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.

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.

Applying a COVID Virtual Ward model, assessing patient outcomes and staff workload.

A COVID virtual ward (CVW) is recommended by NHS England, but 'usual care' outcomes have not been reported. A retrospective study of all adults with COVID-19 attending Queen Elizabeth Hospital Birmingham between 01/06/2020-31/01/2021, assessed against CVW criteria and followed for 28 days. Of 2301 COVID-19 patients, 571(25%) would have met CVW criteria. Of these, 325(57%) were discharged after review and 246(43%) admitted. Of admitted patients who met CVW criteria, 81% required hospital-supported therapies; 11% died. Of the 325 discharged, 13% re-presented, 9% with COVID-related symptoms, 2% required intensive care admission, and one died (0.3%). In this comparison, discharging patients without a CVW did not lead to more re-presentations, re-admissions, ITU escalations or deaths compared to published outcomes for hospitals with a CVW.

The changing characteristics of COVID-19 presentations. A regional comparison of SARS-CoV-2 hospitalised patients during the first and second wave.

BACKGROUND: This study assesses COVID-19 hospitalised patient demography and outcomes during wave 1 and wave 2, prior to new variants of the virus. METHODS: All patients with a positive SARS-CoV-2 swab between 10th March 2020 and 5th July 2020 (wave 1) and 1st September 2020 and 16th November 2020 (wave 2) admitted to University Hospitals Birmingham NHS Foundation Trust were included (n=4856), followed for 28 days. RESULTS: Wave 2 patients were younger, more ethnically diverse, had less co-morbidities and disease presentation was milder on presentation. After matching for these factors, mortality was reduced, but without differences in intensive care admissions. CONCLUSION: Prior to new SARS-CoV-2 variants, outcomes for hospitalised patients with COVID-19 were improving but with similar intensive care needs.

Acute, non-COVID related medical admissions during the first wave of COVID-19: A retrospective comparison of changing patterns of disease.

COVID-19 may have altered the case-mix of non-COVID acute medical admissions. Retrospective analysis of acute medical admissions to University Hospitals Birmingham NHS Foundation Trust, showed that medical admissions decreased in April 2020 compared to April 2019. The proportion of young adults, non-cardiac chest pain, musculoskeletal conditions and self-discharges decreased. The proportion of admissions due to alcohol misuse, psychiatric conditions, overdoses and falls increased. There were a higher number of patients admitted to ICU and greater inpatient mortality but not once COVID diagnoses were excluded. There was a significant change in hospitalised case-mix with conditions potentially reflecting social isolation increasing and diagnoses which rarely require hospital treatment, reducing. This analysis will help inform service planning.

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.

Facilitated early ileostomy closure after rectal cancer surgery: a case-matched study.

BACKGROUND: The aim of this study was to evaluate the outcomes of an early stoma closure protocol facilitated by Seprafilm wrapping of defunctioning ileostomies compared with a similar group of patients with conventional stoma formation and closure. METHODS: Consecutive patients undergoing defunctioning ileostomy following rectal resection with pelvic anastomosis were planned for early closure and had their ileostomy wrapped in Seprafilm at the time of formation. Stoma closure was performed at 4-6 weeks if water-soluble contrast enema showed no evidence of leak, and the patient's physiological parameters had been optimized. Patients were matched for age, gender, American Society of Anaesthesiologists score, neoadjuvant treatment and procedure, with patients undergoing conventional ileostomy formation and closure. Outcomes were compared using the 2-tailed Mann-Whitney U test and Fisher's exact test. RESULTS: Following resection, twenty-two patients (69 %) were suitable for early closure and underwent stoma closure at a median of 37 days (range 25-90 days). Seprafilm-wrapped ileostomies were closed earlier than the conventional ileostomies (median 55 days (range 25-250 days) versus 213 days (range 86-352 days), p < 0.001). There was no difference between the groups as regards length of hospital stay or complications following ileostomy closure. Eighteen Seprafilm stoma patients and 22 conventional stoma patients received adjuvant chemotherapy. Median time to starting chemotherapy from resection was 10 versus 8.5 weeks, respectively (p = 0.36). CONCLUSIONS: An early stoma closure protocol facilitated by Seprafilm wrapping of the ileostomy is practical, does not increase morbidity and significantly reduces the time with a stoma for the patient. An early stoma closure protocol did not significantly delay in the commencement of chemotherapy.