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Right patient, right bed

A new toolkit from the Royal College of Physicians (RCP) for the recognition and care of seriously ill patients recommends that patients admitted as emergencies should only transfer out of the acute medical unit to a ward area that has facilities to meet their clinical needs. The toolkit is being launched today (Thursday 9 May) at the Society for Acute Medicine spring conference in Coventry.

With emergency departments and acute medical units currently under considerable strain due to rising numbers of patients being assessed and admitted, there is great pressure to move patients rapidly to beds on wards throughout the hospital. The toolkit recommends the use of NEWS – the National Early Warning Score, launched by the RCP in 2012, in order to rapidly identify patients who are severely ill or at risk of sudden deterioration. The sickest of these patients should be transferred to the hospital’s intensive care unit or high dependency unit.

The RCP is concerned about those patients identified as requiring an intensity of monitoring and care greater than that available on a standard medical ward. More enhanced care beds (level 1 beds), with higher nurse to patient ratios, should be available on acute medical units. In addition, hospitals should designate enhanced care beds on selected medical wards that manage acutely ill patients.

The medical patient at risk: recognition and care of the seriously ill or deteriorating medical patient, is the sixth in the series of RCP Acute Care Toolkits. The toolkit puts NEWS - a ‘track and trigger’ scoring system for physiological measurements - at the heart of the initial assessment of patients admitted as an emergency. Repeated NEWS values ‘track’ the patient’s progress and, in the event of a deterioration, ‘trigger’ an escalation in medical and nursing care. The score also guides the intensity of care required and the clinical area and staffing level best able to provide this care at any time point during the hospital stay.

Recommendations for assessment:

  • All patients should have NEWS measured on admission and as part of every subsequent clinical assessment
  • Systems must be in place to ensure timely and appropriate responses to NEWS
  • NEWS> 6 is coded red which means that an immediate review of the patient by a senior doctor is required and the patient assessed for potential transfer to the ITU. Patients with NEWS 5-6 are coded amber, require urgent medical review and may benefit from transfer to an enhanced care medical bed
  • All doctors should be aware of red flag scenarios – symptoms and signs of severe illness which may not be detected using NEWS, for example cardiac chest pain
  • NEWS should be used as an aid to clinical assessment but not as a substitute for competent clinical judgement
  • Concern about a patient’s clinical condition should always override the calculated score from NEWS when considering the need to escalate the level of care
  • Patients must always be managed in clinical areas appropriate to their care needs

Recommendations – right patient, right bed

  • No patient should be transferred from the AMU to a ward which is unable to meet their clinical requirements
  • All hospitals managing acutely ill medical patients should have adequate provision of level 1 medical beds (enhanced care beds)
  • It is recommended enhanced care beds (level 1) should be embedded on Acute Medical Units for the management of newly admitted patients who are acutely ill but do not require ITU care

Dr Rhid Dowdle, lead author for the toolkit said:

One of the major drivers for this toolkit was the identification of shortcomings in the care of seriously unwell medical patients by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). I hope the recommendations we have made will, if implemented, improve the care of this vulnerable group of patients.

Dr Mark Temple, RCP acute care fellow and toolkit series lead, said:

The early recognition of the patient who is deteriorating or at risk of deterioration, provides the best opportunity to intervene rapidly and effectively. Acute care toolkit 6 focuses on the use of the National Early Warning Score (NEWS) to detect changes in the severity of a patient's illness and links this to a series of actions by nurses and doctors to escalate care. The toolkit deals with best practice in the management of acutely ill patients throughout the hospital and is fundamental to improving patient outcomes and saving lives.

Dr Chris Roseveare, Society for Acute Medicine president said:

I am delighted that we are able to launch this key document at the Society for Acute Medicine spring conference this week. Ensuring that seriously unwell patients receive prompt, safe care should be a top priority for all staff working on the acute medical unit. The toolkit highlights the importance of early recognition, followed by rapid, senior review for this high risk group of patients; this will be a key message from the three speakers at our opening symposium today. It is crucial to ensure that such patients are managed in the most appropriate ward setting, by staff with the skills to provide this care. Many acute medical units already provide such facilities, and the next generation of acute medicine consultants will all undergo a formal period of critical care training to ensure that these skills are embedded into the AMU team.


For further information, please contact Linda Cuthbertson, head of PR, on +44 (0)203 075 1254 / 0774 877 7919, or email Linda.Cuthbertson@rcplondon.ac.uk

Notes to editors