamine therapy to maintain hemodynamic function. Except for one patient who died before influenza A(H1N1) infection had been diagnosed, all patients received antiviral therapy with oseltamivir and supportive critical care. Acute respiratory distress syndrome due to influenza A(H1N1) infection developed in one patient. Heart function normalized in two of the three surviving patients but remained impaired in the other one at hospital discharge. CONCLUSIONS: Influenza A(H1N1) infection may be associated with severe cardiac dysfunction which can even be the leading clinical symptom at presentation. During an influenza pandemic, a thorough history may reveal flu-like symptoms and should indicate testing for H1N1 infection also in critically ill patients with acute heart failure.