Milwaukee shoulder syndrome (MSS) is a rare destructive, calcium phosphate crystalline arthropathy. It encompasses an effusion that is noninflammatory with numerous aggregates of calcium hydroxyapatite crystals in the synovial fluid, associated with rotator cuff defects. We describe a patient that presented with recurrent shoulder pain and swelling with characteristic radiographic changes and MSS was confirmed on aspiration of the synovial fluid.

The Ambulatory Care Unit (ACU) is a recent addition to Basingstoke and North Hampshire Hospital. In January 2017, additional acute medical consultants were appointed to help develop the service. The clinic is consultant led and operates Monday-Friday from 09.00-18.00. ACU accepts referrals directly from GPs and operates a push/pull system for the Emergency Department (ED). Out-of-hours referrals can be made via the medical registrar on call. Before expanding the service further, we studied the true impact of ACU by looking not only at patients diverted from the medical take, but also at 30-day readmission rates and mortality, thereby reflecting 'true' admission avoidance (TAA).

The NHS in England is facing well-documented pressures related to increasing acute hospital admissions at a time when the acute medical bed-base is shrinking, doctors working patterns are increasingly fragmented and many acute hospital trusts are operating a financial deficit. Novel strategies are required to reduce pressure on the acute medical take. We conducted a prospective cohort study to assess the impact of acute medicine consultant triage of referrals to the acute medical take on the number of acute hospital admissions as compared to a historical control cohort. The introduction of an acute medicine consultant telephone triage service was associated with a 21% reduction in acute medical admissions during whole the study period. True admission avoidance was achieved for 28.5% of referrals triaged by an acute medicine consultant. The greatest benefit was seen for consultant-triage of GP referrals; 43% of all GP referrals resulted in a decision not to admit and in 25% the referral was avoided by giving advice alone. Consultant telephone triage of referrals to the acute medical take substantially reduces the number of acute medical admissions as compared to triage by a trained band 6 or higher nurse coordinator. Our service is cost effective and can be job-planned using 6 full-time equivalent acute medicine consultants. The telephone triage service also provides additional benefits to admission numbers beyond its hours of operation and the general management of the acute medical take.

Hospital at Night (H@N) is a well-established system of providing out-of-hours (OOH) care to patients and has been shown to improve patient safety, reduce mortality and increase productivity. In 2018, Hampshire Hospitals NHS Foundation Trust still had no formal system for OOH working, causing unmanageable workloads for junior doctors, with repeated trainee surveys and the General Medical Council highlighting this as a concern. This led to unsafe working environments, low morale and a high degree of burnout.