1. 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

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

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

4. 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

5. 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...’

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

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

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

9. Managing length of stay50
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.

10. 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%’

11. 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’

12. 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’

13. 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’

14. 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

15. 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

16. 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*

17. 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

18. 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)

19. AMU Quality Indicators
Mortality rates
Within 48 hours of admission
HSMR
Weekend vs Weekday mortality rates
In-hours ( ) 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

20. 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