Acute medical care. The right person, in the right setting first time. Report of the Acute Medicine Task Force

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1 Acute medcal care The rght person, n the rght settng frst tme Report of the Acute Medcne Task Force October 2007

2 The Royal College of Physcans of London The Royal College of Physcans plays a leadng role n the delvery of hgh qualty patent care by settng standards of medcal practce and promotng clncal excellence. We provde physcans n the UK and overseas wth educaton, tranng and support throughout ther careers. As an ndependent body representng over 20,000 Fellows and Members worldwde, we advse and work wth government, the publc, patents and other professons to mprove health and healthcare. Ctaton of ths document: Royal College of Physcans. Acute medcal care. The rght person, n the rght settng frst tme. Report of the Acute Medcne Task Force. London: RCP, Copyrght All rghts reserved. No part of ths publcaton may be reproduced n any form (ncludng photocopyng or storng t n any medum by electronc means and whether or not transently or ncdentally to some other use of ths publcaton) wthout the wrtten permsson of the copyrght owner. Applcatons for the copyrght owner s permsson to reproduce any part of ths publcaton should be addressed to the publsher. Copyrght 2007 Royal College of Physcans ROYAL COLLEGE OF PHYSICIANS OF LONDON 11 St Andrews Place, London NW1 4LE Regstered Charty No ISBN Cover photograph: Crspn Hughes, by permsson of Kng s College Hosptal, London. Typeset by Dan-Set Graphcs, Telford, Shropshre Prnted n Great Brtan by The Lavenham Press Ltd, Sudbury, Suffolk

3 Contents Members of the Acute Medcne Task Force Acknowledgements Foreword Executve summary and recommendatons Glossary v v x x xx 1 Vson, remt and background 1 Vson and remt 1 Methodology 1 References and nformaton sources 2 Structure of the report 2 Background 3 Readng ths report 5 2 Acute medcal care 6 Clncal decson makers 7 Expandng the provson of dagnostc support 7 Improvng access to urgent medcal assessment and treatment 8 Confguraton of acute medcal servces at the communty/hosptal nterface 8 The spectrum of acute care 8 Models of acute medcal care provson 9 Urgent care centres 10 Acute deteroraton n long-term llness 11 Acute medcal llnesses n nursng homes, resdental homes and communty 12 hosptals End-of-lfe care 13 Emergency medcal care 13 The emergency care network 13 Navgatng acute medcal servces: gettng the patent to the rght person, 14 n the rght place frst tme Pre-hosptal care and ambulance servces 16

4 Acute medcal care Acute medcal admsson to an acute hosptal generc prncples 17 Acute and local hosptals 17 Emergency medcne and acute medcne 19 Acute medcal care n hosptals wthout an emergency department 20 Acute specalst medcal servces 20 Acute general surgery 20 Acute medcne and acute general surgery confguratons 21 Watershed condtons 21 Crtcal care (hgh dependency and ntensve care) 21 Patent flow and plannng the transfer of care (dscharge plannng) generc 22 requrements Leadershp, organsaton and management 22 3 Patent safety and clncal effectveness 24 Standardsng the assessment of llness severty 24 Improvng the standard of patent clncal records and documentaton 25 Standardsng clncal management protocols for common acute medcal llness 25 Montorng clncal performance clncal performance ndcators 26 The mportance of accurate clncal codng n acute medcal care 26 Recordng patent and carer experence 26 Informaton technology 26 4 Acute medcal care wthn hosptals 28 The acute medcal unt 29 AMU confguraton 30 Locaton 30 Sze 30 Desgn prncples 31 Operatonal prncples 32 Patent flows gearng up capacty to meet changes n demand 33 Interface wth other specaltes and ther bed bases 34 Acute medcne commtment from medcal specaltes 34 Specalst n-reach 34 Care of older people: specal consderatons for older patents admtted 34 to hosptal wth acute medcal llness Access to dagnostcs 35 v

5 Contents Patent transfers to the specalty bed base 35 Confguraton of the specalty bed base beyond the AMU 36 AMU and medcal outreach and the acute response team 36 Acute medcal unt staffng and operatons general prncples 37 The medcal team 37 The nursng team 38 Other acute medcal unt staff 38 Acute medcal unt ward rounds, patent revew and handover of care 39 Extended day workng 40 5 Workforce plannng, educaton, and tranng 41 The acute medcal unt as a tranng envronment 41 Flexblty and career opportuntes 42 Structures mportant to promote recrutment and retenton 43 Job plannng and workforce confguraton 43 Implcatons for job plannng for specaltes 44 Innovatve roles 45 Opportuntes for medcal staff dual tranng and dual roles 45 Fundng 46 Research and development 47 References 48 Appendx: Further nformaton 49 v

6 Members of the Acute Medcne Task Force Executve group Members Bryan Wllams (Char), Professor of Medcne, Unversty of Lecester and Unversty Hosptals of Lecester NHS Trust Solomon Almond, Consultant Physcan, Royal Lverpool Hosptal NHS Trust Derek Bell, Professor of Acute Medcne, Imperal College, Chelsea and Westmnster Campus, London Mke Jones, Presdent, Socety for Acute Medcne Rhd Dowdle, Vce Presdent, Socety for Acute Medcne Susan Shepherd, Secretary, Royal College of Physcans George Albert, Natonal Drector for Emergency Access, Department of Health Graham Archard, General Practtoner, Vce Char, Royal College of General Practtoners Davd Astley, Chef Executve, St George s Healthcare NHS Trust Laurence Burke, Acute Physcan, Belfast Trust Stuart Carney, Assocate Postgraduate Dean, East Mdlands Healthcare Workforce Deanery and Specal Advsor, UK Foundaton Programme Offce Chrs Clough, Medcal Drector, Jont Royal Colleges of Physcans Tranng Board Davd Coln-Thome, Natonal Clncal Drector for Prmary Care and Medcal Advser, Commssonng and System Management Drectorate, Department of Health Alastar Crosswate, Prmary Care Physcan, Lothan NHS Martn Culshaw, Acute Physcan, Nottngham Unversty Hosptals NHS Trust Glyns Dack, Senor Nurse, Norfolk and Norwch Unversty Hosptal NHS Trust Ngel Edwards, Polcy Drector, NHS Confederaton Davd Evans, RCP Patent and Carer Network member James Halsey, RCP Patent and Carer Network member Taj Hassan, College of Emergency Medcne Clare Hggens, Consultant Physcan, Char, Acute and General (Internal) Medcne Commttee, Royal College of Physcans Nck Hulme, Drector of Operatons, Bucknghamshre Hosptals NHS Trust v

7 Acute Medcne Task Force Paul Jenkns, Acute Physcan, Norfolk and Norwch Unversty Hosptal NHS Trust Kerry Johnston, Matron, Acute Medcal Unt, Unversty Hosptals of Lecester NHS Trust Sonya Lam, Drector, Alled Health Professonals, NHS Educaton for Scotland Kevn O Kane, Consultant n Acute Medcne, St Thomas Hosptal, London Era Makepeace, RCP Patent and Carer Network member Alastar McGowan, College of Emergency Medcne John Mell, Clncal Drector for Acute Medcne, Lewsham Hosptal NHS Trust Rchard Mddleton, General Manager for Medcne and Emergency Department Servces, Unversty Hosptals of Lecester NHS Trust Lz Myers, Nurse Consultant, NHS Taysde Ben Pearson, Acute Physcan, Derby Hosptals NHS Foundaton Trust Clare Perry, Chef Executve, Lewsham Hosptal NHS Trust Roy Pounder, Royal College of Physcans lead for the workng tme drectve Jonathan Robn, Consultant Physcan, Ashford and St Peter s NHS Trust Mark Smmonds, Specalst Regstrar n Acute Medcne, Queens Medcal Centre, Nottngham Unverstes NHS Trust Hannah Skene, Specalst Regstrar n Acute Medcne, Queens Medcal Centre, Nottngham Unverstes NHS Trust Ian Starke, Char, Specalst Advsory Commttee n Acute and General Medcne, Royal College of Physcans; Clncal Drector for Medcne for Older People, Lewsham Hosptal NHS Trust Chrs Streather, Renal Physcan, Medcal Drector, St George s Healthcare NHS Trust Ian Sturgess, Consultant Physcan, East Kent Hosptals NHS Trust Audrey Taylor, RCP Patent and Carer Network member Mchael Trmble, Consultant Physcan, Belfast Trust Jenny West, RCP Patent and Carer Network member Chand Vellod, RCP Councllor; Head of Acute Medcne, Barnet and Chase Farm Hosptals NHS Trust v

8 Acknowledgements As Char of the Acute Medcne Task Force t has been an honour and a pleasure to have had the opportunty to work and nteract wth so many talented people over the past two years. In 2005 Dame Carol Black, past presdent of the Royal College of Physcans (RCP), recognsed the tme was rght for an updated RCP report on acute medcne and went on to launch the Task Force. Snce 2006, Presdent Ian Glmore has been tremendously supportve and has provded nvaluable gudance and advce n managng the many professonal nterfaces that delver and depend on acute medcne servces. The Task Force brought together a wealth of talent from many stakeholders n acute medcal care, rangng from the full spectrum of healthcare professonals, NHS managers, polcymakers and patent representatves. They all gave ther tme to partcpate enthusastcally n dscussons and to support the work of the Task Force n many ways, on many occasons, alongsde ther busy lves. It has been nsprng to wtness ther commtment and passon to contnuously mprove acute medcal care. Beyond the Task Force, there has also been nvaluable dscusson wth leaders and representatves of many other key stakeholder groups, specalst socetes and the Councl of the RCP, London: a process whch has further mproved ths report. It was produced n collaboraton wth the Socety for Acute Medcne, and many members of the socety sat on the Task Force. In wrtng ths report, I am ndebted to the outstandng work and commtment of the leaders of the workng groups who comprsed the executve team: Professor Derek Bell, Dr Solomon Almond, Dr Mke Jones, Dr Rhd Dowdle and especally Dr Susan Shepherd who was Secretary to the Task Force and wthout whose skll and gudance the clmb would have been much more dauntng and far less enjoyable. October 2007 Professor Bryan Wllams Char, Acute Medcne Task Force v

9 Foreword In January 2006 the RCP convened a workng party the Acute Medcne Task Force to consder n depth the changng landscape of acute medcal care n England. The outcome of that work s dstlled nto ths report and provdes a blue prnt for the development of acute medcal servces gong nto the 21st century. Professor Bryan Wllams and members of the Acute Medcne Task Force are to be congratulated on settng out ther vson so clearly. The care of patents wth acute medcal llness needs to be mproved rght across the NHS: to ensure a consstently hgh qualty of care throughout the servce and wth respect to access to an approprate level of care, out of tradtonal offce hours. Ths prncple apples to patents developng acute medcal llness n the communty, as well as to those who develop acute medcal llness whle n hosptal. The report makes a number of recommendatons that, f mplemented, wll mprove the effcency and effcacy of patent assessment and treatment, whle at the same tme enhancng ther experence and clncal outcome. Ths report s not just for doctors. It s for all those who work n acute medcal servces and those who plan, commsson, and use them all of whch were reflected n the Acute Medcne Task Force composton. Consultaton was at the heart of the way the Acute Medcne Task Force went about ts work, but specal thanks are due to the Socety for Acute Medcne who collaborated extensvely at all stages n the development of the report. The RCP wshes acute medcal care n the NHS to be at the cuttng edge of medcne wth rapd translaton of new developments nto patent care. The overarchng phlosophy of ths report s captured by ts ttle to ensure that patents get access to the hghest qualty of acute medcal care by the rght person, n the rght settng frst tme. Ths s a formdable challenge a challenge to harness the talent and commtment of all those who work at the front lne of medcne to shape and lead the reform of acute medcal servces. A challenge to change what we do, when we do t, and how we do t. October 2007 Professor Ian Glmore Presdent, Royal College of Physcans x

10 Executve summary and recommendatons Executve summary Ths report of the Acute Medcne Task Force of the Royal College of Physcans (RCP) s about excellence n the provson of acute medcal servces, and provdes recommendatons for the organsaton and delvery of clncal care for people wth acute medcal llnesses. Acute medcal care The report makes a number of recommendatons, at the heart of whch s the need to ensure that the frst assessment of acutely ll patents s by competent clncal decson makers, supported when necessary by ready access to senor clncal decson makers. Competent decson makng also requres dagnostc support, and the avalablty of these servces must be mproved and better algned to when and where they are needed. The combnaton of competent frst assessment and approprate levels of dagnostc support guarantees that the rght assessment and treatment are delvered frst tme. Ths may be lfe savng for the crtcally ll but s mportant at every level of llness severty to provde a fast and effcent servce. The Task Force wshes to replace see and greet wth see and treat. Patent access to out-of-hosptal general practce or communty-based acute medcal care, especally out of hours, s largely nadequate and nflexble. Too often patents present to acute hosptals because there s nowhere else for them to go to get the reassurance and care they need. An expanson of the range of servces, provders and facltes offerng unscheduled and acute medcal care n the communty s requred. However, there s an mportant caveat. Those who delver acute care n the communty must acqure and mantan the same competences n acute medcal care as those who delver t n hosptal. Ths s partcularly mportant n the context of current polcy to move more care nto the communty and by nference, away from acute hosptals. Careful plannng s requred, drven by clear evdence that t wll delver mprovements n the qualty of acute medcal care. Before exstng servces are decommssoned, we must be certan that new servces wll delver care that s more convenent, safer and better organsed than that offered now. Acute medcal care for older patents For older patents developng acute llness n communty-based longer-term care facltes, we recommend the wder use of outreach from specalst multdscplnary hosptal teams to manage these patents more effectvely n stu. Ths would avod hosptal admsson whenever possble, and facltate t when necessary. In addton, such patents should have long-term care plans that defne the most convenent and approprate pathways for acute medcal care, agreed levels of nterventon, and plans for end-of-lfe care. Acute medcal care n hosptals Acute medcal care n hosptals also needs to develop n a number of ways. Not all hosptals admt patents wth lfe-threatenng acute medcal llness but those that do should follow the prncple x

11 Executve summary and recommendatons of ensurng rapd streamng of patents to the rght settng. We recommend consoldaton of acute servces n large acute hosptals, whle takng account of local demographcs and the need to provde safe travel tmes. We support the development of drect acute care pathways for acute myocardal nfarcton and acute stroke. We recognse the mportance of emergency physcans n the emergency department (A&E) for the mmedate assessment and management of those wth a range of undfferentated acute llnesses. We also endorse and expand recommendatons from prevous RCP reports about the mportance of the development of acute medcne as a specalty and the establshment of acute medcal unts (AMUs) as the focus for acute medcal care n hosptals. We emphasse the mportance of crtcal care teams and adequate crtcal care facltes and support n all hosptals carng for patents wth acute medcal llness. Acute medcal care the front door However, t s clear that more could be ganed by closer workng of these related clncal specaltes. We recommend that n large acute hosptals that receve crtcally ll patents, the front door should comprse an emergency floor wth co-locaton of the emergency department, the AMU, crtcal care, and other acute and urgent care facltes and key support servces, ncludng the ambulance servce. Ths would foster greater ntegraton and collaboraton and would mprove the nterface between these key servces, brngng together ther dfferent skll mxes and expertse wthn a sngle settng. In turn, ths would facltate more effectve streamng of patents to the rght place for ther ongong care. The acute medcal unt We provde detaled recommendatons about the remt, confguraton and operatonal polces for the AMU. The qualty of the frst 48 hours of acute medcal care s an mportant determnant of clncal outcomes and we recognse the need to guarantee the qualty of ths care and access to ths care, 24 hours a day, seven days a week (24/7). The AMU wll provde the optmal envronment for acute medcal care n hosptals, consoldatng the approprate clncal and support servces n a ft for purpose sngle settng staffed by clncal staff wth competences n acute medcal care and supported by n-reach from specalst multdscplnary teams. A closer nterface wth crtcal care teams s essental and many AMUs wll requre embedded hgher dependency care facltes. Many patents wth acute medcal llness wll complete ther care wthn the AMU, whle those requrng more specalst ongong care wll be streamed to the specalst bed base wthn the hosptal network. When deemed approprate, patents developng acute medcal llness n the communty should be streamed drectly to the AMU. The new cadre of acute physcans wll need to expand. They wll play a key role n the leadershp of the AMUs. However, t s essental that other specalsts contnue to partcpate fully n acute medcne to provde a broad-based skll mx, and to retan ther own competences n acute medcal care. Some patents develop acute medcal llness when n hosptal and the qualty of the mmedate response and care of these patents must contnue to mprove, especally out of hours. The AMU clncal team, workng closely wth crtcal care teams, should become the hub for coordnatng medcal outreach wthn hosptals. x

12 Acute medcal care Emergency care networks The plannng and management of an expanded provson of acute and urgent care optons n the communty and n hosptals wll requre the establshment of emergency care networks n regons to provde better coordnaton of acute servces. Moreover, some lfe-savng nterventons, specalst servces and complex dagnostcs wll be provded across local and regonal networks, rather than n every hosptal. These networks must be led by senor boards wth strong clncal leadershp, comprsng key commssoners and provders, wth drect accountablty. The networks wll need to ensure that patents are granted safe access to acute medcal care wherever they are and whenever they need t. Publc nformaton We also recognse that there s lttle pont n developng a wder range of acute servces f patents and staff workng wthn the NHS do not know how to access them. Much more detaled publc nformaton about the remt and boundares of local urgent and emergency care servces s requred and we recommend the development of a local navgaton hub, wth a well publcsed sngle access number dstnct from 999, that enables a dalogue wth a competent decson maker to reassure and/or drect patents to the most approprate servce wthn the local network. The ambulance servce wll play a key role n acute medcal servces and we make a number of recommendatons to extend ths role and strengthen ther nterface wth acute clncal teams. Patent safety and clncal effectveness Our report s founded on mprovng patent safety and we want to ensure that all patents and staff are confdent that acute medcal care s of the hghest qualty wherever and whenever t s needed. We need to standardse processes for the assessment, documentaton and treatment of acute medcal llness across the NHS. We recommend the development and mplementaton of an NHS early warnng (NEW) score. Ths NEW score should be famlar to all staff and should be used to trgger the most approprate response, ether n the communty or n hosptal. We also recommend the development of natonal clncal performance ndcators to benchmark and mprove performance. Workforce plannng, educaton and tranng All of our recommendatons have major mplcatons for the NHS workforce especally for those workng at the front lne of acute servces. Clncal leadershp for local servces should evolve from wthn the servce. Such leadershp s essental to drve the development of servces and nspre others to follow. We encourage the development of a supportve culture of educaton, tranng, self-mprovement, excellence and teamwork founded on the prncples at the core of ths report, notably patent safety and qualty clncal care. Robust tranng programmes are requred for all staff to guarantee the competences requred to empower clncal decson makng. Tranng budgets and dedcated tme n job plans must reflect tranng needs and leadershp roles. The workforce wll need to change and adapt to the requrement for a greater presence of competent decson makers at the front lne of servces across extended hours. In so dong, we must recognse that acute servce work s especally demandng and the rsk of burn out s real. Staff workng n these areas must be supported and ther job plans should be flexble and vared, wth clear x

13 Executve summary and recommendatons opportuntes for career progresson. Ths s essental to encourage recrutment of the most able staff nto acute specaltes at all levels, and to retan the exstng expertse. All specaltes nterfacng wth acute medcne wll need to gan and mantan competences n acute medcne. Acute medcne should become a mandatory component of the medcal undergraduate currculum. Research and development We want acute medcal care n the NHS to be at the cuttng edge wth rapd translaton of new developments nto patent care. The evdence base for best practce n acute medcal care s weaker than t should be and needs to be strengthened. For ths to occur, the culture of research and development n acute medcal servces should be gven a hgher prorty than t has at present. We have recommended the development of a research and development network for acute medcne to facltate ths. Fundng Fnally, acute medcal care must be adequately resourced and fundng mechansms should be carefully evaluated to ensure that they do not dstort clncal prortes and nstead drve the development of a world class coordnated servce, provdng comprehensve and safe levels of care. Acute medcal care s not a luxury we have to get t rght, not least of all because one day, we wll all need t. Recommendatons Acute medcal care We recommend that patents wth acute medcal llness should get access as soon as possble to a competent clncal decson maker at the front-lne of acute medcal servces. We recommend the need for an expanded provson of out-of-hours dagnostc facltes for communty- and hosptal-based care. For communty care these servces should be avalable as a mnmum for extended seven-day workng. However, t s essental that ths s algned to competent clncal decson makng provdng a one stop shop for certan clncal presentatons. We recommend that wthn regons there must be a wder range and more nnovatve optons for acute medcal care, scaled to meet patents specfc needs, ft for purpose and convenently located. We recommend that medcal care out of hours (both n hosptal and communty) must be supported by better access to dagnostcs to enable a competent clncal decson maker to complete an assessment and delver approprate treatment frst tme. We recommend that defned pathways to facltate rapd access to specalst n patent care for people wth acute deteroraton of long-term llnesses should be developed. These pathways may also nclude mental health servces and end-of-lfe care. We recommend that there should be clear lnes of clncal accountablty and responsblty and that the mplementaton of communty care plans should be rgorously evaluated and montored to ensure patent safety and satsfacton. We recommend the development of more multdscplnary specalst outreach teams from acute hosptals to support communty-based healthcare. x

14 Acute medcal care xv We recommend that explct and effectve acute care plans should be developed for patents n long term care, n order to reduce unscheduled hosptal admssons. Such plans should be clear about levels of agreed nterventon and should be dscussed and agreed wth patents and/or ther representatves, especally regardng levels of nterventon and resusctaton. Acute care plans must be accessble by ambulance servces and other responders to acute crses n these settngs. We recommend that end-of-lfe care plans should become an mportant part of clncal assessment and ongong revew of patents wth termnal llness. We recommend the development of major acute hosptals servng local regons, provdng the most ntensve level of emergency and complex acute medcal care. These hosptals should have major emergency departments co-located wth the acute medcal unt and crtcal care unts, deally as part of an emergency floor. We recommend that emergency care networks should be establshed n regons to develop and coordnate acute servces. We further recommend that emergency care networks should be managed by a Senor Board comprsng provders and commssoners wth strong clncal leadershp. These Boards must have real power to commsson and confgure local emergency servces and should be fully accountable for the work of the network. We recommend the development of a navgaton hub for the emergency care network to drect patents requrng urgent medcal care to the most approprate servce. We recommend that the local navgaton hub should have a sngle, well publcsed telephone number for patents who need access to urgent medcal care ths could be ntegrated wth a more locally relevant NHS Drect servce. We recommend that there s a need for more extensve publc nformaton about the role, remt, and boundares of the varous servces wthn the emergency care network. We recommend that acute medcne servces should be n close geographcal proxmty to the emergency department, to facltate drect access to the AMU for dfferentated acute medcal problems for the communty. We recommend that all hosptals wthn an acute care network admttng patents wth acute medcal llnesses (even those wthout emergency departments) should establsh AMUs as the focus for acute medcal care. We recommend that AMUs develop an augmented care area (up to level 2 care) and staff wth competences to delver ths level of care. Safe transfer arrangements must be n place to ensure level 3 care when requred. We recommend that large acute hosptals dealng wth complex acute medcne must have onste access to level 3 crtcal care (e ntensve care unts wth full ventlatory support). We recommend that a date of transfer of care should become a routne part of the admsson process, and be n place wthn 12 hours of admsson. We recommend that all AMUs should have nomnated clncal and nursng leads for acute medcne. These leads should work on a regular bass wthn the unt. Servces nterfacng wth the AMU, for example, the emergency department, crtcal care, magng and prmary care. should also have

15 Executve summary and recommendatons a defned clncal lead. We further recommend that leaders of the nterface servces should meet on a regular bass to facltate plannng and development of the acute servce. Patent safety and clncal effectveness We recommend that clncal assessment, clncal documentaton and clncal management of common acute medcal condtons should be standardsed natonally, to reflect best practce. Ths would mprove clncal practce, support clncal governance, and facltate case revew, transferablty of clncal nformaton and clncal audt. We recommend that the physologcal assessment of all patents should be standardsed across the NHS wth the recordng of a mnmum clncal data set result n an NHS early warnng (NEW) score. We recommend that a workng group s commssoned to develop the NEW score and evaluate t. Ths work should take nto account both the levels of tranng and the settng of the healthcare professonals makng these assessments. We recommend that the NEW score be used at all stages n the acute care pathway, ncludng pre-hosptal assessment, eg by the GP, ambulance servce or other healthcare professonals seekng advce on acute medcal care. The NEW score should also be used as part of npatent assessment of llness severty and as a trgger for approprate prortsaton of patent revew. We recommend that all healthcare staff would be traned n the use of the NEW score and the level of response requred at each level of NEW scorng. We recommend that documentaton should be standardsed across the NHS n three key areas: clerkng forms for acute medcal admssons to hosptal npatent basc observaton charts eg for temperature, pulse rate, blood pressure, conscous level and urnalyss, whch could be part of the NEW scorng npatent drug and v flud prescrpton charts. We recommend that roll-out of the EPR, when avalable, should be prortsed for acute care areas ths would help standardse the ongong documentaton by multple practtoners and carers and also mprove hand-over and transfer of care documentaton all of whch are mportant guarantors of patent safety. We recommend standardsng clncal management wth the development of evdence-based natonal gudance for the clncal management of common acute medcal llnesses. Ths would mprove patent care and provde a more effectve bass for tranng and audt. We recommend that an approved lst of natonal clncal performance ndcators (CPIs) should be developed for acute medcal care. These should be used to provde a more standardsed evaluaton of clncal performance and outcomes for out-of-hosptal and n-hosptal acute medcal care. These should assess at least three domans: mortalty; some cause-specfc outcomes and patent satsfacton and experence. We recommend that accurate clncal codng nformaton should be recorded by a competent clncan on the clerkng forms. xv

16 Acute medcal care We recommend that networks should record data on patents experences of ther whole epsode of acute care to help emergency care networks dentfy ways to mprove ths servce. We recommend that the provson of relable, hgh qualty, IT support s prortsed n acute clncal areas to support effcent workng of the emergency care network and ts related parts. Acute medcal care wthn hosptal We recommend that the AMU should be the hub for all acute medcal care wthn hosptals. Ths wll nvolve close collaboraton wth crtcal care teams and should lead to the establshment of a sngle, multdscplnary Acute Response Team that provdes 24/7 outreach care from the AMU to all areas of the hosptal, for patents requrng urgent medcal revew. Because the clncal condton of patents n hosptal can deterorate unpredctably at any tme, all hosptals wll need an AMU and staff wth competences n acute medcal care, rrespectve of whether or not they have an emergency department. We recommend that the AMU operates a number of streams for patents related to clncal need. These nclude the acutely unwell requrng close supervson and montorng, short stay patents, older patents, complex needs patents, and ambulatory care. We recommend that vstor access to AMUs should be controlled because of the contnuous ongong admssons process and frequent revew of acutely ll patents. The desrablty of open vstor access must be balanced by the prortes of acute clncal care, patent comfort and dgnty. We recommend that the AMU should ncorporate suffcent capacty for sngle sex bay accommodaton whenever possble recognsng that ths s not always feasble n montored envronments. We recommend that where the AMU receves drect admssons, t should have a fully montored drect admsson area wth approprate levels of medcal and nursng staff support and nclude modern trolleys/chars/and watng areas. We recommend that AMUs should have operatonal procedures for defnng approprate and safe mental health accommodaton and behavoural problem areas. Ths s to cater for patents wth mental llness who develop acute medcal problems, or patents wth acute medcal llness who develop acute confusonal states. We recommend that the AMU should provde the base for Hosptal at Nght teams and for Hosptal out of hours servces and acute medcal outreach. Ths wll need admnstratve space and IT support. Ths focus s approprate as the majorty of patents managed by these teams have medcal problems. For the tranees takng part n these actvtes, t s mportant that they have ready access to the senor physcans workng wthn the AMU for support and educatonal feedback. We recommend that the AMU should also contan ready access to teachng and tranng facltes for staff and students. For larger unts a semnar room for teachng and tranng should be embedded because t s less practcal for staff to leave the AMU for tranng perods. We recommend that transfer of care plannng should begn at the tme of the ntal patent assessment and an accurate codng of the dagnoss and an estmaton of antcpated length of stay should be recorded for all patents and revewed regularly. xv

17 Executve summary and recommendatons We recommend that length of stay for a patent on an AMU should be dctated by the clncal need of the patent and not by predefned arbtrary lmts ths wll nvolve typcal lengths of stay of between hours, wth an average length of stay n establshed AMUs of approxmately hours, allowng many patents to complete ther epsode of care wth the same clncal team. We recommend that the pace of lfe n the man hosptal bed base beyond AMU must be geared to respond dynamcally to changes n demand so as to ncrease capacty durng busy perods. Ths gearng requres real tme montorng of demand and capacty, and robust escalaton polces that are capable of respondng quckly to early sgnals to dstrbute acute pressures more evenly from the front door to the entre bed base. Ths gearng must also nvolve communty bed access beyond the acute hosptal and must be operatonal 24/7. We recommend that modern acute hosptals wll requre daly clncal revew of the entre bed base by a competent clncal decson maker to ensure effcent patent flows and to reduce length of stay. Ths s an essental component of gearng to meet fluctuatons n demand. We recommend that physcans from other medcal specaltes contnue to commt to sessons n ther contract dedcated to acute medcne on the AMU. Ths provdes a healthy mx of dscplnes workng n the acute care envronment and enables all partcpatng medcal specalsts to retan competences n acute clncal care. We recommend clearly defned contact pathways for named senor clncal opnons (SpR or consultant) should be on a rota for all specaltes lkely to requre regular nteracton wth the AMU. These nclude: geratrc medcne, gastroenterology, dabetes and endocrnology, dermatology, rheumatology, neurology, cardology, respratory medcne, nfectous dseases and mental health teams We recommend that specalty teams should develop rotas of clearly dentfed adequately experenced staff who can provde advce or attend and revew patents expedtously on the AMU, wthn a maxmum of 4 hours of a request and deally sooner. Ths s mportant for clncal governance, patent safety, educaton, and to facltate effcent patent dscharge. We recommend that AMUs talor ther operatons to meet the needs and expectatons of an ageng populaton wth more complex llness. Operatonal polces should reflect ths to ensure the dgnty and the hghest qualty of care for fral, older and vulnerable patents wth acute llness. Ths requres a multprofessonal approach, workng n close lason wth the specalst teams. We recommend that there should be no dscrmnaton on the bass of patent age when decsons are made about access to acute medcal servces, and about the qualty of servce subsequently provded and receved. We recommend that the AMU should have scheduled seven-day access to dagnostc and treatment procedures such as dagnostc GI endoscopy, echocardography, dagnostc ultrasound, bronchoscopy and CT and MR magng wth easy and convenent access for larger AMUs n large acute hosptals, and avalable to smaller AMUs va clearly defned pathways wthn the local emergency care networks. We recommend that there should also be 24/7 urgent access to lfe savng nterventons such as GI endoscopy wthn the emergency care network, deally located on the same ste as the AMU n large acute hosptals. xv

18 Acute medcal care We recommend that patents requrng contnued specalst npatent care should be streamed from the AMU to a hosptal bed base approprate to ther clncal needs as defned by ther dagnoss and llness severty. When patents requre npatent care wthn the specalty bedbase, there should be no barrers for patent transfer to that bed base. Patent transfers from the AMU should only occur f the recevng envronment provdes an approprate, safe and suffcent level of contnung acute clncal care ths s an mportant consderaton for the most acutely ll patents out of hours and at weekends. We recommend that the acute hosptal bed base beyond the AMU should reflect the patent need. The confguraton of the hosptal bed base wth regard to specalty should reflect the acute care demand. The bed confguraton of most hosptals needs to be reconfgured to match the acute patent flows and demand to ensure that there s the greatest opportunty to transfer patents to the most approprate specalty destnaton for ther ongong clncal care. We recommend that the AMU should be the hub for coordnatng acute medcal outreach care and many of the actvtes currently undertaken by the Hosptal at Nght team and out-of-hours medcal cover arrangements for the hosptal. Ths would provde a focus for coordnatng acute medcal outreach care and would provde contnuty and revew to ensure the patent s cared for n the most approprate envronment accordng to ther dependency score. We recommend that acute medcal outreach should nvolve much greater ntegraton between the exstng on-call medcal team and the crtcal care outreach team wth competences n emergency resusctaton, arway management and acute medcal care. Ths could result n the development of a multdscplnary acute response team (ART) that would replace the ndependent medcal on-call and crtcal care outreach teams and would provde a sngle team to respond to urgent calls for support. We recommend that consultant work patterns should nclude protected sesson tme for AMU, deally n blocks of days. Seven-day blocks are consdered too onerous and work less well. Precse work patterns should be developed to reflect local needs and all other clncal dutes and responsbltes should be cancelled for clncal staff whle workng on AMU. We recommend that junor medcal staff should be allocated to the AMU n blocks, for example, two to four months at a tme. Ths helps buld teamwork and provdes a concentrated perod of tme to develop competences n acute care. The model of junor medcal staff dppng n and out of AMU for solated short shfts of duty s strongly dscouraged as beng much less effectve, less safe and an nadequate tranng experence. Acute physcans must be ther mentors and be responsble for ther tranng and apprasal durng ths attachment. Physcans must never work n solaton n acute medcne. We recommend that nurses based n AMUs should develop enhanced sklls (ECG, venepuncture, cannulaton, IV drugs, arteral blood gas analyss). Those workng n hgher dependency areas should develop and mantan crtcal care competences. It s also mportant that nurses have had experence of nursng patents wth severe physcal dsablty, lack of whch may compromse outcomes and delay transfer of care. We recommend that nurses based n AMU should also be encouraged to develop specalst nursng sklls by secondment or rotaton. Larger AMUs should desgnate a lead nurse wth clncal leadershp and tranng responsbltes for specfc specalst areas, such as crtcal care, NIV, xv

19 Executve summary and recommendatons asthma care and oxygen therapy, care of the elderly, mental health and so on. Lkewse, nurses from specaltes other than acute medcne should be seconded to, or rotate to, the AMU to acqure and mantan competences n undfferentated acute medcal care. We recommend that the clncal team on the AMU should be consultant led. We recommend that there should be a twce-daly consultant-led ward round/revew of all patents n the AMU, seven days a week, to support ongong decson makng and to revew the management plans and results. We recommend that the NEW score and plans for nvestgatons and dscharge or transfer plans for each patent should be clearly dsplayed wthn the AMU usng a clncal management board and should be revewed and updated regularly and at the end of every ward round. We recommend that there must be tme ncluded n the shft patterns for junor medcal staff to ensure there s a formal handover of care, akn to that adopted for many years by nursng teams. We recommend new models of workng that are predcated on ensurng adequate levels of competent clncal decson makers are present on the AMU and other front-lne servces 24/7. Workforce plannng, educaton and tranng We recommend that exposure to the AMU should be part of the core undergraduate medcal currculum. We recommend that medcal and nursng educaton and tranng leads are dentfed to promote and coordnate educaton and tranng for medcal and nursng AMU staff. We recommend that all medcal specaltes n acute hosptals or n emergency care networks servcng acute hosptals wll need to acqure and mantan competences n the assessment and clncal management of acute medcal problems pertnent to ther specalty. Ths mportant aspect of tranng needs to be ncorporated nto specalst tranng programmes. We recommend that tranng objectves for physotherapsts and occupatonal therapsts should be adopted for all alled health professonals n AMUs. We recommend that flexble career optons are encouraged and mantaned for those practsng acute medcne. We recommend that the typcal programmed actvtes that are avalable wthn a job plan should be comparable across AMUs accordng to the commtment of the ndvdual. Ths wll facltate job plannng and s a pece of work that should be promoted wthn management. Wthn job plannng there must be a reasonable balance of capacty and demand wth regard to the actvty of the AMU and the personnel avalable. We recommend that job plannng recognses the work that flows from the clncal nterface ncludng the necessary admnstratve work and talkng to carers and relatves. We recommend the development of natonally agreed allocatons of programmed actvtes to these roles and model job plans to facltate equtable job plannng and approprate resource (both staff and fundng) allocaton to prortse and sustan the proposed reconfguraton and enhancement of acute medcal servces for patents. xx

20 Acute medcal care We recommend that people workng n support roles should not work n solaton, but must work as part of a multdscplnary team wth clear lnes of responsblty and support. We recommend standardsaton of tranng packages for transferable sklls to ensure ther wder and more consstent applcaton. Ths wll also decrease the need for local ntatves that may restrct the ablty of the tranee to extend ther role beyond a specfc department or clncal dscplne. We recommend that there should be opportuntes for doctors who are sklled at acute and crtcal care medcne to combne these nterests and tran n both acute medcne and crtcal care medcne to CCT level. There should also be opportuntes for prmary care physcans to tran n acute medcne and to work wthn the AMU. We recommend that new tranng structures are suffcently flexble to allow physcans to tran n related areas of acute care to CCT level and thereby develop job plans that allow them to combne clncal roles beyond the AMU, eg AMU, ITU, or Emergency Department responsbltes. Fundng We recommend that clncal leaders develop an understandng of the fundng mechansms so as to allow them to effectvely mpact on servce development and ultmately, patent care. We recommend that payment systems and tarffs should be better algned to best clncal practce so that they do not dstort clncal prortes. We recommend that fundng mechansms should be adjusted to ncentvse the development of hgh qualty emergency and acute medcal care whle at the same tme not dsenfranchsng chronc dsease management. Research and development We recommend the establshment of a natonal clncal research network for acute medcne that wll provde the nfrastructure for hgh qualty research programmes n acute medcal care. As explaned on p5 under Readng ths report, addtonal ponts are set out n the body of the report n green but wthout the precedng words we recommend. These should also be regarded as Task Force recommendatons. xx

21 Glossary Acute care common stem programme: a tranng programme mmedately after foundaton years that ncorporates experence n acute medcne, emergency medcne, anaesthetcs and crtcal care over a two-year perod. Acute medcne s that part of general (nternal) medcne concerned wth the mmedate and early specalst management of adult patents sufferng from a wde range of medcal condtons who present to, or from wthn, hosptals requrng urgent or emergency care. Acute physcan: a doctor who has taken responsblty for acute medcal care wthn an acute medcal unt and, often, admnstratve responsblty for that unt. Acute medcal unt: a specalsed area of an acute hosptal where patents sufferng from acute medcal llness can be assessed and ntally admtted. Acute response team: a team of ndvduals who have the capacty, and are equpped, to respond to urgent patent need. Ths may be an acute clncal need and the team s often based n a crtcal care settng or, n the context of a socal work response team, may be respondng to the patent s complex needs. Ambulatory care s clncal care whch may nclude dagnoss, observaton, treatment and rehabltaton, that s not provded wthn the tradtonal hosptal bed base or wthn tradtonal out-patent servces, and that can be provded across the prmary/secondary care nterface. In the context of acute medcne, t s care of a condton that s perceved ether by the patent or by the referrng practtoner as urgent, and that requres prompt clncal assessment, undertaken by a competent clncal decson maker. The healthcare settng may vary, but for optmal clncal care wll often requre prompt access to dagnostc support. Ambulatory care must be hgh qualty care, desgned to ensure the best outcomes for patents. It s the responsblty of those delverng the care to ensure that resources are deployed n the most cost-effectve manner. CCT (Certfcate of Completon of Tranng): ths s awarded to tranee doctors who successfully complete a tranng programme. Clncal dscusson: there has been an eroson of clncal dscusson opportuntes at the prmary/secondary care nterface. There s a real need for more effectve dalogue between clncal decson makers to drect the patent to the most approprate urgent care faclty for ther needs, and reduce the default to hosptal admsson. Clncal performance ndcators: comparatve data that demonstrate the performance of a clncal servce compared wth others or more frequently agreed standards. Competent clncal decson maker: competence n clncal decson makng comes after a perod of specfc tranng to use the varous tools of clncal assessment combned wth approprate use and nterpretaton of nvestgaton. Ths facltates the development of a ratonal dfferental dagnoss followed by prompt, safe and effectve treatment of the patent. These sklls are subject xx

22 Acute medcal care to assessment by more senor members of the team who have already developed these specfc competences. Emergency admsson: an admsson that s unpredctable and at short notce because of clncal need, ncludng: to an A&E or dental casualty department of the hosptal to a GP after a request for mmedate admsson has been made drect to a hosptal, e not through a bed bureau to a bed bureau to a consultant clnc, of ths or another hosptal (healthcare provder) patents admtted from the A&E department of another hosptal where they had not been admtted. Emergency medcne: a feld of practce based on the knowledge and sklls requred for the preventon, dagnoss and management of acute and urgent aspects of llness and njury affectng patents of all age groups wth a full spectrum of undfferentated physcal and behavoural dsorders. It further encompasses an understandng of the development of pre-hosptal and n-hosptal emergency medcal systems and the sklls necessary for ths development. Wthn ths defnton, the day-to-day practce of emergency medcne n the UK encompasses the recepton, resusctaton, ntal assessment and management of undfferentated urgent and emergency cases and the tmely onward referral of those patents who are consdered to requre admsson under npatent specalst teams or further specalst assessment and/or follow up. Consultants n the specalty have responsbltes for the standards of care n emergency departments as well as the tranng and development of staff wthn these departments. Emergency medcne consultants contrbute to research nto all aspects of emergency medcne, ncludng accdent preventon and related subjects. Source: College of Emergency Medcne Emergency care networks: these were establshed by the Department of Health under the auspces of reformng emergency care. The defned remt of ths was: to optmse the emergency care of all patents n the localty to ensure that the patent perspectve and qualty of care are the prortes n plannng emergency healthcare n the local health and socal care communty to ensure ease of access to approprate servces at the approprate tme wthout unnecessary duplcaton for the patent and n lne wth natonal standards to coordnate emergency healthcare across all organsatons n a communty to ensure the engagement of external organsatons whose servces contrbute to the effectve delvery of emergency care to work wth health and socal care commssoners to determne prortes n emergency care to promote knowledge of developments n emergency care among health and socal care professonals and users xx

23 Glossary to develop and mantan mprovement work ncludng that ntated by the Emergency Servces Collaboratve to agree and develop local standards and protocols to facltate comparatve audt and tranng. Extended day workng: workng hours that are outsde the tradtonally accepted 9 am 5 pm. Extenson of the day may nclude am starts and/or completon by 9 pm. Hosptal durng the day and nght: the Hosptal at Nght team has developed as a multprofessonal team provdng care across a hosptal ste to cope wth the unexpected needs of patents at nght. Ths s now beng extended to cope wth smlar problems durng the day. Levels of care: crtcal care ncludes Level 2 and Level 3 patents: Level 1: patents at rsk of ther condton deteroratng, or those recently relocated from hgher levels of care, whose needs can be met on an acute ward wth addtonal advce and support from the crtcal care team. Level 2: patents requrng more detaled observaton or nterventon ncludng support for a sngle faled organ system or postoperatve care and those steppng down from hgher levels of care (eg HDU). Level 3: patents requrng advanced respratory support alone or basc respratory support together wth support of at least two organ systems (eg ICU). Source: Crtcal to success, Audt Commsson, London, 1999 Natonal early warnng score (NEW): a proposed physologcally based system of scorng a patent s condton to help determne severty of llness and predct patent outcomes. Although many smlar systems may exst, the development of a natonal system would promote clncal communcaton and facltate wde adopton. Navgaton hub: a mechansm by whch the frequent opactes of pathways of patent care may be overcome. Ths takes the form of a localty-based organsaton that s able to drect, n real tme, patents or clncans to the servce that s most approprate for ther needs. Out-of-hours servces: servces provded outsde of tradtonal workng hours usually by prmary care organsatons to cope wth unexpected acute llness. Payment by results: a Department of Health ntatve that should provde a transparent, rulesbased system for payng trusts. It should reward effcency, support patent choce and dversty and encourage actvty for sustanable watng tme reductons. Payment wll be lnked to actvty and adjusted for case mx. For acute care there may be a perverse ncentve for trusts to promote more admssons to ncrease ncome. Physcan of the day: the consultant physcan who s responsble for the acutely ll medcal patents admtted to hosptal wthn a specfed 24-hour perod. Prmary care provdes the assessment, management and prortsaton of undfferentated problems n the general populaton n all age groups. Most of ths care s delvered by GPs and ther teams. Senor clncal decson maker: a medcal practtoner who has the competences and experence to make a prompt clncal dagnoss and decde the need for specfc nvestgatons and treatment, the mode of treatment and the most approprate settng for that treatment and ongong care. xx

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