Endocrine and Metabolic Medical Emergencies

A Clinician's Guide

Glenn Matfin, Glenn Matfin

• Publisher: Wiley-Blackwell
• Year: 2018
• ISBN:
  9781119374756
• Edition: 2
• Topic: Medicine
• Subtopic: Endocrinology & Metabolism

The Essential Guide to Recognizing and Treating Acute Endocrine and Metabolic Illness

Endocrinology covers some of the most common conditions and serious public health challenges facing medicine today, and endocrine and metabolic emergencies constitute a large proportion of the clinical workload. Endocrine and Metabolic Medical Emergencies: A Clinician's Guide provides a singular reference to help endocrinologists, acute and general medicine clinicians, hospitalists and critical care physicians, and general practitioners recognize the symptoms of endocrine emergencies and provide the highest standards of care. Already the definitive and most comprehensive guide to endocrine emergency care, this new second edition: provides acute care guidance for a range of both common and unusual endocrine emergencies; details the effects of acute medical and critical illness on metabolic and endocrine systems, and their impacts on endocrine investigations; discusses special patient populations, including the impacts of aging, pregnancy, transplantation, late-effects, perioperative, inherited metabolic disorders and HIV/AIDS on presentation and management; and features detailed coverage of disorders by system, as well as, metabolic bone diseases, neuroendocrine tumors, and more.

Packed with case studies, images, and chapters written by distinguished authors, this guide is designed for both quick reference and study. Coverage includes the presentation, diagnosis, management, and treatment of endocrine and metabolic disorders in an acute care setting, as well as the most up-to-date guidance on issues including clinical lipidology, glucose, sodium, calcium and phosphate, and more.

Blending the latest science with clinical and practical advice, this invaluable resource helps clinicians stay up to date with the field's relevant body of knowledge while providing the practical, clinical insight they need in order to provide their patients with the utmost level of care.

Part I
General Aspects of Acute Medical Emergencies

Introduction
Acute Medical Care: A Crisis with Solutions

Glenn Matfin

Key Points

• There is a crisis in acute medical care for multifarious reasons.
• These include rising acute medical admissions with increased bed occupancy levels; increasingly older and frailer patients with complex, high-acuity illnesses and multimorbidities; systemic failures of care; poor patient experience; existence of healthcare disparities; multi-ethnic populations; medical and nursing workforce crisis; social and primary care crisis; constant reconfiguration in health and social care delivery and legislation; and ever increasing costs of health and social care in a time of austerity and/or financial instability. There is also a lack of candor when things go wrong.
• A new model of care for hospitals of the future has been proposed and the first principle is that of putting patients first (i.e., patient-centred). Patients should be treated with compassion and dignity. They should be involved in decisions on their condition and treatment (i.e., shared-decision making). Teams should work together towards common goals and in the best interest of patients. Patient safety is critical, and having an open culture of providing safe care and utilizing tools such as electronic prescribing can help. A duty of candor when problems arise is needed.
• Seven-day care is important too and there should be cover 24 hours a day, 7 days a week. Patient care should cross the boundaries of primary, secondary, post-acute and social care with care pathways designed for each of the morbidities that a patient experiences. In this regard, as in all, effective communication is key.
• There are important consequences of this and that is that there needs to be more doctors trained and engaged in generalist medicine. This does not mean that specialist care (such as diabetes and endocrinology) is less important or less prioritized. This will remain essential and indeed the degree of expertise available in the specialties is ever increasing.
• On-going postgraduate training requirements as well as maintenance/assessment of competencies and other professional attributes is expensive, complicated, and time-consuming. However, it is critical if we want a medical workforce that is up-to-date and fit-to-practice; and can also train the next and future generations of clinicians.
• The challenges and opportunities involved in delivering safe, timely, high-quality, patient-centred, holistic, cost-effective acute medical care, will resonate with all stakeholders globally involved with this complex, expensive, yet essential undertaking.

Introduction

There is a crisis in acute medical care for multifarious reasons. We are all living in increasingly “graying” societies due to increasing numbers of the older population. In the USA alone, this population (defined as persons 65 years or older) numbered 41.4 million in 2011 (or one in every eight Americans). By 2025, this number is expected to increase to 62.5 million people (or almost one in every five Americans) according to the Endocrine Society's workforce analysis (1). This has important implications for healthcare. For example, the life expectancy at birth in the UK is now 12 years longer than what it was at the inception of the National Health Service (NHS) in 1948; and people aged over 60 now make up nearly a quarter of Britain's population. Half of these have a chronic illness and this proportion will increase as the number of people aged 85 or older doubles in the next 20 years. Nearly two-thirds of patients admitted to hospital are over 65 years old and around 25% of these patients have a diagnosis of dementia (with more than a third of people living in care homes having this diagnosis). Diabetes and endocrine problems are also common in this population, with almost one-quarter US older adults having diabetes (1,w464646441160002). Approximately half of those persons with diabetes are undiagnosed and an additional one-half of older adults have prediabetes (2). The frail elderly in particular make up a large proportion of patients presenting for acute medical care, including endocrine and metabolic emergencies (e.g., hypoglycemia, hyperglycemia, hyponatremia, and hypercalcemia) (3).

There are increased numbers of acute medical admissions with higher inpatient bed occupancy levels. Pressure on beds in the NHS (and elsewhere) results in increased waiting times in emergency departments (so-called “trolley waits”). This crowding in the emergency departments (and other parts of the hospital) can lead to patient safety concerns (including maintaining cleanliness and controlling infections), is stressful for the patient (especially as these patients tend to get moved around to accommodate others) and also staff. As the various assessment units (e.g., medical admissions unit or equivalent) also become fuller due to increased admissions and an inability to “push” patients to the most suitable wards (i.e., specialist or general medical beds), this increases the likelihood that the patient will end up on the “wrong” ward such as medical outlier wards (i.e., medical patients within the surgical or non-medical bed base). The additional burden of staffing these non-medical wards with appropriately skilled medical, nursing and other relevant healthcare professionals (e.g., physiotherapists, occupational therapists) is a major daily challenge. All of these (and many other) issues can further delay timely access to the right specialty, and discharge-dependent investigative and/or therapeutic procedures. In addition, the inability to discharge patients who are “medically fit” but who have onward community care needs (i.e., post-acute care such as rehabilitation, or social care) is also concerning, due to significant issues in post-acute and social care delivery (including chronic underfunding and lack of staff). The number of patients stuck in hospital in the UK because of delays in discharge has increased 80% in the past 5 years (4). Consequently, the average length of stay in acute care in the UK in 2010 was 7.7 days which is significantly higher than Australia (5.1), the Netherlands (5.8) and the USA (4.9). Most recent figures (2017) for average length of medical stay from the author's facility are 7.95 days (for patients staying more than 24 hours).

There is also an increase in mortality of around 10% among patients admitted at weekends. Although the reasons are complex, there is an association between the presence of senior doctors and improved clinical outcome for patients. There are other problems as well. Junior doctors are working shorter hours (due in part to safety concerns and consequent limits on work hours) and there is often a lack of communication at handover. Due to an increase in demand for medical care and other reasons (including not training enough “home-grown” doctors or being able to retain them), medical trainees are under increased pressure and there is evidence that they do not get the mentorship or training that they deserve because of increasing demands on senior staff.

Ongoing postgraduate training needs as well as maintenance/assessment of competencies or certification and other professional attributes are expensive, complicated, time-consuming and do not always translate into improved patient care (5). The last two decades have witnessed a multitude of changes in postgraduate medical education. These changes are in part a response to the changing environment which doctors practice medicine. These drivers for change are related to both patients and doctors. Patient-related drivers include changes in patient demographics (an increase in older population as noted above), higher patient expectations both in terms of their own health status and the public's expectations of better services from the medical profession. Doctor-related drivers includes improvements in medical technology (e.g., influence of information technology [IT]) and advances in therapy, complexities of multiprofessional healthcare delivery, greater emphasis on patient safety, and the expectations of the medical professionals themselves in terms of a better work-life balance (6).

Health workers are the cornerstone of health systems. Jobs in the health and social care sector accounted for more than 10% of total employment in most OECD countries in 2016 (7). The current health workforce is suffering from growing pressures (with increased risk of clinician burnout leading to physical and emotional exhaustion and drop in productivity). In addition, the medical workforce is ageing rapidly (i.e., baby-boomers) with almost third doctors aged 55 or older in USA and the OECD countries (7). Manpower issues in healthcare provision are significant with a lack of workforce planning and/or expenditure resulting in inadequate numbers of medical, nursing, and other healthcare professionals. This has resulted in migration of healthcare professionals from many other potentially more needy populations around the world (especial...