1 Acute care toolkit 2 High-quality acute care October 2011 Consultant physicians are at the forefront of delivering care to patients presenting to hospital with medical emergencies. Delivering this care depends on competent and expert clinical staff, organised with optimal working arrangements to match patient demand, supported by the right level of resources and facilities. The pressures on acute medical services are relentless and intense. Factors that may compromise timely, high-quality care to patients largely relate to staffing, casemix and the organisation of care (see Box 3). Background The Royal College of Physicians (RCP) recognises the requirement for consultant physicians to lead on the provision of high-quality care of acutely ill medical patients. The 2004 report Acute medicine: making it work for patients recommended that acute physicians lead the provision of acute medical services in dedicated acute medical units (AMUs). 1 The report acknowledged the growing demand for early, detailed assessment and complex care. It envisaged delivery of this care by both acute and general internal medicine (GIM)/specialty physicians, according to agreed protocols, in an AMU structured and staffed to maintain patient flow through to early discharge from AMU (up to 72 hours), or transfer out to specialist medical wards. Close joint working of the acute medical and GIM/ specialty teams with shared objectives (see overleaf) is crucial to delivering high-quality care across acute services and releasing bed capacity to allow patients to transfer promptly to specialist wards. In 2007, the Acute Medicine Task Force made recommendations about the operation and staffing of the AMU and how it should interrelate with the emergency department (ED), intensive care units (ICUs) and specialty wards. 2 Additionally, the AMU should have strong links with community services, such as intermediate care. Consultant-led work on the acute floor was seen as critical to rapid decision making, maintaining standards of care, patient flow, education, training, supervision and improving handover and communication with specialist colleagues. Defined training programmes for acute medicine are now well established. New consultant posts in the UK increased by 10.2% in 2009, with the greatest increases in acute medicine and geriatric medicine. 3 Financial pressures in the NHS in may slow this expansion. However, trusts seeking the highest quality of patient care must find ways to continue to expand the number of consultants responsible for this care. Close joint working of the acute medical and GIM/specialty teams with shared objectives is crucial to delivering high-quality care...
2 Acute care toolkit 2: High-quality acute care October All consultants involved in acute medical care should recognise their educational responsibilities and ensure that teaching is prioritised. Problem areas 1 Limited acute physician hours in AMU Issue: There are currently insufficient acute physicians (and physicians undertaking acute duties) in post, to staff the periods of high-intensity work consistently in AMUs throughout weekdays, weekends and bank holidays. > The principles of high-quality care for acutely ill patients (see Box 1) should be applied widely. Furthermore, job plans, rotas and work patterns designed to meet these principles, will assist acute trusts to determine the number of physicians, including acute physicians, required. > Trusts should recognise the importance of GIM physicians on call continuing to support the acute take on the AMU. It is crucial that physicians whose duties include working on the emergency floor are supported and their job plans made attractive. The duties should be shared widely, with careful consideration of the duration of out-of-hours working and the support available from other medical staff. Trust support for these physicians should include flexible negotiation of job plans, recognising the acute nature and intensity of the onsite duties, both in and out of hours. > Consultants from other medical specialties should continue to commit to sessions dedicated to acute medicine on the AMU. 2 This provides a healthy mix of disciplines working in the acute care environment and enables continuity of care and participating medical specialists to retain competencies in acute clinical care. New specialty medicine consultant appointees, trained in GIM in particular, can help trusts to meet the evolving service requirements. > All consultants involved in acute medical care should recognise their educational responsibilities and ensure that teaching is prioritised. Consultants have a critical role in leading and motivating the team throughout the hospital and ensuring that the next generation of physicians is equipped to provide care of the highest quality. 2 Standardisation of early warning score to track deteriorating patients and trigger intervention Issue: Emergency patients presenting to the AMU reflect the spectrum of illness severity, from ambulant to critically ill, and may have a fluctuating clinical course. The early warning score (EWS) allows the progression of disease course and response to treatment to be monitored throughout the pathway (AMU to specialty base ward). Acute trusts have adopted different EWS tools for the assessment of illness severity, leading to confusion for clinical staff moving between different hospitals. > The standardised NHS early warning score (NEWS) recommended by the Acute Medicine Taskforce 2 will be launched in Guidelines, based on NICE guidance on the recognition of the acutely ill patient, 6 list actions to be taken by staff and their urgency, if a trigger score is reached. They enable nursing staff to obtain appropriate and timely assessments, irrespective of the clinical setting, expertise of the nurse, or depth of knowledge of the patient s clinical status. Box 1 Principles of high-quality care for acutely ill patients 1 Acute medical care should be of the highest quality wherever and whenever this is required. 2 2 The quality of care provided in the first hours is a critical determinant of clinical outcomes. The AMU is the focal point for delivery of this care, although urgent care is delivered in a wide variety of settings. 3 The staffing, resources and specialist support services involved in the provision of care to medical emergencies should be organised on the basis of seven-day working. 4 The assessment, documentation and treatment of acute medical illness should be standardised across the NHS. 2 The NHS early warning score (NEWS) should be integral to the assessment of illness severity and the trigger for prioritisation of review and intervention throughout the acute care pathway. 2 5 Staff duties and ward activity throughout the hospital should be geared to support the emergency service. 2 6 The provision of care within the local health economy should ensure that care of emergency patients is not compromised by patients remaining in acute medical beds when this level of care is no longer required. 7 The level of care required should determine the rate at which patients progress along the emergency pathway. Unstable patients should not be transferred out of AMU until stable the AMU should have sufficient capacity and staffing to manage such patients. All AMUs should have a level 1 area, with level 2 areas in larger units. 10 continued overleaf
3 Acute care toolkit 2: High-quality acute care October Box 2 Care bundles Care bundles (eg sepsis resuscitation bundle) ensure clinical staff are prompted to: > identify patients with a specific clinical problem requiring a set of clinical interventions specified by the bundle > provide standardised, comprehensive assessment > deliver rapid, consistent treatment in line with best practice guidelines > follow (and document) a stepwise format which determines what clinical interventions are required and whose responsibility these are. > The importance of NEWS and the triggering of urgent clinical interventions cannot be overestimated. Nursing and medical staff caring for acute medical patients should be trained in the integration of NEWS into clinical decision making and handover at each stage of the patient pathway. 3 Standardisation of documentation and prescribing Issue: On the AMU, multiple clinicians assess and treat patients with emergencies of varying severity. For each patient, the complexity of clinical decision making mandates reliable written and electronic clinical records. However, the quality of clinical record keeping is compromised by a lack of standardisation of documents. Opportunities to prompt specific clinical actions or flag electronic alerts during prescription are missed. Staff working in an area where they are under acute pressure to complete tasks rapidly are faced with documentation that varies widely between hospital sites and may not be fit for purpose. Documentation should be standardised across the NHS in key areas: 2 > clerking forms for acute medical admissions that comply with the Academy of Medical Royal Colleges standards for the content of admission records 8 > care bundles for the management of common acute medical conditions (see Box 2) > inpatient observation charts (incorporating NEWS see problem area 2 above) > inpatient prescription charts for medications and intravenous fluids > fluid balance charts. Advantages of standardising documentation include: > incorporating best practice in relation to clarity, structure and content to optimise completion by busy clinical staff in a high-pressure setting > allowing inclusion of priority clinical prompts (eg prophylaxis of venous thromboembolism), providing a consistent, structured stimulus for clinical actions to improve patient safety and quality of care > optimising the recording and collation of predetermined data relating to clinical presentation for the electronic patient record (EPR), indicators of quality and for audit and research > improving the quality, safety and effectiveness of clinical review and handover > ensuring that staff moving between trusts remain familiar with documentation common to acute care areas, facilitating integration of best practice, eg checklists and safety prompts. Box 1 Principles of high-quality care for acutely ill patients continued from page 2 8 A consultant physician without conflicting duties should be available on site to review patients at least 12 hours per day. 4 Although on-site consultant duties should be tailored to the needs of all patients, acute duties should be centred on the AMU, where at least two consultant-led rounds should be conducted in the 12-hour period. 9 During periods that the AMU is staffed by a consultant, all newly admitted patients should be seen within 6 8 hours. Patients admitted overnight should have a consultant review within a maximum of hours. 10 Clinical review, transfer and handover occurring on the AMU should be designed to minimise the risk of patient deterioration soon after transfer out. 11 Patients transferring out of AMU should be the focus of enhanced review arrangements on their new ward, with a consultant review within 24 hours of the transfer seven days a week. 12 Clear, timely communication with the patient and/or carer should be a priority at all times, particularly relating to changes in the patient s condition, management or plans for transfer or discharge. 13 The input of specialty medicine teams should be integral to the care of patients on the AMU to allow stabilisation and transfer to specialty wards according to patient need. 14 Multiple transfers of patients to different wards should be avoided as this has detrimental impact on morbidity, mortality (particularly in the elderly) and length of stay. n
4 4 Acute care toolkit 2: High-quality acute care October Procedures for transfer out of AMU handover Issue: A system of high-quality handover is vital on the AMU because of frequent transfers of care between clinical staff, particularly at change of shift and when patients transfer out. See Acute care toolkit 1: Handover 9 for recommendations on the handover process and example templates: Clinical documentation and verbal handover must be of sufficient quality to ensure that subsequent owning teams immediately grasp key information including: > what has been done in AMU (assessments, diagnoses, management, treatment) > what still needs to be done > decisions made relating to ceilings of care and the involvement of the patient, staff and relatives in clinical decision making. Staff on the receiving ward need to be available to take the handover as soon as the patient is ready to be transferred. 5 Patients transferred out of AMU: continuity of care and early consultant review Issue: The enhanced staffing, dedicated consultant time and procedures for dealing with acute medical emergencies on AMU often contrast sharply with the situation on the wards that receive AMU transfers. Most patients transferring out of AMU are within hours of admission and despite careful selection for transfer and handover, patients may deteriorate post-transfer. The risk to the patient is increased where the receiving ward is poorly staffed, has little experience of the patient s illness, or has no ready access to consultant decision Box 3 Factors threatening the delivery of timely, high-quality care Staffing: > fewer clinical staff out of office hours, particularly senior decision makers > rotas and working practices that fail to provide adequate on-site consultant cover seven days a week and continuity of care > gaps in junior doctor rotas due to sickness, failure to recruit, and absence of locum cover > depletion of ward-based junior doctors in hours, due to restricted working hours (including mandatory rest days) > reduced junior doctor hours with failure to run rotas designed to optimise continuity of care and teaching > reduced clinical experience of junior doctors with increased demands on supervising doctors > increased workload of ward nurses and allied health professionals due to staff numbers failing to match demand. Casemix and the organisation of care: > increased age, complexity, comorbidity and dependency of emergency medical patients > increased expectations of complexity of care that should be offered to all patients (including access to hospital assessment/admission) > changes to out-of-hours care and referral patterns, including increasing patient self-referral to the emergency department (ED) and care home residents sent to ED for assessment, rather than primary care > insufficient daily senior decision making to maintain progress towards discharge on all medical wards > failure to discharge patients as soon as they no longer require an acute medical bed, eg due to non-medical delays such as difficulties accessing social services support or lack of discharge pathways operating seven days a week. n
5 Acute care toolkit 2: High-quality acute care October making circumstances that should not be tolerated. In the absence of specific arrangements for early consultant review, the patient who transfers out of AMU immediately before a weekend may wait more than 48 hours for the next scheduled consultant round. > Transfers from AMU should be needs-based, not timedriven. > All patients transferred out of AMU should have a consultant review within 24 hours of their transfer, irrespective of their ward location. This provides reliable consultant review at a critical time in the development of the acute illness; confirms decisions related to treatment, discharge and any ceilings of care; and communicates these to the staff on the patient s new ward. > Consultant review of recently transferred patients, represents an important element of seven-day working for consultant physicians and a priority duty in the first hour of the working day golden hour review. The review provides a framework for consultant duties on all medical wards, and identifies a cohort of patients likely to benefit from review, including patients requiring review for clinically urgent reasons or potential discharge. On weekdays the review is carried out daily by the consultant to whose care the patient has transferred. At weekends, consultants who share specialty ward beds and/or rotas should agree which consultant conducts these reviews. In stable patients the review may be brief and prompt discharge, but for any patient who is acutely ill, it enables timely consultant decision making. > The 2010 RCP position statement included the following recommendation: While much of the work of the consultant physician will be on AMU, provision should be made for a daily consultant visit to medical wards. In many hospitals this will require input from more than one physician. 4 > At the time of transfer out of AMU, the consultant responsible for ongoing care of the patient should be clear. In the event that a patient is transferred from AMU as a medical outlier to a surgical ward, it is recommended that agreed buddy arrangements are in place, linking each non-medical ward to a designated medical consultant team to ensure continuity of care. These patients should be included in the consultant review occurring within 24 hours of transfer out of AMU. 6 Discharge and maintaining flow through the medical admission pathway Issue: Major factors that contribute to reduced patient flow through the AMU and the inpatient pathway include the following: > The rate of admission of emergency medical patients is not matched by coordinated discharge activity by staff on all medical wards seven days a week. > Discharges occurring late in the day cause a mismatch in bed capacity. > Patients whose inpatient treatment for an acute medical illness is complete, remain in hospital because of poor discharge planning or a suboptimal response from community support services. > Over-investigation of some inpatients, rather than the use of ambulatory care facilities. > A key principle is to enable consultant-led teams to set a tempo of reviewing and discharging selected patients at the start of each working day, seven days a week. > The golden hour review (see 5 above). For patients not ready for discharge at the time of this review, the management plan should include an estimated date of discharge (EDD), planning to enable discharge early in the day and communication of the criteria for discharge to the ward team. > All staff should be clear about their responsibilities to ensure that bed capacity is made available on all wards early each day, seven days a week, including the provision of transport, to take out medications, and the use of the discharge lounge. > Consultant physicians with inpatient responsibilities should ensure that: all staff work as a team to deliver timely safe discharge and are able to overcome or escalate obstacles. An integrated assessment with evaluation of social care The risk to the patient is increased where the receiving ward is poorly staffed, has little experience of the patient s illness, or has no ready access to consultant decision making circumstances that should not be tolerated.
6 Acute care toolkit 2: High-quality acute care October provision and community care input is needed at the point of first assessment. This should also identify patients who are in a cycle of regular readmission or failed discharge. best discharge practice is adopted including the use of EDD, discharge checklists and the use of regular focused multidisciplinary meetings to monitor progress against discharge plans 7 mechanisms are in place to ensure that staff and carers are made aware that discharge is imminent and all discharge documentation is completed in advance on each ward round potential discharges are reviewed first and any outstanding discharge documentation completed at the time of review where discharge is anticipated out of hours (eg weekends) the discharge criteria are clearly recorded in the case notes and communicated to ward nursing staff, enabling nurse-led discharge where possible. Appendices Click here to access two online appendices: the RCP position statement on out-of-hours care, and guidance notes on the provision of 12-hours-per-day, 7-days-per-week consultant care. References 1 Royal College of Physicians. Acute medicine: making it work for patients. Report of a working party. London: RCP, Royal College of Physicians. Acute medical care: the right person in the right setting first time. Report of the Acute Medicine Task Force. London: RCP, The Federation of the Royal Colleges of Physicians of the UK. Census of consultant physicians and medical registrars in the UK, London: RCP, Royal College of Physicians. Care of medical patients out of hours RCP position statement. London: RCP, node/359 5 Royal College of Physicians. Standardising the assessment of acute illness severity in the NHS: recommendations for a NHS early warning score (NEWS) [working title]. Report of a working party. London: RCP, in press due late National Institute for Health and Clinical Excellence. Recognition of and response to acute illness in adults in hospital. Concise Guidance 50. London: NICE, Department of Health. Achieving timely simple discharge from hospital: a toolkit for the multi-disciplinary team. London: DH, Academy of Medical Royal Colleges. A clinician s guide to record standards Part 2: standards for the structure and content of medical records and communications when patients are admitted to hospital. London: NHS, Royal College of Physicians. Acute care toolkit 1: Handover. London: RCP, acute-care-toolkit 10 The Intensive Care Society. Levels of critical care for adult patients. London: ICS, Royal College of Physicians 11 St Andrews Place Regent s Park London NW1 4LE Tel: +44 (0) Fax: +44 (0) Royal College of Physicians 2011 You may copy or distribute this work, but you must give the author credit, you may not use it for commercial purposes, and you may not alter, transform or build upon this work.