Society For Acute Medicine Research Articles

2203 Avoiding therapeutic nihilism in critically ill older adults: a single Centre approach to enhanced care in patients with frailty

Abstract Introduction Enhanced care units (ECU) are a novel concept, targeting the gap between ward-level and critical care. They care for patients requiring intensive medical or nursing care, who may not require, desire, or be suitable for, escalation above ward care (Society of Acute Medicine and Intensive Care Society, 2022). The ECU at Barnet Hospital opened in March 2022, and, because of the local population demographic, admits a high number of older patients living with frailty. We aimed to assess the performance of the ECU for this subset of patients. Methods A retrospective audit of electronic records of 75 randomly selected patients admitted to ECU between March and August 2023. Data were gathered on Clinical Frailty Score (CFS) at baseline, comorbidity, escalation status, APACHE II illness severity score, and outcome measures. Results The majority of patients in the sample, 52 of 75 (69.3%), were over 65 years of age with an average of 69.1 years. Baseline frailty score was high, with a modal CFS of 6. Of these patients, 32 (61.5%) had a DNACPR, and 17 (32.7%) had treatment ceiling at ECU level. Illness severity was similar across CFS groups, with a mean APACHE II score of 15.2 (representing a 25% mortality risk). Overall mortality in the over 65 s was 23.1% (12/52), without significant change when stratified by CFS. Mortality in the under 65 s was 8.7% (2/23). Conclusions Acutely unwell patients with frailty may benefit from ECU level care. In our centre, we found no significant increase in mortality linked to a higher frailty score. We suggest that this may represent good case selection by clinicians experienced in working with frailty: admitting patients with more reversibility and targeting therapies towards reversible causes. Limitations remain, especially in assessing illness severity, as the assessment tools are not targeted to this cohort.

Quality metrics for same day emergency care—Consensus of a multi-professional panel of experts using a modified Delphi process

Same Day Emergency Care (SDEC) services are at the heart of recovery plans for Emergency Care in the National Health Service. There are no validated metrics for the quality of care in SDEC.The Society for Acute Medicine's Quality Improvement Committee invited to a three-stage modified Delphi process to gather metrics used by clinicians. Proposed metrics were ranked and further explored by 33 participating experts from a broad range of backgrounds including clinicians, data scientists and operational managers.Experts ranked five system-based metrics highest. These focus on optimisation of the proportion of patients receiving same day care in and out of SDEC units. Patient and staff experience metrics were ranked low, possibly due to present lack of viable examples.The paper adds a glossary with the rationale for ranking of metrics and their use for the improvement of quality and safety of clinical care.

Society for Acute Medicine’s Patients: Learning from Experience Report (SAM-PLER) A service evaluation of patient reported experience in Acute Medicine – establishing the feasibility of a quality improvement collaborative

Patient reported experience measures (PREMS) are a key part of measured quality. There is no tool currently used in the UK in Acute Medicine. On the 8th of September 2022 10 units based in England, Scotland and Wales collected data for the validated PREM, alongside the EQ-5D and variables from the Society for Acute Medicine’s Benchmarking Audit (SAMBA) dataset. 365 patients were screened, 200 were included (55%): 159 patients from AMUs and 41 from SDEC units. Overall experience of patients was rated 8.5/10, patients rated their experience of safety, trust and listening highly. Collection of PREMS was feasible. Further research is required to link experience to clinical outcome and explore tools that capture experience of patients with altered mental status.

Enhanced Care Units: Guidance on development and implementation within Acute Medicine.

The Society for Acute Medicine (SAM) and Intensive Care Society (ICS) have produced joint guidance on the standards of care and infrastructure required to deliver enhanced care within Acute Medicine. The cohort of patients this relates to are in the most part already being looked after on the AMU, but co-location and providing enhanced monitoring and nursing input will ensure safe, high-quality care can be delivered to them. We strongly support the development of enhanced care units, whilst clearly acknowledging that they are not a replacement for critical care where that is indicated. Enhanced care and critical care complement each other and will help foster the close working between the two specialties that modern acute care requires. This guidance draws on expertise and existing relevant guidance from the two societies, alongside that from the Faculty of Intensive Care Medicine (FICM), British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE) and NHS England / Improvement (NHSE/I). We recognise this is an area with limited evidence and so will aim to review it regularly as the knowledge and experience in this area increases.

Nurse staffing levels within acute care: results of a national day of care survey

IntroductionThe relationship between nurse staffing levels and patient safety is well recognised. Inadequate provision of nursing staff is associated with increased medical error, as well as higher morbidity and mortality. Defining what constitutes safe nurse staffing levels is complex. A range of guidance and planning tools are available to inform staffing decisions. The Society for Acute Medicine (SAM) recommend a ‘nurse-to-bed‘ratio of greater than 1:6. Whether this standard accurately reflects the pattern and intensity of work on the Acute Medical Unit (AMU) is unclear.MethodsNurse staffing levels in AMUs were explored using the Society for Acute Medicine Benchmarking Audit 2019 (SAMBA19). Data from 122 acute hospitals were analysed. Nurse-to-bed ratios were calculated and compared. Estimates of the total nursing time available within the acute care system were compared to estimates of the time required to perform nursing activities.ResultsThe total number of AMU beds across all 122 units was 4997. The mean daytime nurse-to-bed ratio was 1:4.3 and the mean night time nurse-to-bed ratio was 1:5.2. The SAM standard of a nurse to bed ratio of greater than 1:6 was achieved in 99 units (81.9%) during daytime hours and achieved by 74 units (60.6%) at night.The estimated time required to deliver direct clinical care was 35,698 h. A deficit of 4128 h (11.5% of time required) was estimated, representing the time difference between the total number of nursing hours available with current staffing and the estimated time needed for direct clinical care across all participating units.ConclusionThis UK-wide study suggests a significant proportion of AMUs do not meet the recommenced SAM staffing levels, particularly at night. A difference was observed between the total number of nursing hours within the acute care system and the estimated time required to perform direct nursing activities. This suggests a workforce shortage of nurses within acute care at the system level.

A change in perspective to see the bigger picture. A thematic analysis of Audit and Quality Improvement submissions to the last seven UK based SAM Conferences

Aims: To create a profile of Society for Acute Medicine (SAM) Audit and Quality Improvement (A&QI) accepted abstracts from the last seven UK based conferences. Methodology: The profile elements for 380 SAM A&QI abstracts accepted for poster presentation were compiled from their respective conference programme booklets. Abstracts were classified into 30 categories based on key themes. Further sub-categorisation of abstracts was based on secondary detail of the submissions. Data was analysed with Pareto charts. Findings: The majority of submissions were covered by a small representation of themes, with 30% of category themes covering 80% of A&QI abstracts. There is a repetitive trend of theme categories across all the conferences.

Gaps in point of care ultrasound provision and the cost of ultrasound equipment provision: results of a nationwide audit of acute medical units

Introduction: Advances in ultrasound technology have allowed an investigation previously restricted to the radiology department to be used more liberally in clinical decision making. Point-of-Care-Ultrasound (PoCUS) has superior diagnostic performance to traditional clinical examination across a range of pathologies in the hands of a suitably experienced practitioner. The utilisation of PoCUS has the potential to greatly influence the delivery of acute care, but little is known about the current level of resource provision within the acute medical setting. Methods: To establish the availability of ultrasound equipment and appropriately trained clinicians within Acute Medical Units (AMUs) in the United Kingdom (UK) we asked specific questions with an annual day of care survey, undertaken by the Society for Acute Medicine. We compared data across two years to assess interval changes. Results: 58.1% (75/129) of AMUs had access to dedicated ultrasound equipment in SAMBA’19. This represents a small increase from SAMBA’18. Ultrasound expertise is concentrated across a small number of AMUs. Growth in the number of ultrasound trained clinicians is greatest units with established expertise. Conclusion: The equipment to provide PoCUS is not present on all AMUs and appropriately trained clinicians are not distributed evenly across units. This is likely to affect individual AMUs ability to deliver bedside ultrasound to appropriate patients who may benefit. Bridging the gap to ensure all AMUs have the option to use PoCUS will require planning and investment.

British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding

Medical care bundles improve standards of care and patient outcomes. Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency which has been consistently associated with suboptimal care. We aimed...

EDITORIAL VOLUME 19 ISSUE 4: COVID-19: Exemplifying the importance and challenges of Acute Medicine

COVID-19 has challenged healthcare providers and systems. It has dominated the international news agenda for the majority of 2020; arguably opinion becoming more fractured and disparate as the pandemic has evolved. The changing tone of discourse is concerning, although perhaps not surprising. As the majority of the population become increasingly baffled, bored and betrayed desperate for their lives return to “normal”, progressively binary, toxically expressed and opposing scientific views as to how to manage the “second wave” of the pandemic permeate. The initial failings of personal protective equipment (PPE) and a lack of preparedness to face a viral pandemic against the background of a strained acute care sector must not be forgotten and lessons learned. In the UK, COVID-19 has highlighted both the challenges and importance of Acute Medicine. Acute Medicine teams have provided innovative and rapidly adaptive models of care in response to the pandemic. The fundamental tenets of Acute Medicine – MDT working, rapid initiation of treatment, sound use of diagnostics, early senior clinician input and recognition of those in whom ambulatory care is appropriate – are essential components in the management of all acute medical care and demonstrably equally apply to COVID-19. Our increasing global community of Acute Physicians and Acute Medicine teams have once again demonstrated the importance of our specialty. The innovative practice of Acute Medicine teams and the impact of COVID-19 features prominently in this issue of Acute Medicine. There has been wide commentary regarding the impact of COVID-19 on both mental health issues and non-COVID-19 presentations. Riley et al. report an important analysis of presentations to AMU during the first wave of COVID-19 demonstrating a significant change in patient case mix.1 There were increased numbers of presentations potentially associated with social isolation such as falls, alcohol-related pathologies and overdoses alongside smaller numbers of traditionally lower risk presentations, such as non-cardiac chest pain. Ambulatory management of low risk patients with suspected COVID-19 is fundamental to the safety and sustainability of acute care services during the “second wave” and moving forward. Nunan et al. report the experience of the TICC-19 – a virtual ward monitoring oxygen saturations for COVID-19 triaged using a 30 metre rapid walk test.2 This strategy appears safe and feasible with high levels of patient satisfaction and similar models are being utilised across many organisations. The role of POCUS in the diagnosis and management of COVID-19 is increasingly recognised.4 Knight et al. describe a simple aggregated score formed by summating the degree of pleural and interstitial change within six anatomical lung zones showing good discriminatory performance in predicting a range of adverse outcomes in patients with suspected COVID-19.4 This may form an important addition to COVID-19 ambulatory pathways. SAMBA, the Society for Acute Medicine’s Benchmarking Audit, initially focused on the Society’s key quality indicators, continues to flourish and grow. It now not only benchmarks performance but is being used to guide the development of UK clinical quality measures. Colleagues in the Netherlands are commencing similar work and describing international standards of acute medical care, an iterative process, is one of the ultimate goals of this work. SAMBA 19 continues to demonstrate the evolving complexity of acute medical pathways and highlights the need to define optimal quality indicators for acute medical care.5 The inaugural winter SAMBA adds further evidence to the concerns that during this period there is an unfortunate cocktail of both sicker patients and poorer performance.6 Adapting acute medical services to meet this challenge requires innovation and investment. Those working in Acute Medicine should feel proud of their continued contribution to managing the acutely unwell patient and their impact on the sustainability of acute care services, particularly during this most challenging of years. The Society for Acute Medicine has tremendous pride in representing this brilliant workforce. Alongside, the fantastic work of teams this year, there have been multiple emotional and physical stressors. Many AMUs have experienced large numbers of patient deaths, often having to support their loved ones by telephone. The seroprevalence of SARS-CoV-2 was greatest among colleagues working in Acute Medicine.7 Tragically, some AMUs have lost valued colleagues from COVID-19. We remember these friends for their fantastic work they have done, thank them for their contributions to Acute Medicine and on behalf of all the patients they served, we express thanks; their dedication resulted in the ultimate personal sacrifice. They will never be forgotten.

Missing: Outlying medical patients. If found please bleep the medics.

The Society for Acute Medicine has recently updated its third Clinical Quality Improvement (CQI) standard, which states that, ‘All patients should be reviewed by the admitting consultant physician or an appropriate specialty consultant physician within 12 hours of arrival to hospital’.1 This is in line with NHS Improvement which recommends that all patients should receive a ‘consultant approved care plan’ within 12 hours of admission.2 This CQI is subsequently used as a benchmarking tool during the annual Society of Acute Medicine Benchmarking Audit (SAMBA). In the 2018 benchmarking audit, overall 62.8% of all patients received a consultant review within this time period.1 Within Aneurin Bevan University Health Board the statistics for time between patient admission and consultant post-take ward round (PTWR) are in line with national average. However, medical patients are still missed off PTWR due to a number of identified factors including:

Missing: Outlying medical patients. If found please bleep the medics

The Society for Acute Medicine has recently updated its third Clinical Quality Improvement (CQI) standard, which states that, ‘All patients should be reviewed by the admitting consultant physician or an appropriate specialty consultant physician within 12 hours of arrival to hospital’.1 This is in line with NHS Improvement which recommends that all patients should receive a ‘consultant approved care plan’ within 12 hours of admission.2 This CQI is subsequently used as a benchmarking tool during the annual Society of Acute Medicine Benchmarking Audit (SAMBA). In the 2018 benchmarking audit, overall 62.8% of all patients received a consultant review within this time period.1 Within Aneurin Bevan University Health Board the statistics for time between patient admission and consultant post-take ward round (PTWR) are in line with national average. However, medical patients are still missed off PTWR due to a number of identified factors including:

Acute Internal Medicine Trainee Survey 2017

Introduction: Survey to ascertain views of Acute Internal Medicine trainees regarding their training programme. Methods: Online survey circulated to higher specialty trainees (HSTs) via the Society of Acute Medicine (SAM), Training programme Directors (TPDs) and social media platforms. Results: A total of 57 trainees participated in the survey; 43.86% trainees are either ‘happy’ or ‘very happy’ with their training, 10.53% are ‘quite unhappy’ with their training. Trainees enjoy the variety of workload and the variety of specialist exposure. Discussion: The number of trainees who responded to this years survey was significantly lower than the previous two years. Perhaps this is because trainees feel that there is a lack of change/improvement over time and hence do not feel the need to participate in such a survey.

Curriculum mapping for Focused Acute Medicine Ultrasound (FAMUS)

Dear sir/madam, Point of care ultrasound (POCUS) in the hands of the non-radiologist has seen a steady growth in popularity amongst emergency, intensive care and acute medical physicians. Increased accessibility to portable, purpose-built ultrasound machines has meant that clinicians often have access to a safe and non-invasive tool to enhance their management of the unwell. Focused Acute Medicine Ultrasound (FAMUS) is the point of care ultrasound curriculum created to aid the management of the acutely unwell adult patient. Following a survey of trainees and consultants, it was apparent that there was a strong desire for Acute Medics to be able to use point of care ultrasound to aid their clinical diagnostic skills. The FAMUS committee was set up to develop competencies using the evidence base available. FAMUS stands in contrast to traditional radiology training modules, which focus on carrying out comprehensive assessments of anatomy and pathology. Instead, FAMUS delivers a syndrome-based sonographic assessment with the aim of ruling out gross pathology and interrogating underlying physiology. It serves as a useful adjunct to history and clinical examination by way of providing key information quickly and non-invasively. Furthermore, it provides a feasible way to monitor response to treatment or progression of disease and thereby providing useful dynamic information quickly and safely. The accreditation in FAMUS involves the sonographic assessment of three systems: lung, abdomen and the deep veins of the lower-limb. Accrediting in each one involves theoretical learning, a formal course attendance and achieving a set number of supervised and mentored scans. As well as technical skills, the candidate must demonstrate competence in recognising key pathology and drawing appropriate conclusions about each scan, including when to refer for departmental imaging. FAMUS was met with enthusiasm by trainees and consultants in acute medicine, and its popularity rises as more courses are becoming available for accreditation paired with increasing access to portable ultrasound units. It is envisioned that this will continue to grow and formal ‘train the trainer’ courses have been held in order to increase the pool of available supervisors. Currently, FAMUS is endorsed by the Society for Acute Medicine and recognised by the AIM training committee as a specialist skill that can be undertaken during specialist training. It has been proposed that FAMUS should be considered for integration into the acute internal medicine (AIM) curriculum, which will be re-written for 2022 in line with the GMC’s revised standards for curriculum and assessment. Thus we present in this letter, a curriculum mapping exercise that utilises a ‘knowledge, skills, behaviours’ framework in order to be considered for the AIM curriculum rewrite. We believe this will provide a standard and framework to integrate focused ultrasound in AIM training programmes with the aim of ultimately incorporating FAMUS as a core skill for all AIM trainees.

Focused Acute Medicine Ultrasound (FAMUS)

Point of care ultrasound (POCUS) has seen steady growth in its use and applications in aiding clinicians in the management of acutely unwell patients. Focused Acute Medicine Ultrasound (FAMUS) is the standard created specifically for Acute Medicine physicians and is endorsed by the Society for Acute Medicine and recognised by the Acute Internal Medicine (AIM) training committee as a specialist skill. In this document we present a curriculum mapping exercise which utilises a ‘knowledge, skills and behaviours’ framework and incorporates the GMC’s ‘Good Medical Practice’ (GMP) domains. We believe this will provide a standard for consideration of integrating focused ultrasound in AIM training programmes, with the aim of ultimately incorporating FAMUS as a core skill for all AIM trainees.

Editorial Volume 17 Issue 2

As those working in Acute Medicine gather at SAMsterDAM2, the spring conference of the Society for Acute Medicine, the growth, reputation and global representation of the specialty continues to grow. Alongside, the traditional strongholds of the UK, Ireland, Netherlands, Denmark and Australia growth in Asia continues with an AMU now established in Pakistan among other countries. The global growth and interest in Acute Medicine is reflected in this issue of the journal, in which we are delighted to have a truly international cohort of authors. The papers in this issue add to the understanding of some of the fundamental tenets of the specialty key to delivering high quality acute medical care, including international adaptation of the AMU model of care, the Acute Medicine/Primary Care interface, the referral of older patients to Critical Care, readmissions and a reminder of the opportunities an acute medical admission presents to perform important health screening interventions. Rombach et al. describe the impact of implementing an AMU model of care in Amsterdam. The results of the first four years of the model mirror those seen following their introduction in the UK with improved patient flow and reduced length of stay with no effect on readmission rates. The crucial topic of trying to ensure and describe optimal transfer of clinical information between the Acute Medicine and Primary Care interface is addressed through a quality improvement project by Lockman et al. with an accompanying editorial by Professor Dan Lasserson. Their success highlights the opportunities to drive quality through multi-specialty working and innovative thinking. Nannan-Panday et al. examine the vital sign changes in readmitted patients. They describe that deterioration in key physiological signs is common in patients with unplanned readmissions and suggest early intervention through wearable technologies may be a strategy for reducing this adverse event. Bosch et al. retrospectively analyse the outcomes of elderly patients admitted to Intensive Care directly from the Emergency Department compared to those admitted from general wards finding the former group have better outcomes. This reinforces the importance of early decision making, particularly in elderly patients, so fundamental to the practice of Acute Medicine. Rice et al. report the results of a quality improvement project focusing on HIV testing in their Emergency Department at the world’s largest cancer hospital. They reflect that acute care specialties are uniquely positioned to influence clinical practice because of the large cross section of patients for whom it supports. As we as Acute Medicine practitioners reflect on what we are achieving and what there is to accomplish, we need to remind ourselves that the global footstep of our specialty is increasing and we have the opportunity to imprint its principles further in the acute care of medical patients.

Medical referrals: introducing a GP-priority clerking shift to ensure equitable patient care

The Society of Acute Medicine (SAM) guidelines indicate that all medical patients should be assessed within 4 hours of referral. Our initial audit cycle revealed that in our institution, significantly less patients referred via their GP were seen within recommended time, when compared with patients referred via the Emergency Department (ED). We undertook a targeted educational intervention, improved the communication process for referrals and modified the senior house officer (SHO) clerking rota, and re-audited the service to determine the effect of these changes. Subsequently, the proportion of GP-referred patients reviewed within recommended time significantly improved for both initial clerking (from 60% to 95.5%, p=0.011) and consultant review (from 50% to 90.5%, p=0.009), with no detrimental effect on waiting times for ED-referred patients. This is likely to be clinically important, impacting on best practice and patient safety.

Guidelines on the management of abnormal liver blood tests

These updated guidelines on the management of abnormal liver blood tests have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under...

Editorial Volume 16 Issue 4

My time has come. After 15 years and over 50 editions it is time for me to hang up my metaphorical red biro, and hand over the role of Editor. It has been an interesting job, and I am extremely grateful to everyone who has contributed and supported the journal over this period. When I took on the position in 2002, this journal was very different to how it is today. Some readers may recall its original incarnation as the CPD journal of Internal Medicine, part of a series of publications produced at that time by Rila. Initially this was comprised predominantly of commissioned review articles, running over a 5 year cycle which was designed to cover the common conditions managed by ‘general’ physicians. As time progressed, the number of unsolicited submissions grew steadily – initially (and continually) dominated by case reports, but with a slowly increasing number of research-based articles as the readership expanded. The quality of these submissions improved further when we finally attained indexing in PubMed, which also attracted more international submissions. I am delighted that the current edition features research papers from the Netherlands and Singapore, both of which have a growing community of Acute Physicians. I remain hopeful that the number of acute medicine-related research submissions from the UK will rise as the speciality grows. The number of high quality abstracts presented at the Society for Acute Medicine (SAM) meetings is indicative of the amount of work that is going on, but it is disappointing that so few of these turn into publications in peerreviewed journals. Acute Physicians are busy people with constant and year-round operational pressures, which may mean that writing up research is continually pushed down the list of priorities. Perhaps also the fact that the number of consultant posts across the continues to exceed the number of Acute Internal Medicine trainees removes some of the ‘pressure to publish’ which is felt by trainees in other hospital specialities. My hopes for the future of this journal have been boosted by the appointment of Tim Cooksley as my replacement ‘Editor in Chief’, who will take over from the Spring 2018 edition onwards. Tim has been a hard working member of the editorial team over recent years, and prior to this was a regular contributor to the journal. He has a strong research background and is a leading member of the SAMBA academy and SAM research committee. I would also like to thank the other members of the editorial board without whose support and contributions this job would have been completely untenable. I understand that Tim plans to keep many of these colleagues in post, as well as bringing in some ‘new blood’ to create a fresh new vision for the future. I wish them all well, and will look forward to reading (as opposed to writing) these editorials. Thanks, finally, to all of the loyal readers who have stuck with the journal over the past 2 decades. I hope that we have managed to keep you entertained and educated on those occasional moments of respite during the acute medical on-call. I wish you all well for the future.

Abstracts from Oral Presentations at the Society for Acute Medicine Autumn Conference

As usual a large number of abstract submissions were received for the autumn meeting of the Society for Acute Medicine, which was held this year in the Birmingham International Centre on 11th-12th September. A large number of these were displayed as posters throughout the meeting, and twelve were selected for oral presentation. The abstracts from the oral presentation session are published here.

Measuring impact of telephone triage in Acute Medicine

The Society for Acute Medicine’s Benchmarking Audit (SAMBA) was undertaken for the 5th time in June 2016. For the first time, data on telephone triage calls prior to admission to Acute Medical Units were collected: 1238 patients were referred from Emergency Departments, 925 from General Practitioners (GPs), 52 from clinics and 147 from other sources. Calls from Emergency Departments rarely resulted in admission avoidance. Calls from Primary Care resulted in avoidance of an admission in 115 (12%) patients; the percentage of avoided admissions was highest if the call was taken by a Consultant. Consultant triage might result in admission avoidance but the impact of local context on the effectiveness is not clear.