NCEPOD Report Caring to the end?

Issues for physicians Prof IT Gilmore PRCP

Coping with general medical take – what’s the problem?

• ‘proper’ physicians have always taken part in emergency medical admissions • it has gone hand in hand with access to beds / junior staff / standing in the hospital

So what has changed?

 Volumes of medical admissions  Range of skills / interventions possible   Experience of junior staff Expectations of ‘consultant-delivered service  Patient expectations  Tensions with specialty commitments  EWTD

3 2 1 0 -1 -2

Total admissions per head: annual % change 1989-1998

0-14 15-64 65+

age (years)

Strengthening the medical ‘take’

medical assessment units medical admission units

Acute Medicine Units

Aims: • Seeing and managing acutely sick patients promptly • Encouraging specialty triage • Identifying appropriate patients for alternatives to secondary care • Discharge of appropriate patients

RCP ACUTE MEDICINE TASK FORCE REPORT – OCTOBER 2007

‘The right person, in the right setting – first time’

 The primary aim is urgent patient access to acute medical care when required.

 A patient should get direct and prompt access to a competently trained acute clinician (this includes non-medical professionals)  Access should be obtained without going through any unnecessary steps in the process  It will require the development of effective and responsive systems of care

NCEPOD: In 25% (407/1635) of cases there was, in the view of the advisors, a clinically important delay in the first review by a consultant.

• • The RCP report recommended: Patients with acute medical illness should get access as soon as possible to a competent clinical decision-maker at the front-line of acute medical services; There should be twice-daily consultant led review of patients – 7 days a week

Acute medical admisssions audit standards

 Patients should be seen by a consultant 2 times daily 7 days per week (RCP)  Consultants should have job plans adjusted to allow for 2 times daily wards rounds when on for acute medicine (RCP)  Consultants should be relieved of other commitments to allow twice daily wards rounds (NCEPOD).

NCEPOD: Poor communication was a significant factor in the NCEPOD report

Teamwork is essential for patient safety and continuity of care. Physicians and the multidisciplinary team should not work in isolation.

The RCP report recommended clearly defined contact pathways for named senior clinical opinions should be on a rota for all specialties likely to require regular interaction.

NCEPOD: Poor communication was a significant factor in the NCEPOD report

• • Standardised records and management protocols would facilitate better communication The RCP report recommended: documentation should be standardised across the NHS in three areas; the development of evidence-based national guidance for the clinical management of common acute medical illnesses. This would improve patient care and provide a more effective basis for training and audit.

Standardised medical records

Health Informatics Unit at the RCP has developed:  Standardised admissions clerking  Standardised handover record  Standardised discharge record Approved by Academy of Medical Royal Colleges Approved in principle by NPfIT

NCEPOD: There were instances of poor decision making and lack of senior input, particularly in the evenings and night time.

• • Acute care networks require strong clinical leadership.

The RCP report recommended: Leaders of the interface services should meet on a regular basis to facilitate planning and development of the acute service; The AMU clinical team should be consultant led

NCEPOD: Access to CT scanning and MRI scanning is a substantial problem with many sites having no or limited (less than 24 hours) on site provision.

The RCP report recommended that the AMU should have scheduled seven day access to diagnostic and treatment procedures such as diagnostic GI endoscopy, echocardiography, diagnostic ultrasound, bronchoscopy and CT and MR imaging – with easy and convenient access for larger AMUs in large acute hospitals, and available to smaller AMUs via clearly defined pathways within the local emergency care networks.

NCEPOD: End of life care – some issues

    In 1 of 6 of patients who were expected to die, no evidence of discussion with patients/relatives on treatment limitation Lack of use of pathways, such as LCP Need for more training for non-palliative care doctors in recognising where end of life pathway is appropriate Need for better access to palliative care specialists, including increase in numbers of specialists

RCP ACUTE MEDICINE TASK FORCE The wishes of the patient regarding the intensity of intervention and site for end-of-life care should be clearly documented and respected.

In acute hospital settings for patients with life threatening acute illnesses, discussions and decisions about end-of-life care are essential and should be documented in the clinical management plan.

The RCP report recommend that end-of-life care plans should become an important part of clinical assessment and ongoing review of patients with terminal illness.

National Care of the Dying Audit 2008/9     Recognised by DH and profession as way of ensuring good quality care in dying Increase in hospitals participating in audit from 118 to 155 in 2009 In last 24 hours of life, vast majority of patients reported to be comfortable Communication with patients and relatives about care plan and that the patient has entered the dying phase recorded in three quarters of cases, but room for improvement

NCEPOD: End of life care – some issues

 Real challenges in identifying terminal illness in short time-frame  Being expected to die is not the same as appropriate to die  Reaching consensus with patient or (more usually) family takes time  We need urgent further work with care homes, coroners etc to minimise unnecessary admission at the end of life

NCEPOD: other key issues

 How do we improve consultant involvement out-of-hours in the context of:  Calls for ‘Productivity’ in other areas  Threats to consultant expansion in a financial downturn?

 How do we improve the standard of handover when:  Doctors are having to do more in less hours  Rota gaps ++?