Emergency Admissions: A journey in the right direction?

1. Emergency Admissions:A journey in the right direction? A report of the National Confidential Enquiry into Patient Outcome and Death (2007)

2. Study aim To identify remediable factors in the organisation of care of adult patients admitted as an emergency

3. Indicators of care • Emergency admissions systems • Access to investigations • Bed management • Timing of first consultant review • Communication and information • Quality and quantity of staff • Preventable adverse events

4. Inclusions • Died on or before midnight on day 7 • Transferred to an adult critical care unit on or before midnight on day 7 • Discharged on or before midnight on day 7 and subsequently died in the community within 7 days of discharge

5. Exclusions • Patients who were brought in dead • Patients who died within an hour of arrival • Patients whose prime reason for admission was palliative care or a psychiatric diagnosis • Obstetric cases

6. Data • Admission questionnaire • Ongoing care questionnaire • Casenotes • Organisational questionnaire • Advisor groups peer reviewed all cases where casenotes were returned

7. Case assessment • Good practice • Room for improvement – clinical care • Room for improvement – organisational care • Room for improvement – clinical and organisational care • Less than satisfactory

8. Data returned

9. Age range

10. Medical vs surgical admissions

11. Patient outcome

12. Overall assessment of care

13. Overall assessment of care

14. Initial assessment

15. Initial assessment • Prompt clinical assessment • Differential diagnosis • Clear management plan • Appropriate investigations • Early decision making • Involvement of relevant specialties • Timely review by an appropriately trained senior clinician The Society of Acute Medicine, 2007 Emergency Assessment Units – a Checklist, DH 2003 The interface of A&E and Acute Medicine, RCP 2002

16. Quality of initial assessment

17. Quality of initial assessment

18. Location of initial assessment

19. Type of EAU

20. Quality of initial assessment

21. Quality of initial assessment Documentation • Dates, times, designation, legibility • Documentation of management plan • Nursing notes better standard than medical notes • Proforma documents generally better but lack standardisation

22. Quality of initial assessment Key findings • Of those hospitals that had an EAU 98% (169/173) had a medical EAU and 60% (104/173) a surgical EAU • The overall standard of initial assessment of emergency admissions was good or adequate but 7.1% (90/1275) were poor or unacceptable in the advisors’ opinions • There were examples of poor medical documentation particularly in respect of basic information on the dates, times or designation of the person making an entry in the casenotes

23. Quality of initial assessment Recommendations • The initial assessment of patients admitted as an emergency should include a doctor of sufficient experience and authority to implement a management plan. This should include triage of patients as well as formal clerking. The involvement of a more senior doctor should be clearly and recognisably documented within the notes (Clinical leads and heads of service) • The quality of medical note keeping needs to improve. All entries in notes should be legible, contemporaneous and prompt. In addition they should be legibly signed, dated and timed with a clear designation attached (Medical directors)

24. First consultant review

25. First consultant review • Earlier diagnosis • Earlier management plan • Greater ability to recognise more severely ill patients • Improve outcome Seward E et al Clin Med 2003;3:425–34 Safer care for the acutely ill patient: learning from critical incidents. NPSA 2007

26. First consultant review • No evidence in casenotes of consultant review in 158 (12.4%) out of 1275 cases • In 682 (53.5%) of cases unable to determine the time the patient was first reviewed by a consultant • Documentation issues

27. First consultant review Current standards • 90% of patients should be reviewed by a consultant within 24 hours of admission(Good medical practice for physicians, RCP, 2004) • Acutely ill patients should be seen by critical care consultants within 12 hours of admission to AICU (Good medical practice for physicians, Intensive Care Medicine RCP 2004) • Senior doctors should review patients admitted as an emergency within an hour of referral from the Emergency Department(Transforming Emergency Care DH 2004, The Emergency Department: Medicine and Surgery Interface Problems and Solutions. London, RCS)

28. First consultant review

29. First consultant review

30. First consultant review Unacceptable time to first consultant review by overall quality of care as viewed by the advisors

31. First consultant review Advisors’ opinion

32. First consultant review • Delays in seeing a doctor of adequate seniority and experience may have a detrimental effect on patient care • more important for patients to be seen by a consultant within a reasonable time frame determined by clinical condition rather than by a consultant of appropriate specialty • can result in delayed definitive care and poor outcome • Decision making by training grades • examples of lack of and poor decision making by trainees • Ability of trainees to recognise critical ill patients is poor • examples of trainees underestimating the severity of physiological dysfunction

33. Case study 4 A very elderly patient was admitted to the emergency department from a nursing home at 02:00 with pneumonia. The patient had a known history of ischaemic heart disease and Parkinson’s disease. A medical SHO made a comprehensive initial assessment but no management plan was documented. The patient was not re-assessed again until the first consultant review 17 hours after arrival in the emergency department. By this time the patient had deteriorated and had a heart rate of 120 and a respiratory rate of 30 with overt signs of sepsis. Despite aggressive therapy with IV antibiotics the patient died 24 hours later.

34. Advisors’ concerns • Lack of a clear management plan on admission • Long duration to the first consultant review • Delay of the initiation of medical treatment • All contributed to the patient’s eventual demise

35. First consultant review Key findings • 60.1% (298/496) of patients were seen by a consultant within 12 hours of admission; 92.3% (458/496) were seen within the first 24 hours • In 12.4% (158/1275) of cases there was a lack of documentary evidence of patients being reviewed by consultants following admission to hospital • It was not possible to determine the time to the first consultant review in 682 (53.5%) of cases due to lack of documentation of time or date in the casenotes

36. First consultant review Recommendations • Patients admitted as an emergency should be seen by a consultant at the earliest opportunity. Ideally this should be within 12 hours and should not be longer than 24 hours. Compliance with this standard will inevitably vary with case complexity (Clinical directors) • Documentation of the first consultant review should be clearly indicated in the casenotes and should be subject to local audit (Clinical directors)

37. First consultant review Recommendation Trainees need to have adequate training and experience to recognise critically ill patients and make clinical decisions. This is an issue not only of medical education but also of ensuring an appropriate balance between a training and service role; exposing trainees to real acute clinical problems with appropriate mid-level and senior support for their decision making (Clinical directors)

38. Consultant commitments while on-take

39. Consultant commitments while on-take Priority to emergency admissions • Improves continuity of care • Improves decision making • Better supervision of trainees The interface of Accident and Emergency and Acute Medicine, RCP 2002 Good Medical Practice, RCP 2004 The Emergency Department: Medicine and Surgery Interface Problems and Solutions, RCS 2004 Good Surgical Practice, RCS 2005

40. Consultant commitments while on-take

41. Consultant commitments while on-take

42. Consultant commitments while on-take

43. Consultant commitments while on-take Key findings • 68.8% (943/1370) of patients were under the care of consultants who had more than one duty when on-take. These may be consistent with their on-take activity but even so 21.2% (298/1370) of consultants were undertaking more than three duties • Some consultants undertake non-emergency clinical care while on-take and this may have delayed their response to the management of emergency admissions

44. Consultant commitments while on-take Recommendation Consultants’ job plans need to be arranged so that, when on-take, they are available to deal with emergency admissions without undue delay. Limiting the number of duties that consultants undertake when on-take should be a priority for acute trusts (Medical directors)

45. Necessity for admission

46. Necessity for admission • 75/1275 (5.9%) unnecessary admissions • No difference in time of arrival • No difference in grade of initial reviewer • Social admissions • Untreatable terminal conditions

47. Necessity for admission Key findings • 5.9% of emergency admissions considered unnecessary • Most of these admissions were for people who could have been cared for in the community

48. Necessity for admission Recommendation Appropriate mechanisms, both in terms of community medicine and palliative care, should be in place so that unnecessary admissions can be avoided (Primary care trusts and strategic health authorities)

49. Availability of investigations and notes

50. Availability of investigations in the first 24 hours • Access to basic investigations and timely return of results essential • Comprehensive investigation should be available for all emergencies • Delayed discharges can be avoided