Ten core principles to guide actions and behaviours for effective front door acute patient care are outlined in new guidance from the GIRFT Urgent and Emergency Care (UEC) team, in collaboration with the Royal College of Physicians.
The principles – underpinned by existing national policy and expert clinical opinion – pinpoint ways of working which NHS teams should promote and deliver to help improve patient flow and their overall experience.
Working together, operational teams and clinicians can use these practical guidance points to gauge whether their service is delivering the care and necessary inter-specialty working as described, identify any gaps or inadequacies, and collaborate with colleagues in specialty teams and the trust executive to ensure the principles are supported and implemented.
The guidance is offered under the overarching principle that ‘patients should have equitable access to professionals with the skills required for their individual care, independent of the location of their bed or the nominal admitting specialty’. As well as the 10 principles for acute patient care to help the functioning of the acute medical unit and guide specialty input into acute care, it also features four core principles for effective delivery of patient care in Same Day Emergency Care (SDEC).
See the full list of principles below*.
Mike Jones, GIRFT’s clinical lead for acute and general medicine, was in the GIRFT UEC group which developed the principles.
“We fully appreciate that some of these principles may not be standard practice for all acute care providers, but we present them as ways of working which should be embedded into normal daily interactions or which services should be striving towards, for the benefit of patients. They should be used as a framework during induction of new staff and as part of annual updates for existing staff, so that over time the described ways of working become standard practice and how things are done every day.”
Alongside the principles and practical guidance, the document contains examples of patient dispositions for common conditions which can be modified locally. The examples are based on the premise that the main presenting complaint will determine which specialty the patient is referred to and which specialty admits the patient.
An evaluation checklist is also provided for regular monitoring of implementation and delivery of the principles, to ensure they are embedded.
Overarching principle:
Patients should have equitable access to professionals with the skills required for their individual care, independent of the location of their bed or the nominal admitting specialty.
The 10 principles for acute care:
- Urgent cross sectional (CT/MRI) imaging requests should be reported within 4 hours of request.
- Core laboratory services should be available 24/7, and turnaround times should be monitored regularly and reported monthly.
- All patients arriving on or being transferred to an assessment unit (e.g. AMU, SDEC, SAU etc) should have NEWS2 calculated. The NEWS2 should be used in conjunction with the presenting condition to prioritise care.
- All patients should have a full assessment undertaken by a competent clinical decision maker*, ideally within one hour and within a maximum of four hours of the decision to admit or of arrival on the assessment unit (whichever is earlier).
- All patients should be reviewed by an expert clinical decision maker within six hours of the decision to admit or of arrival on the assessment unit (whichever is earlier) from 08:00-20:00h or within 14 hours outside of these times.
- When it is agreed that a patient should transfer from the assessment unit to a non-medical ward, e.g. from medicine to general surgery, the receiving specialty team becomes responsible for the patient’s care.
- Patients transferring out of critical care units (CCU, ICU, HDU, ECU) should be prioritised for inpatient bed allocation, above other requests for available beds.
- Where specialties provide an admissions unit, an expert/senior decision maker should receive referrals and provide advice to the community and hospitals every day to prevent unnecessary hospital attendance/admission and to facilitate hospital discharge.
- Twice-daily consultant ward rounds is the optimal model and should be delivered in higher acuity areas, e.g. ICU, AMU, SSW, SAU, CCU, and other medical wards if possible.
- Patients aged over 65 presenting to hospital as an emergency should be assessed on arrival using the Clinical Frailty Scale (CFS) and 4AT tool for delirium.
Principles for same day emergency care (SDEC):
- SDEC must not be bedded overnight as this minimises the effectiveness of the unit which adversely affects patient flow, and prevents or removes the early gains made from moving these patients from the ED.
- A senior/expert clinical decision maker who is responsible solely for the SDEC should be present for the entire opening hours of the unit.
- SDEC services should be provided at least 12 hours/day, 7 days/week, in all relevant specialties, as per national guidelines.
- SDEC services should have acute frailty services operating for a minimum of 70 hours per week during peak demand hours.
