Dr Dan Beckett Consultant Acute Physician NHS Forth Valley Improving patient flows into and out of acute care The admitted patient: Acute Assessment Dr Dan Beckett Consultant Acute Physician NHS Forth Valley

Overview National recommendations for AMUs RCP Acute Medine Taskforce Report Recommendations to improve flow The current national picture Outcome data AMU Quality Indicators

Introduction RCP Acute Medicine task force recommendations published 2007 Blueprint for development of acute medical services

Acute Medical Unit (AMU) All hospitals admitting patients with acute medical illnesses should establish AMUs as the focus for acute medical care The AMU should operate a number of streams for patients related to clinical need Acutely unwell (level 1/2) Short stay – Ambulatory Complex needs patients

Acute Medical Unit (AMU) ‘Transfer of care planning should begin at the time of initial patient assessment...and an estimation of anticipated length of stay should be recorded for all patients within 12 hours of admission’ ‘Where patients require in-patient care within the specialty bed base there should be no barriers to patient transfer...’

Acute Medical Process- needs based Multi- disciplinary Team Patient Assessment Stay Diagnostic uncertainty 24 HR Mobilisation Care package 24 - 48 HRS Specialty Ward Transfer ASAP if LOS > 48-72hrs

Complex needs processes Pharm OT PCP PT Nurse LOS ~ 48hrs GP/A+E 40% Home 36% RIE 24% O/S

Acute Medical Unit ‘The length of stay on an AMU should be dictated by clinical need and not arbitrary limits Typical LOS 24-72 hours Mean LOS 24-30 hours in established units Patients should be ‘pulled’ rather than pushed

Managing length of stay 50 100 150 200 250 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 Length of stay (days) Number of patients Take ½ day off clinically unnecessary LoS and it has a dramatic impact Alternatives to admission Left shift These patients may have more complex support needs Often focus on discharge has been on longer stay patients - DToCs for example. Whilst that is important, reducing the LOS of two 60-day LOS patient by 5 days results in a reduction of 10 beds days, taking half a day of 150 patients staying 5 days can save 75 bed days. There is also a need to focus on patients with stays less than 48 hours - was their admission really necessary? This is when it is important to consider admission prevention, role of the community etc.

Acute Medical Unit ‘An adequately sized and staffed AMU should aim for a significant percentage (about 50%) of acute medical admissions to complete their episode of care within the AMU’ ‘As a guide to size the minimum number of beds will be equivalent to the number of patients admitted over 24 hours plus 10%’

Acute Medical Unit ‘There should be twice-daily, consultant-led ward round/review of all patients in the AMU, seven days per week’ ‘The physician of the day model is strongly discouraged as this is not conducive to continuity of care’ ‘We recommend dedicated blocks of work on the AMU and cancellation of other commitments’

Acute Medical Unit We recommend new models of working that are predicated on ensuring adequate levels of competent clinical decision makers are present on the AMU and other front-line services 24/7. Specialty teams should...provide advice or attend and review patients expeditiously on the AMU within a maximum of 4 hours of a request, or ideally sooner’

The wider hospital ‘The pace of life in the main hospital bed base beyond AMU must be geared to respond dynamically to changes in demand so as to increase capacity during busy periods’ ‘Real time monitoring of demand and capacity’ ‘Robust escalation policies’ ‘Daily clinical review of the entire bed base by a competent clinical decision maker’

Current practice Survey of 126 Acute Hospitals in England, Wales and Northern Ireland October 2010 Audit against national guideline standards on service organisation and staffing arrangements

Current practice Number of hours admitting consultant continuously present Weekday 9 – 12 hours 49% >12 hours 13% Weekend 9 – 12 hours 16% > 12 hours 4% Admitting consultants available for fewer hours at the weekend

Weekend mortality for emergency admissions. A large, multicentre study Weekend mortality for emergency admissions. A large, multicentre study. Aylin P Yunus A Bottle A Majeed A Bell D Qual Saf Health Care 2010;19:213 All admissions 4,317,866 4.9 (162,639) 5.2 (52,415) <0.001** Acute renal failure (CCS 157) 14,134 25.6 (2,924) 33.3 (909) Acute cerebrovascular disease (CCS 109) 70,500 27.5 (14,451) 30.2 (5,437) Acute myocardial Infarction (CCS100) 68,932 13.5 (6,803) 14.4 (2,650) 0.002* Cardiac arrest and ventricular fibrillation (CCS 107) 2,576 64.9 (1,238) 68.1 (455) 0.048* Cardiac dysrhythmias (CCS 106) 86,134 1.9 (1,270) 2.4 (453) Chronic obstructive pulmonary disease and bronchiectasis (CCS 127) 106,951 7.7 (6,174) 7.6 (2,005) 0.840 Congestive heart failure non hypertensive (CCS 108) 56,394 17.9 (7,944) 19.6 (2,351) Coronary atherosclerosis and other heart disease (CCS 101) 91,836 2.4 (1,676) 2.8 (583) 0.008* Fluid and electrolyte disorders (CCS 55) 17,436 9.6 (1,359) 11.3 (365) 0.013* Gastrointestinal haemorrhage (CCS 153) 57,937 7.3 (3,196) 7.8 (1,087) 0.042* Liver disease, alcohol-related (CCS 150) 10,401 18.5 (1,576) 20.4 (382) Pneumonia ( CCS 122) 102,465 24.3 (18,619) 25.4 (6,574) 0.899 Pulmonary heart disease (CCS 103) 16,314 9.1 (1,200) 11.0 (349) 0.046*

Current practice Proportion of sites providing at least twice daily ward round Weekday 61% Weekend 69% However ward rounds at the weekend less likely to see all patients in AMU and more likely to see only new patients, or those thought to be unwell or possible discharges

Current practice 91% of sites still operate a physician of the day receiving model, augmented by the presence of Acute Physicians 48% of sites report that consultants with first-on responsibilities still undertake other duties during the acute take (eg out-patient clinics)

AMU Quality Indicators Mortality rates Within 48 hours of admission HSMR Weekend vs Weekday mortality rates In-hours (0800-1900) vs Out of hours Direct discharge rates within 24 or 48 hours of admission 7 day readmission rate Intermittent audit of tracker conditions Patient experience

References Acute Medical Care: The right person, in the right setting, the first time. RCP Acute Medicine Task Force Report 2007 RCPE UK Consensus Statement on Acute Medicine, November 2008