NCEPOD ReportNCEPOD ReportCaring to the end?Caring to the end?

Issues for physiciansIssues for physicians

Prof IT Gilmore PRCPProf IT Gilmore PRCP

Coping with general medical take – what’s the problem?

• ‘proper’ physicians have always taken part in emergency medical admissions

• it has gone hand in hand with access to beds / junior staff / standing in the hospital

So what has changed?So what has changed?

Volumes of medical admissionsVolumes of medical admissions Range of skills / interventions possibleRange of skills / interventions possible Experience of junior staffExperience of junior staff Expectations of ‘consultant-delivered Expectations of ‘consultant-delivered

serviceservice Patient expectationsPatient expectations Tensions with specialty commitmentsTensions with specialty commitments EWTDEWTD

Total admissions per head: annual % change 1989-1998

-2

-1

0

1

2

3

0-14 15-64 65+

age (years)

An

nu

al %

ch

ang

e

Strengthening the medical ‘take’

medical assessment units

medical admission units

Acute Medicine Units

Aims:

• Seeing and managing acutely sick patients promptly• Encouraging specialty triage• Identifying appropriate patients for alternatives to secondary care• Discharge of appropriate patients

RCP ACUTE MEDICINE TASK FORCERCP ACUTE MEDICINE TASK FORCEREPORT – OCTOBER 2007REPORT – OCTOBER 2007

‘The right person, in the right setting – first time’‘The right person, in the right setting – first time’

The primary aim is urgent patient access to The primary aim is urgent patient access to acute medical care when required.acute medical care when required.

A patient should get direct and prompt access A patient should get direct and prompt access to a competently trained acute clinician (this to a competently trained acute clinician (this includes non-medical professionals)includes non-medical professionals)

Access should be obtained without going Access should be obtained without going through any unnecessary steps in the processthrough any unnecessary steps in the process

It will require the development of effective and It will require the development of effective and responsive systems of careresponsive systems of care

NCEPOD: In 25% (407/1635) of cases there was, NCEPOD: In 25% (407/1635) of cases there was, in the view of the advisors, a clinically important in the view of the advisors, a clinically important delay in the first review by a consultant.delay in the first review by a consultant.

The RCP report recommended:The RCP report recommended:• Patients with acute medical illness should Patients with acute medical illness should

get access as soon as possible to a get access as soon as possible to a competent clinical decision-maker at the competent clinical decision-maker at the front-line of acute medical services;front-line of acute medical services;

• There should be twice-daily consultant-There should be twice-daily consultant-led review of patients – 7 days a weekled review of patients – 7 days a week

Acute medical admisssionsAcute medical admisssionsaudit standardsaudit standards

Patients should be seen by a consultant Patients should be seen by a consultant 2 times daily 7 days per week (RCP)2 times daily 7 days per week (RCP)

    Consultants should have job plans Consultants should have job plans adjusted to allow for 2 times daily wards adjusted to allow for 2 times daily wards rounds when on for acute medicine rounds when on for acute medicine (RCP)(RCP)

    Consultants should be relieved of other Consultants should be relieved of other commitments to allow twice daily wards commitments to allow twice daily wards rounds (NCEPOD).rounds (NCEPOD).

NCEPOD: Poor communication was a significant NCEPOD: Poor communication was a significant factor in the NCEPOD reportfactor in the NCEPOD report

Teamwork is essential for patient safety Teamwork is essential for patient safety and continuity of care. Physicians and and continuity of care. Physicians and the multidisciplinary team should not the multidisciplinary team should not work in isolation.work in isolation.

The RCP report recommended clearly The RCP report recommended clearly defined contact pathways for named defined contact pathways for named senior clinical opinions should be on a senior clinical opinions should be on a rota for all specialties likely to require rota for all specialties likely to require regular interaction.regular interaction.

NCEPOD: Poor communication was a significant NCEPOD: Poor communication was a significant factor in the NCEPOD reportfactor in the NCEPOD report

Standardised records and management protocols Standardised records and management protocols would facilitate better communicationwould facilitate better communication

The RCP report recommended:The RCP report recommended:• documentation should be standardised across documentation should be standardised across

the NHS in three areas;the NHS in three areas;• the development of evidence-based national the development of evidence-based national

guidance for the clinical management of guidance for the clinical management of common acute medical illnesses. This would common acute medical illnesses. This would improve patient care and provide a more improve patient care and provide a more effective basis for training and audit.effective basis for training and audit.

Standardised medical recordsStandardised medical records

Health Informatics Unit at the RCP has developed:Health Informatics Unit at the RCP has developed:

Standardised admissions clerkingStandardised admissions clerking Standardised handover recordStandardised handover record Standardised discharge recordStandardised discharge record

Approved by Academy of Medical Royal CollegesApproved by Academy of Medical Royal Colleges

Approved in principle by NPfITApproved in principle by NPfIT

NCEPOD: There were instances of poor decision NCEPOD: There were instances of poor decision making and lack of senior input, particularly in the making and lack of senior input, particularly in the evenings and night time.evenings and night time.

Acute care networks require strong clinical Acute care networks require strong clinical leadership.leadership.

The RCP report recommended:The RCP report recommended:• Leaders of the interface services should Leaders of the interface services should

meet on a regular basis to facilitate meet on a regular basis to facilitate planning and development of the acute planning and development of the acute service;service;

• The AMU clinical team should be The AMU clinical team should be consultant ledconsultant led

NCEPOD: Access to CT scanning and MRI scanning is a substantial NCEPOD: Access to CT scanning and MRI scanning is a substantial problem with many sites having no or limited (less than 24 hours) on problem with many sites having no or limited (less than 24 hours) on site provision.site provision.

The RCP report recommended that the AMU The RCP report recommended that the AMU should have scheduled seven day access to should have scheduled seven day access to diagnostic and treatment procedures such as diagnostic and treatment procedures such as diagnostic GI endoscopy, echocardiography, diagnostic GI endoscopy, echocardiography, diagnostic ultrasound, bronchoscopy and CT diagnostic ultrasound, bronchoscopy and CT and MR imaging – with easy and convenient and MR imaging – with easy and convenient access for larger AMUs in large acute access for larger AMUs in large acute hospitals, and available to smaller AMUs via hospitals, and available to smaller AMUs via clearly defined pathways within the local clearly defined pathways within the local emergency care networks. emergency care networks.

NCEPOD: End of life care – some issuesNCEPOD: End of life care – some issues

In 1 of 6 of patients who were expected to die, In 1 of 6 of patients who were expected to die, no evidence of discussion with no evidence of discussion with patients/relatives on treatment limitationpatients/relatives on treatment limitation

Lack of use of pathways, such as LCPLack of use of pathways, such as LCP Need for more training for non-palliative care Need for more training for non-palliative care

doctors in recognising where end of life doctors in recognising where end of life pathway is appropriatepathway is appropriate

Need for better access to palliative care Need for better access to palliative care specialists, including increase in numbers of specialists, including increase in numbers of specialistsspecialists

RCP ACUTE MEDICINE TASK FORCERCP ACUTE MEDICINE TASK FORCE

The wishes of the patient regarding the intensity The wishes of the patient regarding the intensity of intervention and site for end-of-life care of intervention and site for end-of-life care should be clearly documented and respected.should be clearly documented and respected.

In acute hospital settings for patients with life-In acute hospital settings for patients with life-threatening acute illnesses, discussions and threatening acute illnesses, discussions and decisions about end-of-life care are essential decisions about end-of-life care are essential and should be documented in the clinical and should be documented in the clinical management plan.management plan.

The RCP report recommend that end-of-life care The RCP report recommend that end-of-life care plans should become an important part of plans should become an important part of clinical assessment and ongoing review of clinical assessment and ongoing review of patients with terminal illness.patients with terminal illness.

National Care of the Dying Audit 2008/9National Care of the Dying Audit 2008/9

Recognised by DH and profession as way of Recognised by DH and profession as way of ensuring good quality care in dyingensuring good quality care in dying

Increase in hospitals participating in audit from Increase in hospitals participating in audit from 118 to 155 in 2009118 to 155 in 2009

In last 24 hours of life, vast majority of patients In last 24 hours of life, vast majority of patients reported to be comfortablereported to be comfortable

Communication with patients and relatives Communication with patients and relatives about care plan and that the patient has about care plan and that the patient has entered the dying phase recorded in three entered the dying phase recorded in three quarters of cases, but room for improvementquarters of cases, but room for improvement

NCEPOD: End of life care – some issuesNCEPOD: End of life care – some issues

Real challenges in identifying terminal Real challenges in identifying terminal illness in short time-frameillness in short time-frame

Being expected to die is not the same as Being expected to die is not the same as appropriate to dieappropriate to die

Reaching consensus with patient or Reaching consensus with patient or (more usually) family takes time(more usually) family takes time

We need urgent further work with care We need urgent further work with care homes, coroners etc to minimise homes, coroners etc to minimise unnecessary admission at the end of lifeunnecessary admission at the end of life

NCEPOD: other key issuesNCEPOD: other key issues

How do we improve consultant involvement How do we improve consultant involvement out-of-hours in the context of:out-of-hours in the context of: Calls for ‘Productivity’ in other areasCalls for ‘Productivity’ in other areas Threats to consultant expansion in a financial Threats to consultant expansion in a financial

downturn?downturn? How do we improve the standard of handover How do we improve the standard of handover

when: when: Doctors are having to do more in less hoursDoctors are having to do more in less hours Rota gaps ++?Rota gaps ++?