Guest Editorial - Bad NEWS: standing still is risky for patients admitted to hospital (even with normal vital signs).

Acute Physicians care for acutely unwell patients. Recognising and prioritising those at greatest risk of death is therefore at the heart of our specialty. The risk of catastrophic deterioration in the Acute Medical Unit is usually quantified through the measurement of vital signs. These are being summarised into the National Early Warning Score or similar instruments. Those with higher Early Warning Scores are usually prioritised by clinicians in and out of hospital and being seen before those with lower grades of abnormalities and preferably assessed by a more senior clinician.

Acute Medicine: How will we grow? - An analysis of organisational capabilities for quality improvement, research & education from SAMBA 2021.

BACKGROUND: Education, research, and Quality Improvement (QI) are key enablers for high quality care. We aimed to map the capability of Acute Medical Units (AMUs) to facilitate excellence in these areas. METHODS: AMUs were surveyed in an organisational questionnaire within the Society for Acute Medicine Benchmarking Audit 2021. RESULTS: 143 units participated. 80 units had a QI lead, 24 had a research lead and 99 had a medical education lead. 15 units had all three leadership roles. Most QI work considered service structure rather than changes in processes or care outcomes. CONCLUSION: The organisational capability of AMUs in the strategic areas considered is variable. Improving leadership and disseminating learning could help build a strategic foundation for acute medicine to grow.

Society for Acute Medicine's Patients: Learning from Experience Report (SAM-PLER) A service evaluation of patient reported experience in Acute Medicine - establishing the feasibility of a quality improvement collaborative.

Patient reported experience measures (PREMS) are a key part of measured quality. There is no tool currently used in the UK in Acute Medicine. On the 8th of September 2022 10 units based in England, Scotland and Wales collected data for the validated PREM, alongside the EQ-5D and variables from the Society for Acute Medicine's Benchmarking Audit (SAMBA) dataset. 365 patients were screened, 200 were included (55%): 159 patients from AMUs and 41 from SDEC units. Overall experience of patients was rated 8.5/10, patients rated their experience of safety, trust and listening highly. Collection of PREMS was feasible. Further research is required to link experience to clinical outcome and explore tools that capture experience of patients with altered mental status.

Developing priorities for quality improvement in acute medicine using a modified Delphi method A consensus process hosted by the Society for Acute Medicine Quality Improvement Committee (SAM-QI).

INTRODUCTION: The SAM Quality Improvement Committee (SAM-QI), set up in 2016, has worked over the last year to determine the priority Acute Medicine QI topics. They have also discussed and put forward proposals to improve QI training for Acute Medicine professionals. METHODS: A modified Delphi process was completed over four rounds to determine priority QI topics. Online meetings were also used to develop proposals for QI training. RESULTS: Same Day Emergency Care (SDEC) was chosen as the priority topic for QI work within Acute Medicine. CONCLUSION: The SAM-QI group settled on SDEC being the priority topic for Acute Medicine QI development. Throughout the Delphi process SAM-QI has also developed proposals for QI training that will help Acute Medicine professionals deliver coordinated meaningful improvements in care.

Society for Acute Medicine Benchmarking Audit 2021 (SAMBA21): assessing national performance of acute medicine services.

INTRODUCTION: The Society for Acute Medicine Benchmarking Audit 2021 (SAMBA21) took place on 17th June 2021, providing the first assessment of performance against the Society for Acute Medicine's Clinical Quality Indicators (CQIs) within acute medical units since the start of the COVID-19 pandemic. METHODS: All acute hospitals in the UK were invited to participate. Data were collected on unit structure, and for patients admitted to acute medicine services over a 24-hour period, with follow-up at 7 days. RESULTS: 158 units participated in SAMBA21, from 156 hospitals. 8973 patients were included. The number of admissions per unit had increased compared to SAMBA19 (Sign test p<0.005). An early warning score was recorded within 30 minutes of hospital arrival in 77.4% of patients. 87.4% of unplanned admissions were seen by a tier 1 clinician within 4 hours of arrival. Overall, the medical team performed the initial clinician assessment for 36.4% of unplanned medical admissions. More than a third of medical admissions had their initial assessment in Same Day Emergency Care (SDEC) in 25.4% of hospitals. 62.1% of unplanned admissions were seen by two other clinical decision makers prior to consultant review. Of those unplanned admissions requiring consultant review, 67.8% were seen within the target time. More than a third of unplanned admissions were discharged the same day in 41.8% of units. CONCLUSION: Performance against the CQIs for acute medicine was maintained in comparison to previous rounds of SAMBA, despite increased admissions. There remains considerable variation in unit structure and performance within acute medical services.

Length of stay in Acute Medical Admissions: Analysis from the Society for Acute Medicine Benchmarking Audit.

INTRODUCTION: Medical admissions to hospital represent a diverse range of patients, from those managed on ambulatory pathways through Same Day Emergency Care (SDEC) services, to those requiring prolonged inpatient admission. An understanding of current patterns of admission through acute medicine services and patient factors associated with longer hospital admission is needed to guide service planning and improvement. METHODS: Data from the Society for Acute Medicine Benchmarking Audit (SAMBA) 2021 were analysed. Patients admitted to acute medicine services during a 24-hour period on 17th June 2021 were included, with data recording patient demographics, frailty score, acuity and follow-up of outcomes after seven days. RESULTS: 8101 unplanned medical admissions were included, from 156 hospitals. 31.6% were discharged without overnight admission; the median hospital performance was 30.1% (IQR 19.3-39.3%). 22.1% of patients remained in hospital for more than 7 days. Those remaining in hospital for more than 48 hours and for more than seven days were more likely to be aged over 70, to be frail, or to have a NEWS2 of 3 or more on arrival to hospital. CONCLUSION: The proportion of acute medical attendances receiving overnight admission varies between hospitals. Length of stay is impacted by patient factors and illness acuity. Strategies to reduce inpatient service pressures must ensure effective care for older patients and those with frailty.

Co-design of interventions to improve acute care in hospital: A rapid review of the literature and application of the BASE methodology, a novel system for the design of patient centered service prototypes.

Co-design in acute care is challenged by the inability of unwell patients to participate in the process and the often transient nature of acute care. We undertook a rapid review of the literature on co-design, co-production and co-creation of solutions for acute care that were developed with patients. We found limited little evidence for co-design methods in acute care. We adapted a novel design driven method (BASE methodology) that creates stakeholder groups through epistemological criteria for the rapid development of interventions for acute care. We demonstrated feasibility of the methodology in two case studies: A mHealth application with checklists for patients undergoing treatment for cancer and a patient held record for self-clerking on admission to hospital.

Quality: What does it mean in Acute Medicine and how do we measure it?

Acute Medicine is a specialty that is not defined by a single organ system and sits at the interface between primary and secondary care. In order to document improvements in the quality of care delivered a system of metrics is required. A number of frameworks for measurements exist to quantify quality of care at the level of patients, teams and organisations, such as measures of population health, patient satisfaction and cost per patient. Measures can capture whether care is safe, effective, patient-centred, timely, efficient and equitable. Measurement in Acute Medicine is challenged by the often-transient nature of the contact between Acute Medicine clinicians and patients, the lack of diagnostic labels, a low degree of standardisation and difficulties in capturing the patient experience in the context. In a time of increasing ecological and financial constraints, reflecting about the most appropriate metrics to document the impact of Acute Medicine is required.

Long-term trends in critical care admissions in Wales*.

As national populations age, demands on critical care services are expected to increase. In many healthcare settings, longitudinal trends indicate rising numbers and proportions of patients admitted to ICU who are older; elsewhere, including some parts of the UK, a decrease has raised concerns with regard to rationing according to age. Our aim was to investigate admission trends in Wales, where critical care capacity has not risen in the last decade. We used the Secure Anonymised Information Linkage Databank to identify and characterise critical care admissions in patients aged ≥ 18 years from 1 January 2008 to 31 December 2017. We categorised 85,629 ICU admissions as youngest (18-64 years), older (65-79 years) and oldest (≥ 80 years). The oldest group accounted for 15% of admissions, the older age group 39% and the youngest group 46%. Relative to the national population, the incidence of admission rates per 10,000 population in the oldest group decreased significantly over the study period from 91.5/10,000 in 2008 to 77.5/10,000 (a relative decrease of 15%), and among the older group from 89.2/10,000 in 2008 to 75.3/10,000 in 2017 (a relative decrease of 16%). We observed significant decreases in admissions with high comorbidity (modified Charlson comorbidity index); increases in the proportion of older patients admitted who were considered 'fit' rather than frail (electronic frailty index); and decreases in admissions with a medical diagnosis. In contrast to other healthcare settings, capacity constraints and surgical imperatives appear to have contributed to a relative exclusion of older patients presenting with acute medical illness.

Society for Acute Medicine Benchmarking Audit 2019 (SAMBA19): Trends in Acute Medical Care.

INTRODUCTION: The eighth Society for Acute Medicine Benchmarking Audit (SAMBA19) took place on Thursday 27th June 2019. SAMBA gives a broad picture of acute medical care in the UK and allows individual units to compare their performance against their peers. METHOD: All UK hospitals were invited to participate. Unit and patient level were collected. Data were analysed against published Clinical Quality indicators (CQI) and standards. This was the biggest SAMBA to date, with data from 7170 patients across 142 units in 140 hospitals. RESULTS: 84.5% of patients had an Early Warning Score measured within 30 minutes of arrival in hospital (SAMBA18 84.1%), 90.4% of patients were seen by a competent clinical decision maker within four hours of arrival in hospital (SAMBA18 91.4 %) and 68.6% of patients were seen by a consultant within the timeframe standard (SAMBA18 62.7%). Ambulatory Emergency Care is provided in 99.3% of hospitals. 61.8% of patients are initially seen in the Emergency Department (ED). Since SAMBA18 death rates and planned discharge rates, while the use of NEWS2 increased from 2.5% to 59.2% of hospitals. CONCLUSION: SAMBA19 highlighted the evolving complexity of acute medical pathways for patients. The challenge now is to increase sample frequency, assess the impact of SAMBA open a broader debate to define optimal CQIs.

Acute care service performance during winter: report from the winter SAMBA 2020 national audit of acute care.

The Winter Society for Acute Medicine Benchmarking Audit (SAMBA) provides the first comparison of performance within acute medicine against clinical quality indicators during winter, a time of increased pressure and demand on acute services. 105 hospitals participated in Winter SAMBA, collecting data over 24-hours on 30th January 2020. 5626 patients were included. Participating units saw a median of 48 patients (range 13-131). Comparison between Winter SAMBA and SAMBA19 found less patients had an early warning score within 30 minutes during winter (74.3% vs 78.9%) and less were seen by a clinical decision maker within four hours (84.9% vs 87.9%). Unplanned admissions represented a higher proportion of workload (92.5% vs 90.1%). Patients were more likely to have a NEWS2 score of 3 or higher (30.1% vs 25.7%). Performance is poorer in winter, and patients are more unwell, needing prompt treatment. Services should ensure high quality care can be maintained through times of increased pressure, including winter.

Who is allowed to read and write?

What makes us human? In 2015 Jeremy Vine asked this question to a selection of leading British thinkers and writers. The answers were as diverse as the people he interviewed. While you might have your own views about the complexity of being human I would suggest that being able to articulate thoughts and communicate them to others might be one of the characteristics that distinguishes us from other life forms. And if we think more about the achievements of human culture then being able to communicate thoughts in writing and reading other.

Testing the effects of checklists on team behaviour during emergencies on general wards: An observational study using high-fidelity simulation.

INTRODUCTION: Clinical teams struggle on general wards with acute management of deteriorating patients. We hypothesized that the Crisis Checklist App, a mobile application containing checklists tailored to crisis-management, can improve teamwork and acute care management. METHODS: A before-and-after study was undertaken in high-fidelity simulation centres in the Netherlands, Denmark and United Kingdom. Clinical teams completed three scenarios with a deteriorating patient without checklists followed by three scenarios using the Crisis Checklist App. Teamwork performance as the primary outcome was assessed by the Mayo High Performance Teamwork scale. The secondary outcomes were the time required to complete all predefined safety-critical steps, percentage of omitted safety-critical steps, effects on other non-technical skills, and users' self-assessments. Linear mixed models and a non-parametric survival test were conducted to assess these outcomes. RESULTS: 32 teams completed 188 scenarios. The Mayo High Performance Teamwork scale mean scores improved to 23.4 out of 32 (95% CI: 22.4-24.3) with the Crisis Checklist App compared to 21.4 (20.4-22.3) with local standard of care. The mean difference was 1.97 (1.34-2.6; p < 0.001). Teams that used the checklists were able to complete all safety-critical steps of a scenario in more simulations (40/95 vs 21/93 scenarios) and these steps were completed faster (stratified log-rank test χ2 = 8.0; p = 0.005). The self-assessments of the observers and users showed favourable effects after checklist usage for other non-technical skills including situational awareness, decision making, task management and communication. CONCLUSIONS: Implementation of a novel mobile crisis checklist application among clinical teams was associated in a simulated general ward setting with improved teamwork performance, and a higher and faster completion rate of predetermined safety-critical steps.

Death after Discharge - Every heart beat counts (probably)!

The assumption would be that patients who are discharged from an emergency or acute medicine department have been thoroughly assessed and are good to return to the safety of their own home. An unplanned death after discharge from hospital is the worst-case scenario for patients, families and indeed clinicians. In order to prevent adverse events after patients leave hospital most units have a multi-layered system to capture risk that includes triage, recording of vital signs, basic blood tests, understanding of existing past medical history and assessment by a senior clinician to add experience and intuition. Discharge decisions depend on a balanced review of all these parameters and a discussion with patients about residual risks. Only after this will patients go home. Despite this a small percentage of patients pass away unexpectedly within days after leaving hospital.

Feasibility of measuring psychological resilience in hospitalized patients with acute illness: The Resilience After the Trauma of Acute Illness (RAFT) study.

Resilience is the 'ability to bounce back'. We want to investigate whether measurement of resilience during an acute hospital admission is feasible. We conducted a feasibility study. Resilience was measured using the Brief Resilience Scale. Results were contextualized by measuring chronic disease burden, anxiety, depression, coping strategies and personality traits. 56 or 103 patients approached took part in the study. A group of 12 patients undergoing pulmonary rehabilitation served as a control group. We found evidence of low resilience in 4/44 (9%) patients admitted as medical emergencies. Low resilience was statistically related to the Hospital Anxiety and Depression Scale and a number of coping strategies and personality traits. We found no relation between measures of resilience and previous admissions to hospital. The concept of resilience might be applicable to unscheduled admissions to hospital. Larger studies are required to establish whether low resilience is common and amenable to intervention. REC number 17/WA/0024.

SAMBA18 Report - A National Audit of Acute Medical Care in the UK.

SAMBA18 took place on Thursday 28th June 2018 with follow up data at 7 days. Acute medical teams from 127 Acute Medical Units (AMUs) across the UK collected data relating to operational performance, clinical quality indicators and standards from NHS Improvement. Data was collected from 6114 patients.

Differences in identification of patients' deterioration may hamper the success of clinical escalation protocols.

BACKGROUND: Timely and consistent recognition of a 'clinical crisis', a life threatening condition that demands immediate intervention, is essential to reduce 'failure to rescue' rates in general wards. AIM: To determine how different clinical caregivers define a 'clinical crisis' and how they respond to it. DESIGN: An international survey. METHODS: Clinicians working on general wards, intensive care units or emergency departments in the Netherlands, the United Kingdom and Denmark were asked to review ten scenarios based on common real-life cases. Then they were asked to grade the urgency and severity of the scenario, their degree of concern, their estimate for the risk for death and indicate their preferred action for escalation. The primary outcome was the scenarios with a National Early Warning Score (NEWS) ≥7 considered to be a 'clinical crisis'. Secondary outcomes included how often a rapid response system (RRS) was activated, and if this was influenced by the participant's professional role or experience. The data from all participants in all three countries was pooled for analysis. RESULTS: A total of 150 clinicians participated in the survey. The highest percentage of clinicians that considered one of the three scenarios with a NEWS ≥7 as a 'clinical crisis' was 52%, while a RRS was activated by <50% of participants. Professional roles and job experience only had a minor influence on the recognition of a 'clinical crisis' and how it should be responded to. CONCLUSION: This international survey indicates that clinicians differ on what they consider to be a 'clinical crisis' and on how it should be managed. Even in cases with a markedly abnormal physiology (i.e. NEWS ≥7) many clinicians do not consider immediate activation of a RRS is required.