Acute and General Medicine

Ensure the acute medical pathway is adequately resourced to manage the projected patient need in a safe, effective, and efficient manner, 24/7. a Trusts to adequately resource their acute medical units to be able to manage the projected numbers of acute medical patients. This should include size of the unit and size of the team managing the patients. b Trusts to ensure that resourcing takes full account of demand, including increasing volume and complexity, and the needs of the specific population they serve in terms of age, frailty, comorbidities, and deprivation. c Trusts to ensure that all patients requiring admission are seen promptly by a senior decision maker for an integrated management plan, including estimated date of discharge (EDD), before they are moved within the hospital system.

Ensure there is seven-day access to medical specialties and services for all patient needs. a Trusts to work together with neighbouring trusts or hospitals to provide timely seven-day access when it is not possible within an individual hospital. b Trusts to follow the NHS England Seven Day Services Clinical Standards for investigations and apply them proportionately throughout the patient pathway. For example, this should include equal turnaround times for ED, AMU and SDEC. c Trusts to regularly monitor turnaround times for investigations ordered on acute medical patients. d Trusts and NHSE/I to investigate the demand for MRI scanning locally and nationally to accurately identify the imaging capacity required. (This process must also take into consideration the downstream cost, such as consultant and radiologist time.) e Trusts to calculate the demand for out-of-hours upper gastrointestinal (GI) endoscopy and the impact on length of stay to determine the most cost-effective method of providing an upper GI bleed (UGIB) service. f Trusts to implement the use of evidence-based radiology guidelines to request radiological imaging as a standard in acute medical patients, such as iRefer. (The guidelines should be embedded in clinical decision support software to enhance the efficiency and efficacy of radiological requesting.)

Ensure that there is cross-trust consistency in the use of acronyms when referring to acute and general medicine services. a Trusts to use the term AMU over other terms. (Trusts may wish to use sub-headings to further explain the role and location according to local need). b Trusts to use the term SDEC for the area where patients are managed in an ambulatory setting.

Ensure that the AMU is sited appropriately. a Trusts to review the acute and emergency pathway to ensure the AMU is appropriately placed geographically for maximal safety and efficiency, including optimal communications between clinical teams.

Ensure the AMU is appropriately resourced in regard to time and space to train all healthcare staff in both acute patient care and the use of relevant equipment. a Trusts to provide an adequately equipped seminar room for teaching all staff and for handover. (The equipment should be able to provide access to e-learning and the room should be suitable for simulation training.) b Trusts to review and utilise the results of the GMC survey aimed at those in the IM and AIM specialties to improve the learning opportunities offered for trainee doctors. c Trusts to provide regular multiprofessional training in the AMU for optimally managing the frail patient. Such training can be undertaken in association with the care of geriatric medicine. d Trusts to provide regular teaching on sepsis to all clinical staff. e Trusts to establish appropriate training leads to manage and promote multiprofessional training.

Ensure the AMU is resourced with the appropriate space and equipment to manage unstable medical patients. a Trusts to develop and implement plans, which should include training for all staff, to optimise patient care in the AMU. (For example, centrally monitored cardiac monitors and areas for level 1a care (CPAP/ NIV/ HFNO2) should be available for unstable patients.)

Ensure there are systems in place to track patients and ensure good communication between staff including handover and referral. a Trusts to use digital systems that facilitate patient tracking in the AMU, and ideally throughout the whole hospital, so that patients who require a review at any time are found easily. b Trusts to record clinical data electronically in accordance with national standards.

Act to improve and repeatedly monitor processes of patient care in the AMU. a Trusts to ensure that community and primary care have direct access to medical specialists for advice and SDEC seven days per week. b Trusts to monitor data from selected sentinel conditions and use the data to identify areas where care can be improved. c Trusts to appoint quality improvement leads within the AMU and provide those leads with appropriate resource, including IT.

Ensure the SDEC pathway is adequately resourced to manage the projected demand in a safe, effective and efficient manner, including prompt access to diagnostic and specialist services. a Trusts to ensure patients presenting with acute medical illness are assessed for their suitability for safe and effective care in an ambulatory setting. b Trusts to ensure that SDEC pathways are used to provide patient care in the most appropriate setting for the patient's needs and not in order to meet external targets (such as activity volumes and waiting times).

Ensure that evidence-based pathways are used optimally within trusts. a Trusts to maximise use of evidence-based practice and optimise pathways of care that are focused on patient needs, including the use of SDEC services. b Trusts to develop pathways to enable patients to receive the initial management to facilitate safe discharge and early follow-up as an outpatient (where access to a medical specialist is not possible seven days per week). c Trusts to ensure the hospital has a robust frailty pathway. d Trusts to ensure that their febrile neutropenia or neutropenic sepsis pathway is robust from first patient contact through to assessment and subsequent admission or discharge.

Ensure admission and readmission data is routinely and accurately recorded and monitored, and used to inform the provision of safe, effective, and efficient pathways. a Trusts to ensure accurate collection of discharge and transfer numbers to base medical wards each day to provide a basis for planning to facilitate adequate patient flow. b Trusts to ensure accurate collection of time of arrival and time of discharge of all patients. c Trusts to collect weekly admissions and length of stay in a run chart (separated into 75 years of age and above and below 75 years of age). d Trusts to monitor 7-day and 28-day readmissions. e Trusts to regularly review readmissions and reattendance rates and identify large variations in, or higher than average, readmission rates. f Trusts to monitor all ED reattendances, some of which may not subsequently be readmitted to the AMU but may be discharged from the ED or admitted to higher level care, such as HDU or ICU. g Trusts to review all data and use it constructively to facilitate optimal care in the diverse acute medical pathways and maximise patient flow. There should be a person or group responsible for oversight of this data with access to the executive team to ensure action is taken. This should include data associated with the Society for Acute Medicine clinical quality indicators.

Ensure that the outcomes for sentinel conditions are regularly monitored to identify any deterioration in performance and provide feedback to medical teams. a Trusts to review rates such as zero length of stay, readmission, mortality etc., to establish their own baseline and then perform ongoing monitoring and review. b Trusts to incorporate reviews into a regular audit cycle within the AMU to drive quality improvement. c Trusts to provide feedback to clinical teams.

Ensure that patients presenting with sepsis are identified accurately and treated safely, efficiently and effectively. a Trusts to improve the accuracy of coding for sepsis in line with the agreed international definition: Sepsis 4.0. b Trusts to ensure that clinicians across the professions review the initial suspicion of sepsis and modify this to an infection when appropriate.

Ensure that all trusts follow the same consistent approach to the application of treatment function code coding and the separate identification of SDEC patients. a Trusts to use code TFC326 (treatment under AIM) for any patient managed within the AMU. b Trusts to use code TFC300 (treatment under general medicine or internal medicine) for any patient receiving care in a medical ward under a consultant who is functioning outside of their specialty. c Trusts to use the SDEC conditions from the ECDS to identify all patients managed in SDEC.

Ensure physicians and clinical coders improve the accuracy of data collection and ensure that all coding is undertaken consistently. a Trusts to provide training on the importance of accurate clinical coding for all physicians at induction. This should specifically highlight the relationship between what is recorded and what is coded. (Ideally, a longer session on clinical coding should be delivered as part of a foundation training programme.) b Trusts to provide regular meetings between clinicians across the professions and clinical coders to: support and reinforce training by providing access to further information; promote effective relationships and knowledge sharing; validate data as a whole; discuss problems or a query about a specific patient; review analysis of coding accuracy.

Establish and follow clinical notation practices that support accurate coding. a Clinicians across the professions to clearly state the following in patient notes: whether or not a diagnosis has been made; the main condition being treated (rather than leaving this to the judgement of a clinical coder); and when 'treated as' conditions are subsequently ruled out (for example, if a patient is 'treated as' having sepsis, but sepsis is later ruled out). b NHS Digital Terminology and Classifications Delivery Service to work with GIRFT and the RCP to clarify the coding standard relating to 'treated as' in order to ensure it can be applied consistently.

Ensure that services are provided in a cost effective and efficient way. a Trusts to ensure that clinical and non-clinical managers review their reference costs regularly to better understand the cost of delivery of the services provided with the aim of improving their cost effectiveness. b Trusts' clinical and non-clinical managers to work together to establish ways to provide services in a cost effective and efficient way.

Ensure the workforce reflects the requirements of the AIM and IM service. a Trusts to ensure that staffing across all relevant professional groups is adequate to reflect the needs of the population they serve in terms of age, frailty, comorbidities, and deprivation. b Trusts to review their nurse-to-patient ratios throughout the AMU and ensure they are in line with national recommendations. (Nationally defined parameters are 1:6 for the AMU and 1:2 for HDU within the AMU). c Trusts to ensure there is adequate Allied Health Professional (AHP) support across the acute and emergency floor to facilitate timely discharges and prevent deconditioning.

Reduce litigation costs by application of the GIRFT programme's five-point plan. a Clinicians across the professions and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts would have received this information in the GIRFT 'Litigation data pack' b Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk c Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support d Claims should be triangulated with learning themes from complaints, inquests, and serious untoward incidents (SUI)/serious incidents (SI)/Patient Safety Incidents (PSI) and where a claim has not already been reviewed as SUI/SI/PSI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all front-line clinical staff in a structured format at departmental/directorate meetings (including multidisciplinary team meetings, morbidity and mortality meetings where appropriate). e Where trusts are outside the top quartile of trusts for litigation costs per activity GIRFT we will be asking national clinical leads and regional teams to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit.