A survey of over 100 hospitals in England by the Royal College of Physicians has shown for the first time 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.
The survey was commissioned by the RCP through its Clinical effectiveness and evaluation unit, in association with the Society for Acute Medicine and the British Geriatrics Society, who helped develop and distribute the survey. It matched various systems of consultant cover against patient outcome data from hospital episode statistics, to see if there was an advantage to patient care from any of the different systems. The results in brief:
- hospitals in which admitting consultants have no other fixed clinical commitments while on acute take had a lower adjusted case fatality rate
- hospitals in which the admitting consultants work blocks of more than one day had lower excess weekend mortality
- hospitals in which there were two or more acute medical unit (AMU) ward rounds per day reviewing all patients on the unit had a lower adjusted case fatality rate for patients with a hospital length of stay of more than seven days
- hospitals where the admitting consultant was present for more than four hours for seven days per week had a lower 28 day readmission rate
- hospitals in which there were two or more AMU ward rounds per day on weekdays and admitting consultants work blocks of more than one day had a lower adjusted case fatality rate (ie less excess mortality).
While some hospitals are already using the system described above, the survey also showed that many hospitals were operating other patterns of care with poorer outcomes, in particular:
- most trusts are still using ‘consultant of the day’ instead of the recommended ‘consultant of several days’
- in almost half of the hospitals, the first consultant on call undertakes other routine clinical duties while managing the acute take as opposed to being dedicated to the acute take
- in many hospitals, acute medical patients are only reviewed once daily by a consultant, not twice daily.
Professor Derek Bell, chair of the steering group, said:
This study is important as it reaffirms previous RCP recommendations in relation to patient outcomes, and provides the foundation for future studies in this area aimed at examining the role of multidisciplinary care in acutely unwell patients.
Dr Kevin Stewart, clinical director of the RCP’s clinical effectiveness and evaluation unit (CEEU) said:
The profile of acute medical patients has changed dramatically over the past 20 years, yet in some hospitals changes in consultant working patterns have been much slower. Traditional rotas are neither safe for patients, nor good for clinicians. Now, patients are older, sicker and have more complex conditions, and they require dedicated consultants to be available on site 7 days per week for at least 12 hours a day.
Dr Simon Conroy, British Geriatrics Society, said:
We welcome the findings of the report, which emphasises the importance of getting frail older people seen at the earliest possible opportunity in their admission to maximise outcomes.
Dr Chris Roseveare, president of the Society for Acute Medicine, said:
This study represents a really important step forward in the management of patients admitted as medical emergencies. For the first time, specific patterns of consultant working on the Acute Medical Unit have been shown to be associated with improved patient outcomes; hospitals now have a fantastic opportunity to identify the number of acute medicine consultants required to deliver best practice and to provide sustainable rotas for 7 day working in acute medicine.
- Download the full An evaluation of consultant input into acute medical admissions management in England report from the Acute medicine evaluation page
- The survey was carried out between February and April 2010. A web based questionnaire was used to collect structured information about the organisation of acute medical cover for acute medical admissions to hospital, from a representative sample of acute NHS secondary care trusts. For trusts in England, the survey responses were analysed for correlations with patient outcome measures derived from hospital episode statistics (HES) data for the financial year 2009/10. Data from 101 hospitals were analysed for the final results.