Acute medicine evaluation

Acute medicine has developed over the last decade in response to the increasing number of medical admissions, concerns over quality of acute care and other pressures including the European Working Time Directive [EWTD].

Improving and understanding quality of care is essential, however it is recognised for example that outcomes for patients admitted as an emergency, including issues related to patient safety, differ between hospitals Although some of this variation may relate to case mix and social deprivation, much remains unanswered. For example, there is evidence that mortality is greater for patients who are admitted at weekends and this appears unrelated to illness severity.

Defined training programmes are now in place for Acute Medicine and trainees are now being appointed to consultant posts. However the systems which operate in hospitals vary and there has been little evaluation of the systems in place and in particular how these relate to patient outcomes. Recent publications supports improved outcomes with more structured systems of care but as yet these have not been validated by similar publications.

Previously, the Royal College has surveyed the numbers of posts in Acute Medicine and some elements of the systems in place but has not related this to patient outcomes. Several factors can influence the quality of care and hence clinical outcome. Two key areas have been recognised for centuries (Hippocrates) – competence and process of care.

Downloads available:

• Consultant input into acute medical admissions - Oct 2010
• RCP pilot survey - acute medical admissions - December 2008
• Acute medicine references

National Institute of Clinical Excellence 

The National Institute of Clinical Excellence [NICE], the Royal College of Physicians and the National Enquiry into Patient Outcomes and Deaths (NCEPOD) have all recently produced reports related to the management of acute medical emergencies. In addition, with the new consultant contract in place and acute medicine developing rapidly as a specialty it is an appropriate time to evaluate the role of the consultant in acute unselected take. This would be seen as the first phase of a longer term project to evaluate the role of the structure and organisation of acute medical care.

Working Group

The Royal College of Physicians has formed a working group evaluate current service provision in hospital for acute medical care. The work includes:

• a survey of current service provision
• an audit against the guidelines and recommendations in the recent reports
• a correlation between Hospital Episode Statistics and clinical outcomes.

The Royal College of Physicians is undertaking a study aiming to describe any correlations between different levels of physician cover for acute medical admissions and patient outcomes such as length of stay, readmission rate and hospital mortality and to audit the patterns of service provision against recommendations in national guidelines such as NICE CG50.

New National Survey of Medical Admissions 2010

The Royal College of Physicians is undertaking a study aiming to describe any correlations between different levels of physician cover for acute medical admissions and patient outcomes such as length of stay, readmission rate and hospital mortality and to audit the patterns of service provision against recommendations in national guidelines such as NICE CG50.

December 2010

An evaluation of consultant input into Acute Medical Admissions Management in England, Wales and Northern Ireland was published was in December 2010. See documents below.

A pilot study conducted in 2008 produced some interesting initial data on correlations between patterns of cover and patient outcomes.

Concerns over quality of acute care 

Acute medicine has developed over the last decade in response to the increasing number of medical admissions, concerns over quality of acute care and other pressures including the European Working Time Directive. The Acute Medicine curriculum has been updated with training programmes established throughout the UK. The Acute Medicine Task Force report outlines the future systems for acute care but at present staffing systems vary between hospitals and to date little evaluation of the systems in place and in particular how these relate to patient outcomes.

The RCP has previously surveyed the numbers of posts in Acute medicine and captured elements of the systems in place, but has not related any of these data to patient outcomes. In 2008, a pilot study demonstrated the feasibility of obtaining details of service organization and Consultant staffing patterns in Acute medicine via an on-line survey, and of linking these data with Hospital Episode Statistics (HES) data to explore correlations between service patterns and patient outcomes. Following the pilot study, a full national study was carried out between Feb-April 2010 to evaluate the role of the structure and organisation of acute medical care in affecting patient clinical outcomes across England, Wales and Northern Ireland.

The overall objectives of this study were to:

1. Describe the current staffing and resources available for management of acute medical admissions in England, Wales and Northern Ireland.
2. Audit data against national guideline standards on service organization and staffing arrangements covering acute medical admissions.  
3. Explore correlations between service pattern and the selected patient outcome measures.
4. Make recommendations as to the optimum model of service and consultant staffing arrangements in Acute Medicine.

The October 2010 report below summarises the descriptive results from the survey and the audit results of the study (objectives 1 and 2). The March 2012 report presents the correlations between service pattern and patient outcomes and recommendations on service models (objectives 3 and 4).

 The final report showed that patients have better outcomes and are less likely to be readmitted to hospital if cared for on wards where the physicians practising acute medical care:

•  are on call for more than one day at a time
• have no other routine duties during that time
• do two or more ward rounds per day in the acute medical unit (AMU)
• are present in the (AMU) for more than 4 hours for 7 days.

As a result, the RCP will now recommend this system of cover above all others.  This new research fully supports the RCP’s recent call for consultant physicians to be on site for 12 hours per day, seven days a week.