The aim of this project was to improve the documentation of treatment escalation decisions at a district general hospital in southwest England. A pilot “Ceiling of Treatment” proforma was trialled on the care of the elderly wards at the Royal United Hospital (RUH), Bath. Successive PDSA cycles enabled revision of the proforma for use across the Trust. Data were collected on the proportion of patients with a documented treatment escalation decision. Formative feedback was collected via questionnaire from trainees and discussion with special interest groups of consultants within the hospital. This approach involved collaboration between acute medicine, intensive care, elderly care, the resuscitation department, palliative care and the legal department. Documentation of ceiling of treatment decisions rose from 30% to 90% during the study. A survey of medical trainees showed 67% (n=36) had seen the ceiling of treatment form, of which, 100% found it useful on on-call shifts. Initiating a proforma to record treatment escalation decisions and combining this with the existing ‘Do not attempt cardiopulmonary resuscitation’ (DNAR) paperwork, increased decision making and documentation. This intervention ensures patients receive the appropriate level of care, as indicated by their consultant, and reduces anxiety for junior doctors during on-call shifts.

Medical short stay units help to increase patient fl ow and decrease length of stay, but selecting appropriate patients for admission to such units is diffi cult. The selection tool used in our unit was effective but cumbersome to apply. We collected prospective data on 297 unselected emergency medical admissions and developed a new scoring system based on four key variables using regression analysis. The model predicted a length of stay of <72 h with an area under the receiver operating characteristic curve of 0.68. The model was then used to select patients for admission to the short stay unit in our trust. Length of stay on the short stay unit had decreased by an average of 2.73 days with our original selection tool, but remained unchanged at an average of 3.02 days using the new simpler tool (p>0.05). This model could now be adopted by other units.

This case illustrates the need for awareness among general physicians of rare tumour manifestations and the need for multidisciplinary input for the optimal management of these patients.

IntroductionCarbon monoxide poisoning is easy to diagnose when there is a history of exposure. When the exposure history is absent, or delayed, the diagnosis is more difficult and relies on recognising the importance of multi-system disease. We present a case of accidental carbon monoxide poisoning.Case presentationA middle-aged man, who lived alone in his mobile home was found by friends in a confused, incontinent state. Initial signs included respiratory failure, cardiac ischaemia, hypotension, encephalopathy and a rash, whilst subsequent features included rhabdomyolysis, renal failure, amnesia, dysarthria, parkinsonism, peripheral neuropathy, supranuclear gaze palsy and cerebral haemorrhage. Despite numerous investigations including magnetic resonance cerebral imaging, lumbar puncture, skin biopsy, muscle biopsy and electroencephalogram a diagnosis remained elusive. Several weeks after admission, diagnostic breakthrough was achieved when the gradual resolution of the patient's amnesia, encephalopathy and dysarthria allowed an accurate history to be taken for the first time. The patient's last recollection was turning on his gas heating for the first time since the spring. A gas heating engineer found the patient's gas boiler to be in a dangerous state of disrepair and it was immediately decommissioned.ConclusionThis case highlights several important issues: the bewildering myriad of clinical features of carbon monoxide poisoning, the importance of making the diagnosis even at a late stage and preventing the patient's return to a potentially fatal toxic environment, and the paramount importance of the history in the diagnostic method.