The barts heart attack centre early discharge pathway:- a novel protocol for next day discharge after primary pci for ST-elevation myocardiai infarction

Funding Acknowledgements

Type of funding sources: None.

Introduction

To respond to the challenges of COVID-19 and based on evidence confirming low rates of Major Adverse Cardiac Events (MACE) occurring between 24- and 48-hours post AMI (Acute Myocardial Infarction), we sought to design and implement a novel Early Hospital Discharge (EHD) pathway

Aim

The goal of the EHD protocol is to accurately and efficiently identify low-risk AMI patients who can be safely discharged between 24 and 48 hours after successful primary PCI, aiming to provide a  safe discharge for low risk patients, reduce length of stay  enhance the follow up of patients post AMI

Methodology :

Project was designed a QI project and patients were discharged with a structured follow up at 48 hours , 2 weeks and 8 weeks and with a interventional cardiologist at 3 months 

Virtual follow up was conducted using a bespoke application enable a 2 way messaging and video consultation

Patients with AMI are taken for primary PCI in an unselected manner which includes post cardiac arrest, intubated and ventilated patients

Results :The median follow-up was 201 days (OQR: 98-268 days). In the early discharge group, there were 2 deaths (0.5%), both due to COVID-19 (both >30 days after d/c) with 0% cardiovascular mortality (comparator group 5% mortality, 2.5% cardiovascular

 Overall, this resulted in a significant reduction in the overall length of stay for all patients presenting with STEMI undergoing primary PCI over the time period. The median length of stay was 3 days (IQR 2-5 days) from October 2019 to March 2020 before the pathway was introduced. Following the pathway introduction, from April 2020 to February 2021 the median length of stay was 2 days (1-4 days) (p < 0.0001), significantly reduced from pre pathway introduction

Conclusion :Driven by the necessity to adapt to the pandemic, we report the safe and successful implementation of an early post MI discharge pathway with an integrated and structural multidisciplinary virtual follow up schedule.  This has shortened hospital admission times, decreasing the risk of nosocomial infections and optimised resource utilization, while at the same time enhancing the quality of post discharge care with high levels of patient satisfaction.

Medicine wastage in a thromboprophylaxis protocol for ambulatory trauma patients

Thromboprophylactic medicine is provided routinely to patients who present to emergency departments (EDs) with lower leg fractures as a preventive measure against forming blood clots in an immobilised limb. A large amount of medicine is provided to these patients at discharge, but once they have recovered their mobility the remaining medicine is unusable and must be destroyed. There is a lack of data to quantify this waste. This article reports a service evaluation that was conducted in an ED to investigate the wastage and the cost implications of this treatment protocol. It shows that over half the medicine dispensed is subsequently wasted and makes recommendations for changing dispensing practice.

Bell's palsy: excluding serious illness in urgent and emergency care settings

Bell's palsy is a relatively benign condition that affects about 20 in every 100,000 patients a year, and in most cases the signs and symptoms resolve fully within around six months. The defining characteristic of the condition is a unilateral facial palsy, but this is also apparent in other conditions with a more serious prognosis, including strokes, some viral infections and tumours. This article reviews the literature on recognition of Bell's palsy, examines the underlying pathology, and compares it with other conditions associated with facial palsy. The article critically analyses the evidence and guidelines to identify best practice, and considers areas for improvement. Finally, it discusses how this information can be incorporated into practice, and provides guidance for clinicians on differentiating between conditions in which patients present with facial palsy to ensure they are managed appropriately.

How healthy are clones and their progeny: 5 years of field experience

There is considerable concern regarding the health of cloned cattle and their safety as a source of food. The objective was to summarize 5 years of commercial experience with cloning in three countries (United States, Argentina and Brazil). Overall, only 9% of transferred embryos resulted in calves; efficiency ranged from 0 to 45% (most were from 1 to 10%, but 24% of cell lines never produced live calves). There was no significant difference in pregnancy rate following transfer of one versus two embryos. Before 90 days of gestation, two ultrasound markers for embryo death were found, either crown rump length (CRL) or heart beat less than 7.5mm and 150bpm, respectively, were observed alone or together in 27% of clones that died. In addition, after 100 days of pregnancy, placental edema, hydrops fetalis and increased abdominal circumference size were used as ultrasound findings of a fetus at risk of loss. At 114 days of gestation, abdominal circumference in clones that died was statistically larger than in clones that survived alive to term and from MOET- and IVF-derived pregnancies (P<0.05). Since elective cesarean section (C-section) was partially replaced by natural or assisted parturition, C-section rates decreased from 100% in 2000 to 54% in 2005. On average, 42% of cloned calves died between delivery and 150 days of life; the most common abnormalities were: enlarged umbilical cord (37%), respiratory problems (19%), calves depressed/prolonged recumbency (20%) and contracted flexor tendons (21%). From 11 blood parameters evaluated during the first week of life, lactate decreased twice and glucose doubled its original value from 24h to 7 days. Adult cloned females had normal breeding and calving rates and cloned bulls produced good quality semen and had normal fertility when used for AI or natural mating. In conclusion, cloning had no risks qualitatively different from those encountered in animals involved in modern agricultural practices, although the frequency of the risks appeared to be increased in cattle during the early portions of the life cycle of cattle clones.