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Acute Medicine Interface

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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

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