Implementing a new emergency department: a qualitative study of health professionals' change responses and perceptions.

BACKGROUND: The aim of the study is two-fold. It explores how managers and key employees at the Emergency Department (ED) and specialist departments in a university hospital in the Capital Region of Denmark respond to the planned change to a new ED, and how they perceive the change involved in the implementation of the new ED. The study investigates what happens when health professionals are confronted with implementation of policy that changes their organization and everyday work lives. Few studies provide in-depth investigations of health professionals' reactions to the implementation of new EDs, and particularly how they influence the implementation of a nationwide organizational change framed within a political strategy. METHODS: The study used semi-structured individual interviews with 51 health professionals involved in implementation activities related to an organizational change of establishing a new ED with new patient pathways for acutely ill patients. The data was deductively analyzed using Leon Coetsee's theoretical framework of change responses, but the analysis also allowed for a more inductive reading of the material. RESULTS: Fourteen types of responses to establishing a new ED were identified and mapped onto six of the seven overall change responses in Coetsee's framework. The participants perceived the change as particularly three changes. Firstly, they wished to create the best possible acute patient pathway in relation to their specialty. Whether the planned new ED would redeem this was disputed. Secondly, participants perceived the change as relocation to a new building, which both posed potentials and worries. Thirdly, both hopeful and frustrated statements were given about the newly established medical specialty of emergency medicine (EM), which was connected to the success of the new ED. CONCLUSIONS: The study showcases how implementation processes within health care are not straightforward and that it is not only the content of the implementation that determines the success of the implementation and its outcomes but also how these are perceived by managers and employees responsible for the process and their context. In this way, managers must recognize that it cannot be pre-determined how implementation will proceed, which necessitates fluid implementation plans and demands implementation managements skills.

Identification of risk factors associated with acute kidney injury in patients admitted to acute medical units.

In 2009, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report identified significant deficiencies in the management of acute kidney injury (AKI) in hospitals in the UK. Many errors arose from failure to recognise patients with AKI and those at risk of developing AKI. Currently, there is no universally accepted risk factor assessment for identifying such patients on admission to acute medical units (AMUs). A multicentre prospective observational study was performed in the AMUs of 10 hospitals in England and Scotland to define the risk factors associated with AKI and to assess quality of care. Data were collected on consecutive acute medical admissions over two separate 24-h periods. Acute kidney injury was present in 55/316 (17.7%) patients, with sepsis, hypovolaemia, chronic kidney disease (CKD) and diabetes mellitus identified as the major risk factors. Deficiencies in patient care were identified, reinforcing the continuing need to improve the management of AKI.

Clinical impact of a comprehensive nurse-led discharge intervention on patients being discharged home from an acute medical unit: Randomised controlled trial.

BACKGROUND: Acute medical units have increasingly been implemented in modern healthcare to ensure a fast track for treatment and care, thus increasing the number of patients being discharged. To avoid early readmissions, new approaches to discharging patients from these settings are needed. OBJECTIVE: To investigate the clinical impact of a comprehensive nurse-led discharge intervention on patients being discharged home from an acute medical unit. OUTCOMES: The primary outcome was 30-days hospital readmission. Secondary outcomes were utilisation of healthcare, including contacting emergency departments, the general practitioner or after-hours physicians; patient experience; and health-related quality of life. DESIGN: This study was a non-blinded randomised clinical controlled trial with a 1 year enrolment period from November 2014 to 2015. Group assignment was performed by computer generated codes. SETTING: The setting was a 34-bed acute medical unit at a Danish University Hospital. PARTICIPANTS: Non-surgical patients aged 18+ with more than one contact to hospitals during the last 12 months were eligible for inclusion. Furthermore, patients had to have been discharged home and had a follow-up appointment after discharge. METHODS: The intervention consisted of (1) an assessment of the patient's overall situation, (2) an assessment of their comprehension of discharge recommendations, (3) a simple discharge letter targeting the individual patient's health literacy and (4) a follow-up telephone call 2 days post-discharge. The study was carried out by a research nurse and the 1st author. Data was collected from medical records, registers and questionnaires. Intention-to-treat and per protocol analysis were performed. RESULTS: In all, 200 participants were enrolled (101 intervention; 99 control). Of these, 17 were excluded due to transfer to another hospital department and 4 did not receive the full intervention, resulting in 86 in the intervention group and 93 in the control group. At 30 days post-discharge, 22/101 (22%) in the intervention group had at least one readmission vs. 19/99 (19%) in the control group. The total number of all-cause readmissions in the follow-up period was 0.28 (SD: 0.67) in the intervention group vs. 0.26 (SD: 0.63) in the control group. There were no statistically significant differences in baseline characteristics or any of the primary and secondary outcomes. CONCLUSION: A comprehensive nurse-led discharge model focusing on the individual patient's situation and needs was not capable of reducing readmissions and healthcare utilisation. No statistically significant effects on quality of life or patients' experiences of the discharge from the acute medical unit were observed.

The evidence for acute internal medicine and acute medical units.

Acute medicine and acute medical units are relatively new innovations. The evolving evidence base is demonstrating the effectiveness of these in improving care given to patients with acute medical illness. This article reviews the available evidence.

Relationship between input and output in acute medicine - secondary analysis of the Society for Acute Medicine's benchmarking audit 2013 (SAMBA '13).

The performance of acute medical units (AMUs) against published quality indicators is variable. We aimed to identify the impact of case-mix and unit resources on timely assessment and discharge of patients admitted to 43 AMUs on a single day in June 2013, as part of the Society for Acute Medicine's benchmarking audit 2013. Performance against quality indicators was at its worst in the early evening hours. Units admitting fewer than 40 patients performed better. Patients who were more frail, as measured by the Clinical Frailty Scale, were also more likely to have significant physiological abnormalities and a higher risk of death, as measured by the National Early Warning Score. Our analysis suggests that resource allocation at the front door is related to quality indicators. Teams will need strengthening in the evening hours and if looking after higher numbers of frail patients.

Trajectories of the averaged abbreviated Vitalpac early warning score (AbEWS) and clinical course of 44,531 consecutive admissions hospitalized for acute medical illness.

BACKGROUND: It is not known how often, to what extent and over what time frame any early warning scores change, and what the implications of these changes are. SETTING: Thunder Bay Regional Health Sciences Center, Ontario, Canada. METHODS: The averaged vital signs measured over different time periods of 44,531 consecutive acutely ill medical admissions were determined and then combined to calculate the averaged abbreviated version of the Vitalpac early warning score (AbEWS) during each time period examined. RESULTS: 18% of all in-hospital deaths within 30 days are in patients with a low AbEWS on admission. Those admitted with a low AbEWS are more likely to increase their score and those admitted with a high score are more likely to lower it. Paradoxically, patients who have an averaged score over the first 6h in hospital that is lower than on admission have increased in-hospital mortality. Thereafter patients with an increase in the averaged score have almost twice the mortality of those with a decreased score. 4.7% of patients have a low averaged score on the day they die. CONCLUSION: AbEWS, without clinical judgment, cannot be used to detect those patients who do not need to be admitted to hospital or are suitable for discharge. A period of observation of at least 12h is required before the trajectory of AbEWS is of prognostic value, and any "improvement" that occurs before this time may be illusory.

Adolescents and young adults on the acute medical unit: how might we do it better?

It is a common perception that young people do not become ill and do not pose a challenge in the unscheduled healthcare setting. The research, however, increasingly suggests that young adults and adolescents (YAAs) are a highly vulnerable group, with poorer outcomes than either older adults or children, and distinct healthcare needs. The acute medical unit (AMU) setting poses particular challenges to the care of this patient group. To improve care and patient experience, adult clinicians need to look critically at their services and seek to adapt them to meet the needs of YAAs. This requires cooperation and linkage with local paediatric and emergency services, as well as the input of other relevant stakeholder groups. Staff on AMUs also need to develop the knowledge, skills and attitudes to communicate effectively and address the developmental and health needs of YAAs and their parents/carers at times of high risk and stress.