Acute Medicine Care Research Articles

1962 Improving end-of-life care in Acute Medicine: A retrospective review

Abstract Background End-of-life (EOL) care aims to anticipate, prevent and treat symptoms experienced by the dying patient. An EOL care strategy described by King’s Health Partners (KHP) outlines the ‘ICARE’ framework, created from the five priorities for the dying patient, giving generalist hospital teams a memorable prompt to consider holistic needs of patients. We aim to reconcile performance of Acute Medical Unit (AMU) in providing EOL care, against KHP's framework, to reduce patient suffering and improve care. Methods A prospective review was performed of all AMU deaths from March-September 2021, reviewing resuscitation status and EOL medications. Sudden deaths for full resuscitation were excluded. Following review, teaching to AMU was delivered and a wall poster of the ‘ICARE’ framework was displayed. A second prospective cycle was performed reviewing deaths from March-September 2022. Results 50 deaths were recorded in cycle one. 21% (12/58) of dying patients were not prescribed EOL medications. Medication omission for 50% (6/12) of patients were due to lack of recognition of EOL. Other reasons included no consultant review, undecided resuscitation status and a missing prescription. In cycle two, 11% of dying patients (6/48 patients) were not prescribed EOL medications, all of which were due to lack of recognition of EOL. 12 deaths had EOL medications prescribed but had an inappropriate resuscitation status. Conclusion The second cycle showed a 50% reduction in deaths with EOL medication omissions, when compared to the first cycle. Reasons for medication omissions were less varied in cycle two, highlighting reduction in avoidable causes. Although not affecting patient care, a notable number of patient records had incorrect resuscitation statuses. Overall, improvement in delivery of EOL care within AMU can be seen. Future considerations involve emphasis on keeping electronic patient record up to date to avoid errors and continual provision of education to new and rolling staff.

Provision of acute medicine services for pregnant women in UK hospitals: Data from the Society for Acute Medicine Benchmarking Audit 2019.

BackgroundMedical problems during pregnancy are the leading cause of maternal mortality in the UK. Pregnant women often present through acute services to the medical team, requiring timely access to appropriate services, physicians trained to manage medical problems in pregnancy, with locally agreed guidance available.MethodsData were collected through the Society for Acute Medicine Benchmarking Audit, a national audit of service delivery and patient care in acute medicine over a 24 hour period.ResultsOne hundred and thirty hospitals participated: 5.5% had an acute medicine consultant trained in obstetric medicine, and 38% of hospitals had a named lead for maternal medicine. This was not related to hospital size (p = 0.313). Sixty-four units had local guidelines for medical problems in pregnancy; 43% had a local guideline for venous thromboembolism in pregnancy. Centres with a named lead had more guidelines (p = 0.019).ConclusionCurrent provision of services within acute medicine for pregnant women does not meet national recommendations.

Acute Medicine Nurses facilitating Patient Flow – A National Unscheduled Care Clinical Skills and Competencies Education Programme

Context: Acute medicine nursing is an emerging discipline within unscheduled care. To September 2016 73,175 patients registered in Ireland’s acute medicine units, of which 26,830 (36.7%) were admitted to acute medical short stay or specialist wards, or discharged on the same day (n=46,345 / 63.3%). Nursing staff in these units (560) come from a variety of clinical general and specialist backgrounds with few possessing specialist acute medicine nursing qualifications to support patients on unscheduled care pathways inclusive of ambulatory care. Aim: To provide clinical education programmes to maximise the development Acute Medicine nurses’ skills and competence’ (H.S.E. 2016, p. 18) to meet identified patient needs. A particular focus being on improving patient access, assessment, care, and management across the patient pathway. Method: Nationally there are 32 acute hospitals which have either an AMAU or an MAU. To identify gaps in knowledge, skills and competencies: An education needs assessment to determine baseline knowledge, skills and competencies of nurses in these units a national survey was undertaken. All 32 hospitals were surveyed. A similar assessment was conducted amongst ED nurses The survey instrument was designed based on a Developmental Framework for Nursing Skills and Competencies in AMAUs, MAUs and MSSUs which was co-designed with the Acute Medicine Nurse Interest Group (AMNIG) and which identified the skills and competencies required of acute medicine nurses at core, specialist, enhanced/advanced levels. Outcome/Results: A 100% response rate was achieved. Hospitals were asked to provide information on numbers of nurses trained in a skill; those currently using the skill; and nurses requiring training in the skill. Demographics were captured in Section 1. Responses to, clinical skills and competencies needs (Section 2), were analysed using six broad categories. Results will be presented. Results were mapped to patient presentations and age profiles using NQAiS Medicine. Findings from the ED nurse survey were cross referenced to enable common core unscheduled care skills and competencies education needs to be identified. A Foundation Programme in Unscheduled Care, Acute Medicine Nursing was designed. On-line clinical skills programmes and currently provided in service programmes were excluded from the programme. 5 key skills and competency areas were validated by the Acute Medicine Programme Nurse Interest Group as required for inclusion. Provision of ongoing Level 8 education foundation programmes’ of 12 weeks duration with Nursing and Midwifery Board accreditation planned to commence 2017. Conclusion: A foundation programme will enable nurses to access educational and professional practice pathways in acute medicine at specialist and advanced practice levels. Having skilled and competent nurses educated to a national standard of skills and competencies in unscheduled acute medicine care inclusive of ambulatory and short stay acute medicine care will improve the patient outcomes,experience create capacity within the system generating greater access and effective efficient use of resource. Provides opportunities for interdisciplinary and cross clinical programme nurse education to generate a commonality of practice within the themes of rapid access, timely assessment , intervention, diagnosis, treatment plan and discharge.

Shared Experiences of Consultant Delivered Care – A toolkit for those responsible for configuring consultant delivered care in Acute Medicine

Background: NHS London released commissioning standards for Adult emergency services in September 2011. The Pan-London Acute Medicine Network (PLAN) agreed to survey its members regarding these standards. Method: A web-based survey asked PLAN members to comment on the standards which were most relevant to Consultant-delivered care in Acute Medicine. The self-reported rate of compliance with each standard was calculated. The free text comments were grouped by thematic analysis. Results: 23 responses were received. The compliance with each standard was variable between 9% and 91%. Discussion: A series of themes are discussed and presented as tips to be considered by those responsible for providing Consultant-delivered care to patients on an AMU. Conclusion: There is still enormous variation between trusts in how acute medical services are supported by Consultant physicians. The demands on each service and the resources available to trusts differ hugely, therefore the solutions to providing a Consultant-led service need to be tailor made for each AMU.

Contrasts in acute medicine: a comparison of the British and Australian systems for managing emergency medical patients

Increasing numbers of patients are presenting for unscheduled medical admission to hospitals worldwide, prompting clinical redesign of "front-door" emergency medical services. In the United Kingdom, there has been considerable investment in the establishment of acute medical units (AMUs) and the training of acute medicine physicians. Some centres in Australia have established similar medical assessment units. While these initiatives have undoubtedly met with some success, the evidence base for their overall benefit remains elusive. We describe key aspects of the recent establishment of acute medical services in Britain and discuss the relevance of these experiences to Australia. Successful models of care in acute medicine have often been shared with other centres. The adaptation of existing models of care to meet local demands is superior to simply adopting an existing model. Once the desired clinical functionality of a service is determined, informed decisions can be made on staffing requirements, skill mix, and the structure of any new clinical unit. The functionality of the acute medical service, rather than simply the physicality of an AMU, should drive service design.

Examining the suitability of medical admissions to the emergency short stay ward of a large UK hospital

In 1996, a UK audit suggested suboptimal involvement of consultant care in acute medicine [1]. Acute medicine has since evolved as a specialty to improve medical inpatient care in the first 48 hours [2]. Many hospitals now incorporate an acute short stay unit through which up to 70% of medical admissions can be directed [3]. These units reduce the length of hospital inpatient stay [4].

Society for Acute Medicine Autumn Meeting October 3rd /4th

The regular autumn meeting of the society for acute medicine was hosted this year by Dr Martin Culshaw at Queen ’s Medical Centre in Nottingham. As in previous years, the meeting was spread over two days with the conference dinner at the Nottingham Hilton hotel on the evening between. This was Derek Bell ’s last meeting as President of the society, and in taking over the helm, Paul Jenkins paid tribute to his achievements over the past three years during the after dinner speeches. Emergency Care Tsar, Professor Sir George Alberti, opened the meeting with an enlightened view of the current, and future state of emergency care in the UK. Entitled ‘Emergency Care – nightmare or sweet dreams’ ,he left us in no doubt that the high profile of ‘front-door ’medicine would continue over the next few decades. Derek Bell followed, in his role as clinical lead of the Emergency Services Collaborative, with a summary of the achievements of the Collaborative to date. The first afternoon comprised three workshops, followed by a plenary session at the end of the day. Liz Myers and Mairi Pollock facilitated the group examining the role of nurse practitioners and nurse consultants at the front door, concluding that such roles need to be developed and encouraged, with the need to standardise practices and training. With contributions from John Heyworth, president of the British Association of Emergency Medicine, Martin Culshaw facilitated the group looking at the interface between A&E and Acute Medicine. The need for close working between these two allied disciplines was emphasised, along with the importance of examining the possibility of dual accreditation in A&E and Acute Medicine. The third group discussed ambulatory care in acute medicine. George Strang from South Glamorgan commented that most patients who were ‘walking, talking sense, eating, drinking and continent’ could be managed in an ambulatory setting. The group echoed the sentiment that large numbers of patients currently admitted to hospital could be maintained in the community, provided the appropriate staff, support and facilities were available. Management of the septic patient in the ITU setting, the importance of a proactive approach to alcoholism and early management of renal failure comprised the clinical programme over the two days, delivered, respectively, by Dr Paul Glynne, Dr Stephen Ryder and Dr Paddy Gibson.Two excellent presentations of local innovation in Nottingham concluded the meeting. Dr Tim Jobson, specialist registrar in Gastroenterology, described an ingenious database developed at Queen’s Medical Centre designed to improve the quality and learning experience gained from mortality and morbidity meetings in the Acute Admissions Unit. This was followed by a presentation of the modifications made to the MEWS scoring system to render it more sensitive to the needs of acute medical patients. Sister Jane Woollard, critical care nurse educator at Queens Medical Centre described how their modifications had improved both sensitivity and specificity of the score when used on the MAU. At the annual general meeting of the society which followed the main meeting, Mike Jones was elected to the position of Vice President, while Rhid Dowdle takes over as Secretary. The need for representation of allied health professions on the committee was again emphasised and calls for nominations of such individuals were re-iterated. The twice yearly meeting structure is planned to continue for the foreseeable future, although the Spring meeting will, in future be predominantly clinical in its focus, with more emphasis on organisational issues in the Autumn meeting. The date for the next meeting was confirmed as 22nd and 23rd April 2004, the meeting being held in Bournemouth, hosted by Dr Martin Taylor and Dr Tanzeem Raza. We will eagerly await the publication of the programme, which it is hoped will be on the Society website (www.acutemedicine.org.uk) by the end of December. Further details and application forms for this meeting will be available from society administrator Audrey Deuchars Edinburgh Royal Infirmary, 51 Littlefrance Crescent,Edinburgh EH16 4SA

Clinical Evidence at the Point of Care in Acute Medicine: A Handheld Usability Case Study

The need to design medical information device interfaces for clinical use has been well documented in medical journals. In this study we apply well known usability techniques such as user requirement elicitation and prototype design and evaluation to design an evidence-based medical information retrieval system intended for a wireless environment. Our immediate goal is to make the daily practice of evidence-based medicine (EBM) for frontline clinicians easier by providing relevant, timely information at the point of care (using a wireless PDA device), delivered in a format that is usable and liked by the target group. Our objective is to use this evidence-based information delivery tool as an educational device and to encourage clinicians to consult, as appropriate, the latest best evidence available to support their clinical decision in hopes of improving clinical outcomes. The development of a handheld user interface for clinicians is described, along with results obtained from usability testing with a sample set of scenarios.