1. Acute Medicine Interface
Vivek Srivastava
Consultant in Acute Medicine
King’s College Hospital

2. Why 5.9% of emergency admissions considered unnecessary
Emergency Admissions: A journey in the right direction?
A report of the National Confidential Enquiry into Patient Outcome and Death (2007)
5.9% of emergency admissions considered unnecessary
50.7% of hospitals did not have a written handover protocol
There was a relationship between the quality of the initial assessment and the overall quality of care
There must be appropriate handover systems in place

3. Why NCEPOD - Deaths in Acute Hospitals (2009)
In 25% of cases there was, a clinically important delay in the first review by a consultant.
Poor communication between and within clinical teams was identified as an important issue in 13.5% (267/1983) of cases.

4. Summary
Appropriately trained doctors must see sick patients in a timely manner
The systems of care need to be overhauled to ensure that emergency patients get a uniformly high standard of care
Communication, documentation and handover must improve

5. The problem Maudsley view King’s view Escalation
Too many pathways
Evaluation
Transfer to KCH
The medically deteriorating patient
King’s view
Avoid emergency referral
Early assessment
Admission prevention
Early discharge back
Medical plans

6. The pilot - principles Develop a pathway that provides
Early recognition of the deteriorating patient
Prompt communication with medical team
Appropriate evaluation and management
Non-emergency transfer to KCH, if required
Reduced A&E waiting
Joint care and discharge planning
Improved patient experience

7. The pilot – the proposal
The service will operate between
Telephone support
Planned assessment by Acute Medicine (AAU)
Assessments at the Maudsley site if there is a risk associated with transferring to Kings
1:1 nursing support for individual service users
Shared teaching provision - SLaM and King’s

8. In case of a Medical Emergency – follow your hospital protocol
The pathway
In case of a Medical Emergency – follow your hospital protocol
Inpatient in SLaM with concerns about medical health
Nurse in charge to record complete set of observations and calculate Early Warning Score. Inform Junior Doctor caring for the patient
Junior doctor carries out examination, blood tests and ECG
Bleep Medical SpR providing ward cover on KCH bleep 221; or
Call Acute Medicine Consultant on (M-F- 10am to 4pm)
Details required
Medical issues and clinical findings
Results of bedside and lab tests

9. Medical SpR / Acute Medical consultant advises
The pathway
Medical SpR / Acute Medical consultant advises
Medical management plan agreed, patient remains in SLaM
Admit to King’s with case summary by ward SHO
Further medical review
Transfer to A&E / AAU
Expected date of discharge (EDD) from KCH set at admission
Bed manager at KCH to liaise with counterpart at SLaM to arrange bed availability on EDD

10. Way forward Evaluation – define scale of the problem
Measures collected in KCH
Total time spent in A&E by SLAM patients.
Route of referral
Reduced length of stay
Lag time between being declared clinically fit for discharge and actually leaving KCH
Same day discharges Length of time in MAU if not admitted
MAU patient experience feedback
Time of day of calls
Profile of conditions referred
SLaM Measures
Number of people from Maudsley who have to go to KCH
Number of ambulances between Maudsley and KCH
Number of 999 calls.
Number/ cost of escorts to KCH.
SLaM PEDIC measure on return.
SLaM length of stay
7. Survey of doctor/ nurses including qualitative information benefits to patients and staff at both sites.
Measures from both sites
Improved medicine reconciliation rates
Proportion of people for whom SLAM bed managers know KCH EDD on admission
Quantify the number of people who would have benefitted from assessment on the Maudsley site

11. Initial results (n=72) Pilot - 14/12/11 – 13/3/12 (n=39)
Control - 14/9/11 – 13/12/11 (n=33)
Unable to capture tele-referrals
39 female : 33 males; Age – 16 – 89y
28/72 (38.8%) presented after 5pm
Since December increasing evening rather than late night referrals.
Benefits – better communication, appropriate admissions, early discharges (some). Staff happy

12. Way forward Challenges Data sharing – IT issues, medico-legal issues
Multidisciplinary working
Medicines reconciliation
Communication and prompt patient transfer across the road in either direction
Standardising mental-physical interface
Education and training – early progress

13. Summary
The overall goal of IMPARTS is to improve mental healthcare provision within medical settings across KHP.
We suggest the need to improve medical healthcare provision within mental health settings across KCP.
Long term - Medical Liaison team(s) (cf Psych liaison team)
Spread across all acute / mental health trusts