Guest Editorial - Bad NEWS: standing still is risky for patients admitted to hospital (even with normal vital signs).

Acute Physicians care for acutely unwell patients. Recognising and prioritising those at greatest risk of death is therefore at the heart of our specialty. The risk of catastrophic deterioration in the Acute Medical Unit is usually quantified through the measurement of vital signs. These are being summarised into the National Early Warning Score or similar instruments. Those with higher Early Warning Scores are usually prioritised by clinicians in and out of hospital and being seen before those with lower grades of abnormalities and preferably assessed by a more senior clinician.

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.

Co-design of interventions to improve acute care in hospital: A rapid review of the literature and application of the BASE methodology, a novel system for the design of patient centered service prototypes.

Co-design in acute care is challenged by the inability of unwell patients to participate in the process and the often transient nature of acute care. We undertook a rapid review of the literature on co-design, co-production and co-creation of solutions for acute care that were developed with patients. We found limited little evidence for co-design methods in acute care. We adapted a novel design driven method (BASE methodology) that creates stakeholder groups through epistemological criteria for the rapid development of interventions for acute care. We demonstrated feasibility of the methodology in two case studies: A mHealth application with checklists for patients undergoing treatment for cancer and a patient held record for self-clerking on admission to hospital.

Long-term trends in critical care admissions in Wales*.

As national populations age, demands on critical care services are expected to increase. In many healthcare settings, longitudinal trends indicate rising numbers and proportions of patients admitted to ICU who are older; elsewhere, including some parts of the UK, a decrease has raised concerns with regard to rationing according to age. Our aim was to investigate admission trends in Wales, where critical care capacity has not risen in the last decade. We used the Secure Anonymised Information Linkage Databank to identify and characterise critical care admissions in patients aged ≥ 18 years from 1 January 2008 to 31 December 2017. We categorised 85,629 ICU admissions as youngest (18-64 years), older (65-79 years) and oldest (≥ 80 years). The oldest group accounted for 15% of admissions, the older age group 39% and the youngest group 46%. Relative to the national population, the incidence of admission rates per 10,000 population in the oldest group decreased significantly over the study period from 91.5/10,000 in 2008 to 77.5/10,000 (a relative decrease of 15%), and among the older group from 89.2/10,000 in 2008 to 75.3/10,000 in 2017 (a relative decrease of 16%). We observed significant decreases in admissions with high comorbidity (modified Charlson comorbidity index); increases in the proportion of older patients admitted who were considered 'fit' rather than frail (electronic frailty index); and decreases in admissions with a medical diagnosis. In contrast to other healthcare settings, capacity constraints and surgical imperatives appear to have contributed to a relative exclusion of older patients presenting with acute medical illness.

Quality: What does it mean in Acute Medicine and how do we measure it?

Acute Medicine is a specialty that is not defined by a single organ system and sits at the interface between primary and secondary care. In order to document improvements in the quality of care delivered a system of metrics is required. A number of frameworks for measurements exist to quantify quality of care at the level of patients, teams and organisations, such as measures of population health, patient satisfaction and cost per patient. Measures can capture whether care is safe, effective, patient-centred, timely, efficient and equitable. Measurement in Acute Medicine is challenged by the often-transient nature of the contact between Acute Medicine clinicians and patients, the lack of diagnostic labels, a low degree of standardisation and difficulties in capturing the patient experience in the context. In a time of increasing ecological and financial constraints, reflecting about the most appropriate metrics to document the impact of Acute Medicine is required.

Who is allowed to read and write?

What makes us human? In 2015 Jeremy Vine asked this question to a selection of leading British thinkers and writers. The answers were as diverse as the people he interviewed. While you might have your own views about the complexity of being human I would suggest that being able to articulate thoughts and communicate them to others might be one of the characteristics that distinguishes us from other life forms. And if we think more about the achievements of human culture then being able to communicate thoughts in writing and reading other.

Reliability of frailty assessment in the critically ill: a multicentre prospective observational study.

Demand for critical care among older patients is increasing in many countries. Assessment of frailty may inform discussions and decision making, but acute illness and reliance on proxies for history-taking pose particular challenges in patients who are critically ill. Our aim was to investigate the inter-rater reliability of the Clinical Frailty Scale for assessing frailty in patients admitted to critical care. We conducted a prospective, multi-centre study comparing assessments of frailty by staff from medical, nursing and physiotherapy backgrounds. Each assessment was made independently by two assessors after review of clinical notes and interview with an individual who maintained close contact with the patient. Frailty was defined as a Clinical Frailty Scale rating > 4. We made 202 assessments in 101 patients (median (IQR [range]) age 69 (65-75 [60-80]) years, median (IQR [range]) Acute Physiology and Chronic Health Evaluation II score 19 (15-23 [7-33])). Fifty-two (51%) of the included patients were able to participate in the interview; 35 patients (35%) were considered frail. Linear weighted kappa was 0.74 (95%CI 0.67-0.80) indicating a good level of agreement between assessors. However, frailty rating differed by at least one category in 47 (47%) cases. Factors independently associated with higher frailty ratings were: female sex; higher Acute Physiology and Chronic Health Evaluation II score; higher category of pre-hospital dependence; and the assessor having a medical background. We identified a good level of agreement in frailty assessment using the Clinical Frailty Scale, supporting its use in clinical care, but identified factors independently associated with higher ratings which could indicate personal bias.

Death after Discharge - Every heart beat counts (probably)!

The assumption would be that patients who are discharged from an emergency or acute medicine department have been thoroughly assessed and are good to return to the safety of their own home. An unplanned death after discharge from hospital is the worst-case scenario for patients, families and indeed clinicians. In order to prevent adverse events after patients leave hospital most units have a multi-layered system to capture risk that includes triage, recording of vital signs, basic blood tests, understanding of existing past medical history and assessment by a senior clinician to add experience and intuition. Discharge decisions depend on a balanced review of all these parameters and a discussion with patients about residual risks. Only after this will patients go home. Despite this a small percentage of patients pass away unexpectedly within days after leaving hospital.

Using trends in electronic recordings of vital signs to identify patients stable for transfer from acute hospitals.

Patients who are stable might not be required to remain in hospital. We aimed to create objective criteria to indicate stability based on vital signs. An index based on NEWS (NBI) was compared to a Patient Stability Index (PSI) algorithm created by random forest analysis. Data from the VITAL II study was used to train the algorithm and data from the VITAL III study to validate it. Failure rate of the algorithms was set close to the rate of readmission to UK hospitals at 15%. After a training period of two days the NBI identified stability with acceptable failure rates only after a further 96 hours with a subsequent release of 2143 bed days compared to the PSI which identified stability after only 12 hours leading to potential earlier release of 2652 bed days. Vital sign-based algorithms might be able to predict safe transfer from hospital and inform management of flow.

Feasibility of measuring psychological resilience in hospitalized patients with acute illness: The Resilience After the Trauma of Acute Illness (RAFT) study.

Resilience is the 'ability to bounce back'. We want to investigate whether measurement of resilience during an acute hospital admission is feasible. We conducted a feasibility study. Resilience was measured using the Brief Resilience Scale. Results were contextualized by measuring chronic disease burden, anxiety, depression, coping strategies and personality traits. 56 or 103 patients approached took part in the study. A group of 12 patients undergoing pulmonary rehabilitation served as a control group. We found evidence of low resilience in 4/44 (9%) patients admitted as medical emergencies. Low resilience was statistically related to the Hospital Anxiety and Depression Scale and a number of coping strategies and personality traits. We found no relation between measures of resilience and previous admissions to hospital. The concept of resilience might be applicable to unscheduled admissions to hospital. Larger studies are required to establish whether low resilience is common and amenable to intervention. REC number 17/WA/0024.

Continuous Monitoring of Respiratory Rate on General Wards What might the implications be for Clinical Practice?

A high respiratory rate is a significant predictor of deterioration. The accuracy of measurements has been questioned. We performed a prospective observational study of automated electronic respiratory rate measurements and compared measurements with electronic counts obtained in the 10 minutes prior to the manual measurement. For 182 patients 1331 matching measurements could be compared. The mean age of these patients was 68 (SD 14) years. 96 (53%) of patients were female. While mean and median measurements were similar frequency distributions were significantly different. Manual measurements were markedly lower than electronic measurements in patients with higher respiratory rates. While electronic measurements are likely to be more reliable clinical implications require further investigation to clarify whether existing algorithms including Early Warning Scores will need adjustment.

Changes in vital signs post discharge as a potential target for intervention to avoid readmission.

Readmissions are treated as adverse events in many healthcare systems. Causes can be physiological deterioration or breakdown of social support systems. We investigated data from a European multi-centre study of readmissions for changes in vital signs between index admission and readmission. Data sets were graded according to the National Early Warning Score (NEWS). Of 487 patients in whom NEWS could be calculated on discharge and again on re-admission, 39.6% had worse vital signs with a NEWS score difference ≥ 2 points while only 7.6% had improved by ≤ 2 points. Changes in individual vital signs of 20% or more were most common in respiratory rate and heart rate. Monitoring of respiratory rate and pulse rate post-discharge might predict some deteriorations.

Into the night: factors affecting response to abnormal Early Warning Scores out-of-hours and implications for service improvement.

BACKGROUND: Early Warning Scores alert staff to preventable deterioration. Raised scores should lead to escalation of care. AIMS: To establish response of staff to patients scoring National Early Warning Score (NEWS) of six or above and to identify patient and environmental factors affecting escalation by nursing staff. METHODS: Service evaluation with prospective review of patient records of 118 beds on four medical wards during 20 night-shifts. RESULTS: During 2360 observed bed days 109 patients triggered NEWS>=6 at least once during the observation period. Nursing staff escalated only 18 (17%) of these patients; nearly all of them had predefined chronic health conditions, the majority fulfilled criteria for frailty. Despite their higher 30-day mortality patients with COPD had lower escalation rates. Additionally wards that had more patients with a NEWS>=6 had lower escalation rates. CONCLUSION: Alarm fatigue and clinical judgement of staff might result in deviation from escalation protocols.

"State of the Nation"--the Society for Acute Medicine's Benchmarking Audit 2013 (SAMBA '13).

BACKGROUND: Benchmarking is important to improve quality of care. AIM: To audit the performance of Acute Medical Units (AMUs) against the clinical quality indicators published by the Society for Acute Medicine (SAM). METHODS: 24-hour data collection on the 20th of June 2013 with follow-up data at 72 hours. RESULTS: 43 units submitted data on 1425 patients. 76% of patients had early warning scores recorded within 30 minutes of admission, 95% of patients had been seen by a competent decision maker within four hours. 79% of patients were seen by a consultant physicians within the appropriate period of time. CONCLUSION: The difference in compliance with quality standards between UK units opens opportunities for learning. The reasons why some units perform better than others require further investigation.

Where do AMU nurses perceive their educational needs? Results of the 20:10 project.

UNLABELLED: Our aim was to identify the perceived educational needs of nurses working in acute medicine to enable development of a training curriculum specifically for this staff group. METHODS: Post-graduate nurses from North Wales were invited to list 20 conditions and 10 skills for which they felt under prepared for their work in acute medicine. A workshop was then organized, attended by acute medicine nurses, medical colleagues and educationalists from two local universities to discuss initial data. RESULTS: Nurses identified particular needs for education around presenting symptoms with perceived deficits in knowledge or training. We found a heavy emphasis on respiratory and cardiac conditions. There was considerable overlap with frequent diagnostic categories from non-surgical hospital discharges and with priorities for training of junior doctors. Skills were often those traditionally associated with medical staff or care of patients with critical illnesses. CONCLUSION: The 20:10 project represents the first attempt to map educational needs of nursing staff on the Acute Medical Units of a large University Health Board using self-reported needs. The identified needs will support professional development, create incentives for recruitment and guide University postgraduate developments and commissioning.

The simple clinical score: a tool for benchmarking of emergency admissions in acute internal medicine.

Quality of care in intensive care and surgery has benefited from establishing comparative standards. At present there is no accepted tool to compare outcomes for emergency admissions in internal medicine. The Simple Clinical Score (SCS) was used in 1098 consecutive medical emergency admissions to adjust mortality for severity of illness. Hospital mortality adjusted for severity of illness and length of stay in the cohort was in keeping with mortality in the Irish derivation study with a trend towards lower mortality in the very high-risk group. Three parameters with poor reproducibility were identified. The SCS has several potential applications: identification of patients with low risk of death suitable for early hospital discharge; early identification of patients with a high risk of death, who will require care in critical care areas (or specialist palliative care); and benchmarking of acute medical departments internationally in a similar way to how APACHE II scoring has been used in critical care units worldwide.

Testing the effects of checklists on team behaviour during emergencies on general wards: An observational study using high-fidelity simulation.

INTRODUCTION: Clinical teams struggle on general wards with acute management of deteriorating patients. We hypothesized that the Crisis Checklist App, a mobile application containing checklists tailored to crisis-management, can improve teamwork and acute care management. METHODS: A before-and-after study was undertaken in high-fidelity simulation centres in the Netherlands, Denmark and United Kingdom. Clinical teams completed three scenarios with a deteriorating patient without checklists followed by three scenarios using the Crisis Checklist App. Teamwork performance as the primary outcome was assessed by the Mayo High Performance Teamwork scale. The secondary outcomes were the time required to complete all predefined safety-critical steps, percentage of omitted safety-critical steps, effects on other non-technical skills, and users' self-assessments. Linear mixed models and a non-parametric survival test were conducted to assess these outcomes. RESULTS: 32 teams completed 188 scenarios. The Mayo High Performance Teamwork scale mean scores improved to 23.4 out of 32 (95% CI: 22.4-24.3) with the Crisis Checklist App compared to 21.4 (20.4-22.3) with local standard of care. The mean difference was 1.97 (1.34-2.6; p < 0.001). Teams that used the checklists were able to complete all safety-critical steps of a scenario in more simulations (40/95 vs 21/93 scenarios) and these steps were completed faster (stratified log-rank test χ2 = 8.0; p = 0.005). The self-assessments of the observers and users showed favourable effects after checklist usage for other non-technical skills including situational awareness, decision making, task management and communication. CONCLUSIONS: Implementation of a novel mobile crisis checklist application among clinical teams was associated in a simulated general ward setting with improved teamwork performance, and a higher and faster completion rate of predetermined safety-critical steps.