Acute Medicine E-Book
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- Kategorie: Fachliteratur
- Serie: Lecture Notes
- Sprache: Englisch
Lecture Notes discusses the principles of the initial assessment, investigation, diagnosis, and management of adult patients with everyday Acute Internal Medicine (AIM) presentations and conditions. This textbook is wide in scope and covers topics ranging from initial identification of acute medical illness, through to effective discharge planning.
Lecture Notes contains the latest developments on the generic professional and specialty specific capabilities needed to manage patients presenting with a wide range of medical symptoms and conditions covered in the UK AIM curriculum (2022).
In Lecture Notes, readers can expect to find detailed information on:
- Generic skills relevant to AIM, such as clinical reasoning, safe prescribing, point of care ultrasound (POCUS), resuscitation, and managing the acute medical take
- AIM across the various acute care settings – home (telemedicine, virtual wards, Hospital at Home), ambulatory (same day emergency care), and in-hospital (acute medical unit, enhanced care, critical care)
- AIM presentations and conditions in special populations such as older people, pregnancy, people with HIV, LGBTQ+, inclusion medicine, people with learning disabilities, perioperative medicine, people with mental illness and more
- Common presentations in AIM
- Standalone chapters can be read in any sequence, making the text perfect for quick reference
With its accessible coverage of a wide range of AIM content, Lecture Notes: Acute Medicine is an essential resource for medical students, physician trainees, consultants, and other members of the multidisciplinary team working in acute care, patient-facing settings.
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
Preface
Contributors
Section One: General Aspects of Acute Medicine
1 Introduction to Acute Medicine
Introduction
Where is acute medical care administered?
Scope of Acute Medicine care – what are the common presentations or conditions?
Challenges in Acute Medicine
Opportunities in Acute Medicine
Training in Acute Medicine
2 Clinical reasoning in Acute Medicine
Introduction
Clinical reasoning overview
Gathering data
Effective problem representation
Illness scripts
Decision making
Diagnostic error
Clinical reasoning in the acutely unwell patient
3 Generic capabilities relevant to Acute Medicine
Introduction
Entrustable professional activities
Generic capabilities in practice
NHS organisational and management systems
Ethical and legal issues related to clinical practice
Communication and professionalism
Patient safety and quality improvement
Carrying out research and managing data appropriately
Acting as a clinical teacher and clinical supervisor
4 Safe prescribing in Acute Medicine
Introduction
Rational prescribing
Medication safety
Adverse drug reactions
Medication errors
Acute Medicine best practice approach to safe prescribing
5 The acutely unwell patient
Introduction
Recognition of medical emergencies
Immediate assessment of the deteriorating patient
The C‐ABCDE approach
Definitive diagnosis and treatment
Assessment and reassessment
6 Resuscitation
Introduction
Peri‐arrest
Cardiac arrest
Basic Life Support (BLS)
Advanced Life Support (ALS)
Identifying reversible causes
Specific causes
Post resuscitation care
Deciding when to stop CPR
7 Enhanced and critical care Acute Medicine
Introduction
What is enhanced care?
Admission to critical care
Enhanced and critical care relevant to Acute Medicine
Example of enhanced and critical care management – sepsis
Example of enhanced and critical care management – COVID‐19
Example of enhanced and critical care management – hypertensive crises
8 Acute Medicine in the ambulatory care setting
Introduction
Principles of SDEC services
Benefits of SDEC
Selection of patients for SDEC
9 Acute Medicine in the home
Introduction
Referral pathways into H@H services
Presenting syndromes and acute medical conditions treated by H@H
Processes of care in the H@H service and acute hospital
Multidisciplinary working in H@H
H@H and communication with primary care
10 Effective discharge planning
Introduction
Reducing length of stay
Avoidance of Acute Medicine admission
Effective discharge planning
Acute Medicine best practice approach to effective discharge planning
11 Point‐of‐care ultrasound in Acute Medicine
Introduction
Basic ultrasound physics
Ultrasound artifacts
Basics of the ultrasound unit and knobology
Getting ready to perform POCUS
Thoracic ultrasound
Focused abdominal ultrasound
Focused renal ultrasound
Deep vein thrombosis ultrasound
Use of POCUS for guidance in performing procedures
12 Putting it all together – managing the acute medical take
Introduction
Managing the acute medical take
Sleep and night working
Clinical decision making and the acute medical take
Handover
The role of debriefing
Section Two: Acute Medicine in special populations
13 Older persons
Introduction
Evolution of geriatric medicine
Frail older people
Assessment of the frail older person
Acute Medicine best practice approach to older persons
14 Perioperative medicine
Introduction
The role of the physician in surgery
The decision to operate – shared decision making
Improving surgical outcomes
Specific perioperative issues
Analgesia
15 The obstetric woman in the acute setting
Introduction
Physiological changes in pregnancy
Radiological investigations in pregnancy
Breathlessness in pregnancy
Chest pain
Palpitations
Nausea and vomiting in pregnancy and hyperemesis gravidarum
Headache
Collapse
Sepsis
Cardiac disease
Hypertension, pre‐eclampsia and eclampsia
Venous thromboembolism in pregnancy
Abnormal liver function tests in pregnancy
Metabolic emergencies
Mental health crises in pregnancy and postpartum
Drugs commonly prescribed in pregnancy
Maternal resuscitation
16 Adolescents and young adults
Introduction
How do AYAs present to Acute Medicine?
Challenges of managing AYAs in Acute Medicine
Acute Medicine best practice approach to AYAs
17 People with learning disabilities
Introduction
How does a learning disability affect everyday life?
What are the indicators of a possible learning disability?
What are the health needs of people with a learning disability?
What is the role of a carer in an acute hospital?
Acute Medicine best practice approach to patients with learning disabilities
18 Inclusion health
Introduction
Inclusion health
Homelessness
Migration‐related concerns
Contact with criminal justice system
Sex workers
Gypsies and other Travellers
Acute Medicine best practice approach to inclusion health patients
19 Lesbian, gay, bisexual, transgender, queer or questioning, and others (LGBTQ+)
Introduction
Definitions
What are the health needs of the LGBTQ+ community?
Acute Medicine best practice approach to LGTBQ+ people
20 People living with HIV
Introduction
HIV transmission
Course of infection
Opportunistic infections
Management of people living with HIV
Acute Medicine best practice approach to people with HIV
21 The poisoned patient
Introduction
Clinical toxicology
General toxicological definitions
Poisoning
General principles of poisoning management
Paracetamol overdose
22 Alcohol, drugs and substance abuse
Introduction
Alcohol
Other recreational drugs (excluding tobacco)
Special circumstances
Generic management of patient where toxins suspected but unproven
Malnutrition in those with drug or alcohol misuse
23 People with diabetes and other hormonal disorders
Introduction
Basic clinical endocrinology
Laboratory considerations
Hypothalamic‐pituitary disorders
Fluid and sodium balance
Thyroid disorders
Calcium and metabolic bone disorders
Adrenal disorders
Diabetes mellitus
Obesity
Inherited metabolic disorders
24 People with neurological disorders
Introduction
Basic neuroanatomy
Basic clinical neurology
Common cranial nerve disorders
Common neurological patterns
Common neurological problems – the Big Five
Other common neurological disorders
25 People with mental health issues
Introduction
Psychological impact of physical illness
Mood disorders
Self‐harm and suicidal thoughts
Psychological reactions to stress and trauma
Medically unexplained physical symptoms
Eating disorders
Severe mental illness
Personality and healthcare
Managing aggressive behaviour
Capacity and mental illness
Mental health services
26 Acute oncology
Introduction
Initial management of an acute oncology patient presentation
Oncological emergencies
Anticancer therapy complications
Cancer‐related complications
New cancer diagnosis
Late effects
Acute Medicine best practice approach to acute oncology
Section Three: Common presentations in Acute Medicine
27 Common presentations in Acute Medicine
Introduction
Abdominal pain
Acute back pain
Acute confusion/delirium
Acute kidney injury (AKI) and chronic kidney disease (CKD)
Blackout/collapse
Breathlessness
Chest pain
Cough
Diarrhoea
Dizziness
Falls
Fever
Fits/seizures
Haematemesis and melaena
Headache
Hyperglycaemia
Jaundice
Lethargy
Limb pain and swelling
Palliative and end‐of‐life care
Palpitations
Poisoning
Rash
Vomiting and nausea
Weakness and paralysis
Index
End User License Agreement
List of Tables
Chapter 1
Table 1.1 Common Acute Medicine presentations and conditions (not including ...
Chapter 2
Table 2.1 Effective problem representation
Table 2.2 Generating illness scripts – example for acute coronary syndrome (...
Chapter 3
Table 3.1 Generic capabilities in practice (CiPs)
Table 3.2 Evidence‐based medicine – the five steps
Chapter 4
Table 4.1 Drugs that are common causes of ADRs. Top four drug classes common...
Table 4.2 DoTS classification system for ADRs
Chapter 5
Table 5.1 UK National Early Warning Score (NEWS2)
Table 5.2 Situation, background, assessment, recommendation and readback (SB...
Chapter 6
Table 6.1 The ‘4Hs and 4Ts’
Chapter 7
Table 7.1 Updated levels of care, including enhanced care (level 1+, 1½ or 1...
Table 7.2 Routine bundle of daily care of critically ill patient – FASTHUGS ...
Table 7.3 Updated Sepsis‐3 definitions
Table 7.4 2021 Sepsis Six care bundle (incorporating Academy of Medical Roya...
Chapter 8
Table 8.1 Condition‐specific risk stratification tools to support patient st...
Chapter 10
Table 10.1 Criteria to Reside tool – maintaining good decision making in acu...
Table 10.2 Consistent implementation of the SAFER patient flow bundle on all...
Table 10.3 The board round checklist for use on all assessment and medical w...
Chapter 13
Table 13.1 The geriatric giants (5 Is) versus the geriatric 5 Ms. Both const...
Chapter 14
Table 14.1 Example of shared decision‐making considerations in a proposed ab...
Table 14.2 Suggested diabetic medication adjustments during the perioperativ...
Table 14.3 Time to withhold direct oral anticoagulation (DOAC) before surger...
Table 14.4 Diagnostic schema for potential causes of acute kidney injury
Table 14.5 Immunosuppression and immunomodulatory medication in perioperativ...
Chapter 15
Table 15.1 Physiological changes and normal findings in pregnancy
Table 15.2 Fetal and maternal radiation dose from common imaging procedures...
Table 15.3 Differential diagnosis and management of chest pain in pregnancy ...
Table 15.4 Tachyarrhythmias in pregnancy – management
Table 15.5 Symptoms and signs suggestive of hyperemesis gravidarum
Table 15.6 Management of nausea and vomiting in pregnancy
Table 15.7 Alarm features for headaches in pregnancy
Table 15.8 Differential diagnosis of headaches presenting during pregnancy
Chapter 18
Table 18.1 Causes of homelessness
Chapter 20
Table 20.1 Summary of key opportunistic infections
Chapter 21
Table 21.1 Antidotes or management strategy for common toxicants (see Table ...
Chapter 22
Table 22.1 Some common features of acute alcohol withdrawal
Table 22.2 Management strategy for common toxins
Table 22.3 Potential common toxidromes
Chapter 23
Table 23.1 Calculated plasma osmolality and effective osmolality
Table 23.2 Common clinical causes of symptomatic hyponatraemia in hospitalis...
Table 23.3 Symptoms and signs of hypothyroidism and hyperthyroidism
Table 23.4 Basic treatment of hypothyroidism and hyperthyroidism
Table 23.5 Clinical findings of adrenal insufficiency
Table 23.6 Complications related to diabetes
Chapter 25
Table 25.1 Risk factors that may inform risk assessment and management follo...
Table 25.2 Risk assessment of anorexia nervosa (summarised from the MARSIPAN...
Table 25.3 Environmental and individual risk factors for aggression
Table 25.4 Early warning signs of aggression
Chapter 26
Table 26.1 Illness scripts for the four most common UK cancers
Table 26.2 Red flags for MSCC – signs and symptoms
Chapter 27
Table 27.1 Basic abdominal imaging
Table 27.2 Stages of CKD
Table 27.3 Main categories of dizziness
Table 27.4 Basic FBC interpretation
List of Illustrations
Chapter 1
Figure 1.1 Changing landscape of Acute Medicine services. The circle in the ...
Chapter 2
Figure 2.1 Clinical reasoning overview.
Figure 2.2 First, rule out worst‐case scenarios (ROWS) for people presenting...
Figure 2.3 Examples of illness scripts relevant to conditions that can cause...
Figure 2.4 The interplay between System 1 and System 2 thinking in the diagn...
Figure 2.5 Clinical reasoning in the acutely unwell patient.
Chapter 3
Figure 3.1 Miller’s pyramid (extended). A new fifth level (‘trusted’) reflec...
Figure 3.2 Diversity matters.
Figure 3.3 The Calgary–Cambridge Guide.
Figure 3.4 An example to show how the generic Swiss cheese model can lead to...
Figure 3.5 Plan, Do, Study, Act (PDSA) cycles.
Figure 3.6 Evidence‐based medicine – the hierarchy of evidence.
Figure 3.7 SNAPPS: a six‐step learner‐centred approach to clinical education...
Chapter 4
Figure 4.1 Pharmacogenomic approach to prescribing.
Chapter 5
Figure 5.1 Responses to increasing hypovolaemia in bleeding.
Figure 5.2 Generic Massive Haemorrhage protocol highlighting the complex, ra...
Chapter 6
Figure 6.1 Resuscitation Council UK adult tachycardia guidelines 2021.
Figure 6.2 Resuscitation Council UK adult bradycardia guidelines 2021.
Figure 6.3 Resuscitation Council UK anaphylaxis guidelines 2021.
Figure 6.4 Resuscitation Council UK refractory anaphylaxis guidelines 2021.
Figure 6.5 Resuscitation UK Adult Basic Life Support guideline 2021.
Figure 6.6 Resuscitation UK adult in‐hospital resuscitation guideline 2021.
Figure 6.7 The chain of survival.
Figure 6.8 Resuscitation UK Adult Advanced Life Support guidelines 2021.
Figure 6.9 Ventricular fibrillation.
Figure 6.10 Ventricular tachycardia.
Figure 6.11 A normal capnograph trace such as of a spontaneously breathing p...
Figure 6.12 Resuscitation UK adult postresuscitation care guidelines 2021. S...
Chapter 11
Figure 11.1 Characteristics of sound waves. (a) Characteristics of high‐freq...
Figure 11.2 Acoustic shadowing artifact caused by a gallstone (G) and a rib ...
Figure 11.3 Posterior enhancement artifact (arrow) posterior to the bladder ...
Figure 11.4 Reverberation artifact (arrows) of the pleura (P), also known as...
Figure 11.5 Mirror image artifact. Mirror image of the liver (arrow) cephala...
Figure 11.6 Basic components of an ultrasound unit.
Figure 11.7 Features of an ultrasound probe. It is covered with a thin layer...
Figure 11.8 How an ultrasound unit produces an image.
Figure 11.9 Scanning planes. (a) Longitudinal view. (b) Transverse view. (c)...
Figure 11.10 Scanning modes. (a) B‐mode. (b) M‐mode. (c) Colour Doppler. (d)...
Figure 11.11 Adjusting the overall gain. Increasing gain (brightness) from l...
Figure 11.12 The surface anatomical landmarks for thoracic ultrasound. The b...
Figure 11.13 Thoracic ultrasound views. (a) Longitudinal view. (b) Coronal v...
Figure 11.14 Normal longitudinal views of thoracic ultrasound using (a) high...
Figure 11.15 Sonographic findings in normal lung. (a) Seashore sign – lung s...
Figure 11.16 Sonographic findings in a normal coronal view of the lung base....
Figure 11.17 Sonographic findings in pneumothorax. (a) Barcode sign: M‐mode ...
Figure 11.18 Sonographic findings in pleural effusion. (a) Simple pleural ef...
Figure 11.19 Sonographic findings in interstitial syndrome – multiple B‐line...
Figure 11.20 Sonographic findings in pneumonia. (a) Subpleural consolidation...
Figure 11.21 Approach to a patient presenting with dyspnoea using the Blue p...
Figure 11.22 Probe positions in abdominal ultrasound with corresponding norm...
Figure 11.23 Abdominal ultrasound with positive intraperitoneal fluid (*) in...
Figure 11.24 Simple ascites will appear as (a) anechoic fluid (arrow) while ...
Figure 11.25 Examples of structures that must be avoided during paracentesis...
Figure 11.26 Probe position for renal ultrasound. (a) Longitudinal view with...
Figure 11.27 Normal renal ultrasound. (a) Longitudinal view and (b) transver...
Figure 11.28 Hydronephrosis grading. (a) No hydronephrosis. (b) Mild hydrone...
Figure 11.29 Bladder volume measurement. (a) In transverse view, measure the...
Figure 11.30 Probe positions for DVT ultrasound of the left lower extremity....
Figure 11.31 The three‐point lower extremity DVT scan protocol relevant to t...
Figure 11.32 Sonographic findings of DVT. (a) Thrombus in the left common fe...
Figure 11.33 Sample clinical protocol for the use of DVT POCUS in patient as...
Chapter 13
Figure 13.1 The Realistic Medicine 7‐Steps approach to appropriate polypharm...
Figure 13.2 4AT tool.
Chapter 15
Figure 15.1 Obstetric cardiac arrest.
Chapter 18
Figure 18.1 Homeless Assessment Tool developed and used by Gloucestershire H...
Chapter 21
Figure 21.1 (a) Metabolism of paracetamol (acetaminophen) under normal circu...
Chapter 22
Figure 22.1 ‘Whippits’ discovered by the side of a road.
Figure 22.2 Amyl nitrates may come in brightly coloured packaging and be adv...
Figure 22.3 A 31‐year‐old man was admitted with a one‐day history of dull in...
Chapter 23
Figure 23.1 MRI pituitary coronal view showing large macroadenoma (non‐funct...
Figure 23.2 The regulation of plasma osmolality – antidiuretic hormone is al...
Figure 23.3 Schematic diagram of brain volume adaptation to hyponatraemia. U...
Figure 23.4 Clinical approach to investigation of causes of hypocalcaemia. 2...
Figure 23.5 Clinical features in primary adrenal insufficiency. (a) Hyperpig...
Figure 23.6 Pathophysiology of hyperglycaemia and its complications in hospi...
Figure 23.7 Matching T2DM pathophysiology with pharmacological agents.
Figure 23.8 Early T2DM treatment pathways. If there are features of severe h...
Figure 23.9 Algorithm for acute management of hypoglycaemia.
Figure 23.10 High‐risk neuropathic foot demonstrating high‐arch, prominent m...
Figure 23.11 Diabetic foot infection with rapidly spreading soft tissue infe...
Figure 23.12 Role of lipotoxicity in obesity‐associated complications. Lipot...
Chapter 24
Figure 24.1 Motor pathways.
Figure 24.2 Sensory pathways.
Figure 24.3 Anatomy of the optic pathway and the field defects produced by l...
Figure 24.4 (a) Humphrey visual fields before and six months after transsphe...
Figure 24.5 (a) A CT scan showing a left cortical infarct. (b) The complete ...
Chapter 25
Figure 25.1 The psychological impact of physical illness depends on the inte...
Chapter 26
Figure 26.1 (a) Cross‐section of the liver showing numerous metastatic pale ...
Figure 26.2 Patterns of metastatic spread for the four most frequent cancers...
Figure 26.3 (a) Osteoblastic bone metastases in lower spine and pelvis. (b) ...
Chapter 27
Figure 27.1 (a) Severe aortic atherosclerosis with fissured plaque occluding...
Figure 27.2 Resuscitation Council UK Acute Coronary Syndrome guidelines 2021...
Figure 27.3 Resuscitation Council UK Adult Reperfusion Therapy STEMI guideli...
Figure 27.4 (a) Transoesophageal echo showing aortic dissection (arrow) and ...
Guide
Cover Page
Title Page
Copyright Page
Preface
Contributors
Table of Contents
Begin Reading
Index
Wiley End User License Agreement
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Acute Medicine:
Lecture Notes
Edited by Glenn Matfin MSc (Oxon), MB ChB, FRCPE
Former Chief of Medicine, University of California, San Francisco (UCSF) Fresno, USA; Valley Medical Foundation Endowed Chair in Medicine, UCSF Fresno, USA; Vice‐Chair of Medicine and Professor of Clinical Medicine, UCSF School of Medicine, San Francisco, USA
This edition first published 2023© 2023 John Wiley & Sons Ltd
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Library of Congress Cataloging‐in‐Publication Data applied forPaperback: 9781119672852
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Preface
Acute Medicine (or Acute Internal Medicine) is the specialty concerned with the initial assessment, investigation, diagnosis and management of adult patients with urgent medical needs. The challenge for Acute Medicine is to provide a range of high‐quality services to a heterogeneous group of patients across the acute care setting (e.g. ambulatory, inpatient, home). Acute Medicine was formally recognised as a specialty with defined training programmes in 2009.
Despite its relative youth as a specialty, most physician trainees now receive much of their training in the care of acutely unwell medical patients while working in the Acute Medicine service. Acute Medicine has been described as the powerhouse of undergraduate and postgraduate generalist training. Despite this recognition, most Acute Medicine textbooks are designed to be used either as an encyclopaedic resource or ‘cook‐book’ style approach. The aim of Lecture Notes: Acute Medicine is to outline the principles of Acute Medicine (i.e. who, what, when, where and why). Therefore, this brand‐new title in the renowned Lecture Notes series is relevant to medical students, physicians, mid‐level clinicians and other members of the multidisciplinary team involved in Acute Medicine provision.
The contents of the book are completely up to date and reflect the newly developed Acute Internal Medicine curriculum introduced in August 2022. The proposed curriculum changes aim to produce doctors with the generic professional and specialty‐specific capabilities needed to manage patients presenting with a wide range of medical symptoms and conditions. This book is divided into three sections. Section One covers general aspects of Acute Medicine care. Section Two focuses on special populations of patients presenting to Acute Medicine. Section Three focuses on common presentations in Acute Medicine.
I would like to acknowledge the tremendous effort and generosity of my co‐authors. I also owe special thanks to the reader. Your commitment to delivering excellent patient care, while maintaining (and even expanding) your knowledge using resources like this book, is to be applauded – it is not easy! Your feedback is always welcome.
Glenn Matfin, Editor
Contributors
Nadia AhmedConsultant HIV and Sexual Health Physician, Central and North West London NHS Foundation Trust, London, UK
Aya AkhrasClinical Research Fellow in Gastroenterology, Mayo Clinic, Rochester, USA
Anita BanerjeeObstetric Physician, Diabetes and Endocrinology and General Internal Medicine Consultant, Guy’s and St Thomas’ NHS Foundation Trust, London, UK; Honorary Reader in Obstetric Medicine, King’s College London, UK
Hani Ben AmerProfessor of Neurology, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
James BoltonConsultant in Liaison Psychiatry, Epsom and St Helier University Hospitals NHS Trust, Carshalton, UK
Rasha BuhumaidAssistant Professor of Emergency Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
Robert GrangeSenior Clinical Fellow in Perioperative Geriatric Medicine and Geriatric Trauma, North Bristol NHS Trust, Bristol, UK
Joshua GriffithsPhysician Associate in Perioperative Geriatric Medicine and Geriatric Trauma, North Bristol NHS Trust, Bristol, UK
Howell JonesAcademic Clinical Fellow and Specialist Registrar in Geriatric and General Internal Medicine, Royal Free Hospital, London, UK
Daniel LassersonProfessor of Acute Ambulatory Care, Warwick Medical School, Warwick, UK; Clinical Lead, Acute Hospital at Home, Department of Geratology/AGM, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
Glenn MatfinChief of Medicine, University of California, San Francisco (UCSF) Fresno; Professor of Clinical Medicine, UCSF, Fresno and San Francisco, USA
Robert MillerHonorary Consultant Physician, Central and North West London, Royal Free and UCL Hospitals, London, UK
Nick MurchConsultant Physician in Acute Medicine, Royal Free Hospital, London; Honorary Clinical Associate Professor, UCL Medical School, London, UK; President‐elect, Society for Acute Medicine, UK
Emma PagePhysician Associate in Emergency Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, UK; Lead Physician Associate Ambassador for London, Health Education England, UK
James PiperSenior Fellow in Emergency Medicine and Education, Sussex University Hospitals, Brighton, UK; Clinical Lecturer in Acute Medicine, UCL Medical School, London, UK
David ShipwayConsultant Physician and Perioperative Geriatrician, North Bristol NHS Trust, Bristol, UK; Honorary Senior Clinical Lecturer, University of Bristol, Bristol, UK
Siara TeelucksinghObstetric Medicine and Education Fellow, Registrar in Acute and General Internal Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
Section OneGeneral Aspects of Acute Medicine
1Introduction to Acute Medicine
Glenn Matfin and Nick Murch
KEY POINTS
Acute Medicine (or Acute Internal Medicine) is the specialty concerned with the initial assessment, investigation, diagnosis and management of adult patients with urgent medical needs.
There is a broad spectrum of clinical work within the specialty, including the immediate management of life‐threatening medical emergencies, the initial treatment (generally first 48–72 hours) of all presenting general medical ailments, and the provision of ambulatory care. More recently, acute medical care within the patient’s home via telemedicine, Hospital at Home service and ‘virtual wards’ has also been implemented.
The delivery of Acute and Internal Medicine care is dependent on the close working and interrelationship between members of the multidisciplinary team.
Most physician trainees now receive much of their training in the care of acutely unwell medical patients while working in the Acute Medicine service.
As Acute Medicine is an evolving specialty, and many acute medical services have a varied configuration and staffing model, the role of the Acute Medicine clinician varies across the UK.
Introduction
Acute Medicine (or Acute Internal Medicine) is the specialty concerned with the immediate and early specialist initial assessment, investigation, diagnosis and management of adult patients requiring urgent or emergency care for one or more of a wide range of medical conditions.
Acute Medicine evolved to provide patients suffering from a wide range of medical conditions who present to, or from within, hospitals requiring urgent or emergency management with the best quality care, in the right environment. These patients are often treated on distinct wards called acute medical units (AMUs) and patient care is generally led by consultant physicians, trained or with an interest in Acute Medicine. A patient admitted to the AMU will receive care that will include the necessary investigations and management required until the patient is discharged, transferred downstream to an internal medicine or specialty ward, or escalated to a higher level of care.
Acute Medicine and AMUs are relatively new innovations aimed at improving care given to patients with acute medical illness. Acute Internal Medicine was formally recognised as a specialty with defined training programmes in 2009, having previously been a subspecialty of General Medicine (now known as Internal Medicine) since 2003. The creation of Acute Medicine as a specialty has been a success in improving NHS urgent and emergency care provision.
Despite its relative youth, the specialty of Acute Medicine has good support and advocacy from clinical professional bodies, such as Royal Colleges and the Society of Acute Medicine (SAM). This organisation and specialisation mean that most physician trainees now receive much of their training in the care of acutely unwell medical patients while working in the Acute Medicine service.
There is a broad spectrum of clinical work within the specialty, including the immediate management of life‐threatening medical emergencies, the initial treatment (generally the first 48–72 hours) of all presenting general medical ailments, and the provision of ambulatory care. AMUs may be co‐located with the emergency department (ED) and same‐day emergency care (SDEC) areas. More recently, acute medical care within the patient’s home via telemedicine, Hospital at Home service and ‘virtual wards’ has also been implemented.
Given the variety of patient presentations to Acute Medicine services, medical specialty in‐reach or co‐location with cardiology, medicine for care of the older person, stroke medicine and respiratory medicine is common. Ready availability of advice and management pathways from the other medical specialties is also critical. Some of this workload is performed by Acute Medicine physicians with subspecialty expertise. As well as medical specialties, Acute Medicine services need to work closely with other disciplines, for example surgical specialties, obstetrics and gynaecology, and psychiatry. Access to higher level care is also important – Acute Medicine specialists work closely with colleagues in high‐dependency, intensive care and coronary care units. There has been a trend to having higher level of care provided on AMUs in enhanced care areas.
It is imperative to explore ways of incentivising doctors to work in the most challenging and in‐demand areas of medicine, such as Acute Medicine. The rapid growth of hospitalists in the USA is a good example of attracting clinicians to an area of unmet clinical need. Bob Wachter (Chair, Department of Medicine, University of California, San Francisco) coined the term ‘hospitalist’ in 1996, more than 25 years ago. In naming a physician whose practice is dedicated to caring for a patient during the entirety of their hospital stay, he and his esteemed colleague (Lee Goldman) started a new movement. Hospitalists usually care for all medical inpatients and, in some organisations, every single inpatient, 24 hours a day, seven days a week. Hospitalists now number more than 50 000 in the USA and are more numerous than any subspecialty of Internal Medicine (the largest of which is cardiology with 22 000 physicians).
Hospital Medicine and Acute Medicine share a lot in common, both having core expertise in managing the clinical problems of acutely ill, hospitalised patients. However, the key lesson for the continued growth of Acute Medicine lies not in hospitalism as a suggested model of care, but in the process of how it became so successful – right leadership, financial impetus, workforce capacity and buy‐in from other hospital specialties (e.g. offering co‐management service, especially perioperative care).
As Acute Medicine is an evolving specialty, and many acute medical services have a varied configuration and staffing model, the role of the Acute Medicine clinician varies across the UK. However, it is critical that there is a multiprofessional approach to providing all the relevant knowledge and skills that the acutely ill medical patient may require.
The roles of the Acute Medicine physician include the following.
Stabilise acutely ill patients, and then either discharge or transfer these individuals, when stable and if required, to the most appropriate acute care setting for their needs.
Minimise length of stay by delivering safe and effective care for short‐stay patients.
Fully differentiate the presenting complaint or problem.
Risk‐stratify the cause of admission (i.e. ‘assess to admit’) to determine the best place for ongoing care and management (e.g. ambulatory, inpatient, home).
Improve hospital patient flow, including reducing ED overcrowding.
Provide leadership and guidance for the medical acute take.
In the UK, there is a shift from the terms General Medicine or General Internal Medicine to the more commonly used international term of Internal Medicine. Internal Medicine is the specialty that encompasses the care, investigation, diagnosis and management of all medical needs, including acute medical problems, of both inpatients and outpatients.
Where is acute medical care administered?
The challenge for Acute Medicine is to provide a range of high‐quality services to a heterogeneous group of patients across the acute care setting. In time‐sensitive conditions where early intervention is paramount – such as sepsis, diabetic ketoacidosis and acute kidney injury – Acute Medicine clinicians can make a real difference to outcomes for patients.
In addition to the assessment and admission of adult patients, Acute Medicine clinicians also have an important role in developing services to enable the safe delivery of care in ambulatory and home settings (Figure 1.1). Many patients previously admitted to hospital for investigation or treatment of conditions such as deep vein thrombosis, pulmonary embolism and cellulitis can now be treated safely as outpatients with the help of Acute Medicine‐led SDEC services and follow‐up clinics. Rapid‐access (‘hot’) medical clinics also allow unwell patients access to specialist clinicians and rapid diagnostics without admission to hospital. Acute medical care within the patient’s home via telemedicine, Hospital at Home service and ‘virtual wards’ is rapidly evolving.
Figure 1.1 Changing landscape of Acute Medicine services. The circle in the middle of the figure represents the patient – who should be at the centre of all we do (i.e. person‐centred care). The solid blue arrows represent the different directions of travel of possible patient journeys throughout the acute medical care setting. The solid orange boxes represent the major bases for the Acute Medicine team. On the left side of the figure, the patient can be managed by the Acute Medicine team at home, either in person by the Hospital at Home team or digitally via the virtual ward or telemedicine. On the right side, patients traditionally entered the hospital ‘front door’ – the point of arrival/entry to hospital – via the emergency department (ED). However, this leads to ED crowding. Front‐door reconfiguration measures to reduce ED crowding and hospital admission include patients attending ambulatory care, such as acute clinics (e.g. rapid‐access ‘hot’ specialty clinics) or same‐day emergency care (SDEC). Alternatively, patients can be admitted directly to the acute medical unit (AMU) or short‐stay ward (SSW). Acute medical patients needing more enhanced care can be managed in the Acute Medicine enhanced care unit (ECU) or transferred to critical care – high‐dependency unit (HDU)/intensive care unit (ICU), coronary care unit (CCU) or stroke unit. The Acute Medicine service also offers specialty in‐reach to ED and out‐reach to the non‐medical wards. The hospital ‘back door’ is depicted smaller than the front door in the illustration, which represents the functional reality that it is more challenging to discharge patients back home or into the community. This ‘exit block’ leads to overall hospital crowding (patient flow ‘gridlocked’) and unnecessarily increases length of stay.
Acute care hub
The Royal College of Physicians (RCP) Future Hospital Commission describes the hospital footprint of acute medical services across five areas, termed the ‘acute care hub’ (see Figure 1.1).
AMU
Short‐stay ward (SSW)
Ambulatory emergency care (AEC)/SDEC
Emergency department
Enhanced care/Critical care
Acute Medicine in the in‐hospital setting
AMUs ‐ defined by the RCP as ‘a dedicated facility within a hospital that acts as the focus for acute medical care for patients who have presented as medical emergencies to hospital’. AMUs, as a base for the practice of Acute Medicine, have become integral to the care pathway of most patients who require hospital‐based acute medical care in the UK. AMUs provide the initial treatment (generally first 48–72 hours) of all presenting Internal Medicine ailments. Those patients requiring longer hospital stays beyond 72 hours should be transferred to Internal Medicine or specialist medicine beds.
SSW – bed base providing targeted care for patients requiring brief hospitalisation (estimated date of discharge of less than 72 hours) and dischargeable as soon as clinical conditions are resolved. Short‐stay beds are based within the AMU or co‐located with AMU in a separate ward‐based environment.
Frailty service – in‐reach or embedded within AMU/SSW/SDEC and typically led by a geriatrician. This service may also provide emergency perioperative medical care (e.g. frail patient with fractured neck of femur).
Enhanced care beds – enhanced care takes place in a ward setting (usually AMU) but provides ready access to the critical care team through established communication links. It is a pragmatic approach to reducing the risk of patients falling into a service gap: patients who would benefit from higher levels of monitoring or interventions than expected on a routine ward, but who do not require admission to critical care.
Specialist out‐reach – Acute Medicine outreach provides urgent and emergency acute care for the hospital, in collaboration with the critical care team. This can be as part of a
medical emergency team
.
Acute Medicine in‐reach to ED.
Review acutely unwell medical patients waiting for a bed in AMU or SSW.
Work collaboratively with the ED team to identify patients who attend ED and can be: 1. sent to AEC (SDEC); 2. referred to a rapid‐access clinic or telemedicine; 3. referred to Hospital at Home or virtual ward service; 4. discharged back to the care of their GP; and 5. discharged home.
Acute Medicine in the ambulatory setting
AEC/SDEC – AEC provides patients with the traditional aspects of acute medical care but avoids hospital admission.
The RCP defines AEC as ‘clinical care which may include diagnosis, observation, treatment and rehabilitation, not provided within the traditional hospital bed base or within the traditional outpatient services, and that can be provided across the primary/secondary care interface’.
The underlying principle of AEC is to convert traditional inpatient care into same‐day emergency care.
Acute and Internal Medicine teams deliver SDEC in AEC units.
Acute care clinics – there are several types of acute care clinics.
Rapid‐access (‘hot’) clinics are for patients accessing specialty care and usually offer same‐day appointments. Can also be triaged or managed via telemedicine.
Early‐discharge clinics are for patients who do not need to remain in hospital but where early follow‐up is best served by their discharging team as opposed to their GP. These clinics may be part of the SDEC services.
Acute Medicine in the community
Interface Medicine: managing patients with undifferentiated illness who are at an interface between primary and secondary acute care.
Hospital at Home – innovative care model that provides hospital‐level care for acute conditions that would normally require an acute hospital bed, in a patient's home for a short episode through a multidisciplinary healthcare team.
Virtual wards – observe and manage patients in their home supported with technological innovations that will enable monitoring of a person’s vital signs and well‐being through phone calls or other virtual technology from a team of clinicians, as well as patient monitoring apps.
Telemedicine (remote) services.
Scope of Acute Medicine care – what are the common presentations or conditions?
The range of clinical problems encountered in Acute Medicine is very wide, which gives the work a great deal of variability. Examples of common Acute Medicine presentations and conditions are outlined in Table 1.1.
Table 1.1Common Acute Medicine presentations and conditions (not including COVID‐19)
Abdominal painAcute back painAcute confusion (delirium)Acute kidney injury (AKI)/chronic kidney disease (CKD)Blackout/collapseBreathlessnessChest painCoughDiarrhoeaDizzinessFallsFeverFits/seizureHaematemesis and melaenaHeadacheHyperglycaemiaJaundiceLethargyLimb pain and swellingNausea and vomitingPalliative and end‐of‐life carePalpitationsPoisoningRashWeakness and paralysis
Challenges in Acute Medicine
There is a crisis in acute medical care for multifarious reasons.
Medical emergencies are the most frequent cause of unplanned hospital admission, and place considerable demands on acute healthcare services (
Box 1.1
). In the Getting It Right First Time (GIRFT) Acute Medicine national report (2022), approximately 92% of the inpatients on medical wards had been admitted as an emergency, and most of these were admitted via the AMU. This has led to rising acute medical admissions with increased bed occupancy levels and hospital crowding. During times of increased pressure, such as the perennial winter period or waves of the recent COVID‐19 pandemic, increased unplanned admissions also negatively impact the delivery of elective services.
Increasing numbers of older, frailer patients with complex, high‐acuity illnesses. Frailty defines the group of older people who are at highest risk of adverse outcomes, such as falls, disability, admission to hospital or the need for long‐term care. Nearly two‐thirds of patients admitted to hospital are over 65 years old and around 25% of these patients have a diagnosis of dementia (with more than a third of people living in care homes having this diagnosis).
Box 1.1 NHS England and SAM (2022) ‘six to help fix’ areas to improve in‐hospital flow
Protect SDEC capacity and function.
Diagnostics should be provided on the basis of clinical need, but areas such as AMU, SDEC and ED must have the same level of access in terms of availability, priority and reporting times.
Ward rounds and handover. Twice‐daily review on the AMU, seven days per week. Internal medical/specialty wards – daily ward and board round on weekdays and board round with targeted patient reviews at weekends.
Workforce optimisation.
Access to Acute Medicine. Develop services to enable direct access, ensuring clinical conversations are used to direct patients to the most appropriate service/areas to meet their clinical needs.
Specialties and in‐reach. It must be recognised that medical patients who present as an emergency admission are the responsibility of
all relevant
specialties working within the hospital.
Multimorbidity. One in three patients admitted now has five or more health conditions compared to one in 10 a decade ago.
Systemic failures of care, with lack of candour when things go wrong.
Poor patient experience.
Existence of racial, social and healthcare disparities.
People who live in areas of higher than average deprivation are more likely to be admitted to hospital and to spend longer in hospital. This is independent of social class, educational level and behavioural factors.
Alcohol and substance abuse. The UK continues to have high numbers of alcohol‐ and drug‐related deaths, as well as associated morbidity. In addition, the COVID‐19 pandemic has had a detrimental impact. For example, alcohol consumption has shifted more towards at‐home, late‐night drinking – and frequently alone. Drug decriminalisation, drugs consumption rooms, managing risky drug use behaviour and addressing the social determinants such as deprivation are all on‐going debates and challenges.
Unwarranted clinical variation – defined as ‘variation that cannot be explained by the condition or the preference of the patient; it is variation that can only be explained by differences in health system performance’. Unwarranted clinical variation in NHS practice has long been accepted as a barrier to quality care.
Healthcare workforce crisis. Healthcare is experiencing a global workforce crisis, with the World Health Organization projecting that an additional 40 million health workers will be needed by 2030. Approximately 13% of the total UK workforce is employed in the health and care sector. However, NHS currently has
130 000
vacancies. For example, 52% of advertised consultant posts were unfilled in 2021, with three quarters of these remaining unfilled due to having no applicants.
Poor workforce planning has resulted in inadequate numbers of medical, nursing and other healthcare professionals.
In addition, the current healthcare workforce is suffering from growing pressures with increased risk of burnout leading to physical and emotional exhaustion and drop in productivity. Working in depleted teams, facing daunting backlogs in patient care, and treating people with more advanced disease have become commonplace.
Workforce safety has also been a growing concern. In the context of COVID‐19, persistent abuse and violence towards NHS doctors by patients and public compound the emotional toll on staff, damages morale and threatens patient safety.
All these factors have led to a potential mass exodus – ‘
the great resignation
’.
Social and primary care crisis.
Medical trainees are also under increased pressure and there is evidence that they do not get the mentorship or training that they deserve because of increasing demands on senior staff and the impact of the COVID‐19 pandemic.
Constant reconfiguration in health and social care delivery and legislation.
Ever increasing costs of health and social care in a time of austerity and/or financial instability. Lack of modernisation of the NHS estate, rising energy costs, and cost‐of‐living challenges all impact negatively on healthcare provision.
Overcomplex, slow, non‐integrated digital health systems (e.g. electronic health records and electronic prescribing).
The climate emergency is a health crisis. Climate change has worldwide effects on health, including Acute Medicine provision: heat waves (defined as ≥2 days of unusually hot weather) are increasing in frequency and intensity and can lead to heat‐related illness; hypothermia (energy insecurity and fuel poverty); extreme weather events (e.g. floods); poor air quality and pollution (e.g. asthma); food insecurity (e.g. malnutrition and obesity); water insecurity and safety; vector distribution and ecology (e.g. mosquitoes, ticks); and social factors (e.g. increased risk of displacement).
Impact of COVID‐19 on health and social care
COVID‐19 has highlighted major issues in the capacity and resilience of the health and care system. Urgent and emergency care services remain under huge pressure with concerns regarding overcrowding, delays in patient care, exhausted staff with a worrying picture of rising burnout and unsustainable workloads exacerbated by the COVID‐19 pandemic (e.g. staff sickness, isolation and long‐COVID). Staff remaining in work suffer ‘left behind syndrome’, where pressure to do more with less is even greater. Sustained moral distress (i.e. ‘the psychological unease generated where professionals identify an ethically correct action to take but are constrained in their ability to take that action’) leading to moral injury and impaired function or longer term psychological harm have also been common during the COVID‐19 pandemic.
Opportunities in Acute Medicine
Academy of Medical Royal Colleges ‘Fixing the NHS’ report (2022) highlighted some of the key healthcare delivery challenges and solutions: Expanding workforce numbers; Improving patient access to care across all settings; Reforming social care; Embracing new ways of working; Grasping the digital agenda; Valuing our staff; Modernising the NHS estate; Revitalising primary care; Greater focus on prevention and tackling health disparities; Making better use of resources and ensuring there is adequate investment.
A new model of care for hospitals of the future has been proposed. The first principle is that of putting patients first (i.e. patient‐centred). Patients should be treated with compassion and dignity. They should be involved in decisions on their condition and treatment (i.e. shared decision making), considering social and cultural norms, especially for multiethnic populations (i.e. cultural distinction).
There should be a medical division led by a chief of medicine (like the current practice in the USA) as the senior doctor responsible for making sure working practices facilitate collaborative, patient‐centred working and that teams work together toward common goals and in the best interest of patients. Therefore, effective leadership is essential.
Patient safety is critical and having an open culture of providing safe care can help. Having real‐time ‘root cause analysis’ (‘huddle’) when things do go wrong is desirable to prevent further occurrences. A duty of candour when problems arise is needed. Seven‐day care is important too and there should be cover 24 hours a day, seven days a week; this should be across the multidisciplinary team, with nurses, pharmacists, discharge teams and radiology services, for example, required seven days per week so not just clinicians working in isolation.
Patient care should cross the boundaries of primary, secondary, postacute and social care with care pathways designed for each of the morbidities that a patient experiences. In this regard, as in all, effective communication is key.
There are important consequences of this and one is that there need to be more doctors trained and engaged in generalist medicine (including Acute Internal Medicine and Internal Medicine). This does not mean that specialist care is less important or less prioritised. This will remain essential and, indeed, the degree of expertise available in the specialties is ever increasing. Postgraduate medical education in the UK (i.e. ‘Shape of Training’) is trying to redirect toward more patient‐focused, generalist training, and with more flexibility of career structure. It is also important to increase the number of medical and nursing students. Undergraduate medical education is also evolving, with greater focus on generalist training. Acute Medicine has been described as the powerhouse of undergraduate and postgraduate generalist training.
Healthcare workers are the cornerstone of health systems. Focusing on the ‘three Rs’ of the workforce – recruitment, retention and returners – is critical. In these challenging times, it is more important than ever to have working environments that are supportive, inclusive and safe. We need to:
improve staff well‐being by ensuring employers ‘get the basics right’, including providing facilities for rest (e.g. after night shifts), spaces to carry out non‐clinical work, and easily accessible hot food and drink so staff can keep refreshed during their shifts
ensure that job planning at all levels facilitates flexible training and working
facilitate improved work–life balance which can be enhanced by the sessional basis of Acute Medicine clinical work, which lends itself to less than full‐time working (improved rostering and use of shifts), and annualised job plans for consultants. It is important to incentivise senior doctors to continue working in our NHS.
The focus on retention must be matched by a commitment to sustainable recruitment. This includes both developing the next generation of UK‐trained talent and ethical international recruitment (more than a third of doctors registered in the UK gained their primary medical qualification overseas). Overseas doctors, who continue to be an essential part of the workforce mix, must be given the tools they need to thrive (such as the new NHS standardised induction programme). Diversity, equity and inclusion (DEI) and antiracism in healthcare are top priorities in all our work. Promoting innovative models of medical staffing including nurse practitioners, physician associates and other mid‐level clinicians is important.
Digital health encompasses the use of technologies such as telemedicine, smartphone apps, wearables and artificial intelligence to deliver healthcare. These digital solutions have rapidly evolved during the COVID‐19 pandemic and have the potential to improve patient outcomes and efficiency of care, which can further enhance safer patient care.
Health equity means that everybody should have the opportunity to lead the healthiest life possible. This requires removing obstacles to health such as poverty, discrimination and their consequences. Greater focus on prevention is also critical.
The world has changed due to COVID‐19. This will undoubtedly influence all aspects of health and social care delivery for the foreseeable future. An appropriate legacy would be for co‐operative working across hospital specialties to be retained. The additional skills obtained by many medical, nursing and allied health professionals need to be usefully retained, such as in enhanced care provision.
Realistic medicine
Realistic medicine recognises that a ‘one size fits all’ approach to health and social care is not the most effective path for the patient or the NHS.
Shared decision making.
Providing a personalised (individualised, patient‐centred) approach to care.
Reducing harmful and wasteful care caused by both overprovision and underprovision of care.
Reduce unwarranted clinical variation.
Managing risk better.
Become improvers and innovators.
Getting It Right First Time (GIRFT)
GIRFT is a national programme designed to improve medical care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies, such as the reduction of unnecessary procedures, and cost savings.
The GIRFT Acute Medicine national report (2022) had 19 recommendations aiming to help trusts across England standardise patient care, and to introduce measures to help care for an increasingly older population (Box 1.2).
Training in Acute Medicine
The range of clinical problems encountered in Acute Medicine is very wide, which enables trainees to become experts in diagnosis, investigation and management across multiple disciplines (see Table 1.1). The practice of Acute Medicine requires the generic and specialty knowledge, psychomotor skills and professional attitudes to manage patients presenting with a wide range of medical symptoms and conditions. It involves particular emphasis on diagnostic reasoning, managing uncertainty, dealing with co‐morbidities, and recognising when another specialty opinion or care is required. Doctors in training will learn in a variety of settings using a range of methods, including workplace‐based experiential learning, formal postgraduate teaching and simulation‐based education.
There is also significant overlap between Acute (Internal) Medicine and Internal Medicine training.
Internal Medicine stage 1 training (2019)
Internal Medicine stage 1 (IM stage 1) will form the first stage of specialty training for most doctors training in physicianly specialties. The purpose of the IM stage 1 curriculum is to produce doctors with the generic professional and clinical capabilities needed to manage patients presenting with a wide range of general medical symptoms and conditions. They will be entrusted to undertake the role of the medical registrar in NHS district general and teaching hospitals and qualified to apply for higher specialist training.
IM stage 1 will normally be a three‐year programme that will include mandatory training in geriatric medicine, intensive care, outpatients and ambulatory care. The scope of Internal Medicine requires diagnostic reasoning and the ability to manage uncertainty, deal with co‐morbidities and recognise when specialty opinion or care is required. There will be a critical progression point at the end of the second year (IMY2) to ensure trainees have the required capabilities and are entrusted to ‘step up’ to the medical registrar role in IMY3. For most, the trainee will be entrusted to manage the acute unselected medical take and manage the deteriorating patient with indirect supervision in IMY3.
At completion of IM stage 1, trainees will be required to meet all curriculum requirements, including passing the summative ‘high‐stakes’ assessment – Membership of the RCP diploma examination – by the time of completion.
Box 1.2 GIRFT Acute Medicine national report (2022) recommendations
Acute medical units (AMU)
Ensure the acute medical pathway is adequately resourced to manage the projected patient need in a safe, effective and efficient manner, 24/7.
Ensure there is seven‐day access to medical specialties and services for all patient needs.
Ensure that there is cross‐trust consistency in the use of acronyms when referring to acute and general medicine services (i.e. at least 30 different names are being used across England for the units that care for acute medical patients when they are first admitted to hospital: the AMU).
Ensure that the AMU is sited appropriately in relation to other parts of acute care hub.
Ensure the AMU is appropriately resourced in regard to time and space to train all healthcare staff in both acute patient care and the use of relevant equipment.
Ensure the AMU is resourced with the appropriate space and equipment to manage unstable medical patients (e.g. enhanced care unit interventions such as non‐invasive ventilation, use of vasopressors).
Ensure there are systems in place to track patients and ensure good communication between staff, including handover and referral.
