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Key Elements

The Acute Medicine Programme is a clinician-led initiative between the HSE’s Clinical Strategy and Programmes Division, the Royal College of Physicians of Ireland (RCPI), the Irish Association of Directors of Nursing and Midwifery (IADNAM), the Therapy Professions Committee (TPC) and the Irish College of General Practitioners (ICGP). The programme has been developed by a multidisciplinary team of clinicians nominated by their professions.

The Acute Medicine Programme (published in December 2010) outlines key recommendations for the delivery of safe, quality driven care to the acutely ill medical patient. The programme believes that the successful implementation of the model of care recommendations will provide benefits to both service users and service providers and will deliver enhanced, high quality care to the acutely unwell medical patient within our health system.

The key benefits arising from the full implementation of the model of care are outlined below:

• No patient will be cared for on a trolley for an extended period.

• Patients will get the correct treatment.

• Unnecessary delays and duplication in assessment, diagnosis and treatment will be prevented.

• All patients will be seen by a senior medical doctor within 1 hour.

• All key decisions will be reviewed by a consultant.

• The patient and family/carers will be afforded the opportunity to have discussions with a senior medical doctor.

GPs

• The relationship between hospital staff and GPs will be a two way process based on mutual respect.

• GPs will have direct methods of communication with consultants, case manager, nurse managers and therapy leads and be able to select the most appropriate patient pathway from a wider range of assessment, diagnostic and treatment options.

• In addition to direct methods of communication, GPs will have accessible appropriate advice, assessment and treatment for patients with acute medical problems about whom the GP is concerned.

• GPs will have direct access to diagnostic services (e.g. radiology, endoscopy) as per agreed protocols.

• GPs will be members of the governance structure for the AMUs/AMAUs/MAUs.

• GPs may wish to work within the hospital models in addition to their primary care role

Nurses and Directors of Nursing

• Nurses will work in an environment which will provide dignified care for their patients.

• Nurses will have an expanded role in the delivery of patient care including discharge planning, X-ray and medication prescribing.

• Standardised, evidence-based care pathways and protocols to ensure that every patient receives the most appropriate care.

• Evidence-based information on nursing and healthcare assistant staffing and skill mix will be developed.

• Identification and development of competencies for nurses working in acute medicine,

• Development of the role of the nurse in acute medicine including: case managers, clinical nurse specialists and Advanced Nurse Practitioners

• The promotion of patient safety and quality of care will lead to better patient outcomes.

• Enhanced interdisciplinary referrals will be determined using protocols.

• Nurses will use the national early warning system (EWS) which facilitates standardised identification of patients at risk of deterioration.

• Nurse-led clinics will be established.

• The case manager will have a nursing background.

• The Director of Nursing is part of the leadership team responsible for ensuring the effective implementation of the programme.

Hospital doctors

• Will be able to assess, diagnose and treat patients in a dignified environment.

• No patient will be cared for on a trolley for an extended period.

• Care pathways and protocols developed will ensure that Acute medical patients most appropriate care.

• Same day diagnostics will be provided.

• Rapid access to consultation and OPD services will be provided.

• Doctors will not have competing responsibilities which will conflict with the provision of acute medical care.

• Doctors will have protected time when off service to develop additional specialty/management interests.

• The programme is a clinician-led initiative involving wide spread clinician consultation.

• The programme recommends that authority should be delegated to clinicians to affect change locally.

• There will be improved training in acute medicine.

Therapy professionals

• Therapy professionals will be able to assess and treat patients in an appropriate setting, which affords the patient respect and dignity.

• Standardised evidence-based care pathways will be provided.

• A combined document/generic therapy screening tool will be developed and implemented to enhance seamless transfer of care between provider sites.

• Therapists will have an expanded role in the delivery of patient care including discharge planning, NIV and arterial blood gas sampling.

• Protocols to enhance interdisciplinary referral within care pathways will be determined.

• The expansion of service provision in line with defined service needs will be addressed e.g. extended hours and weekend service.

• The therapy professions will work together and with the MDT to build capacity in the integrated health care system to deliver this model e.g. staff grade rotation between provider sites, outreach, in reach services.

• The therapy professions will develop a career pathway in acute medicine.

• Dedicated OPD slots will provide rapid access to therapy services optimising outcomes and facilitating timely discharge.

• The clinical service manager as part of the programme leadership team plays a critical role in the operational success of this model of care.

Department of Health

• This programme will facilitate policy improvements recommended by the DOH to improve the patient experience.

• There will be enhanced quality of patient care, ease of access and cost savings.

HIQA

• This programme will assist HIQA in the standardisation of the quality and safety of patient care.

• There will be improvements in quality and safety of patient care, ease of access, cost savings and improved clinical governance.

HSE/hospital management

• The general manager/CEO, director of nursing, clinical director, clinical services manager are the leadership team responsible for ensuring the effective implementation of the programme.

• The programme will ensure the standardisation of quality, safety and access to care and identify and correct variations in the delivery of services.

• This programme provides a framework for roll out of enhanced ICT systems.

Summary

The acute medicine programme provides a strong framework for provision of acute medical care because it:

• Is driven by a quality agenda.

• Is clinically-led, taking a whole system approach.

• Has been developed by a multidisciplinary team nominated by their professions.

• Has benefited from its integration with other national clinical programmes to facilitate the development of an integrated solution development e.g. links between emergency medicine, critical care, surgery and other national programmes.

• Is a national programme, which is jointly led by the HSE and RCPI, and supported by the Irish College of General Practitioners (ICGP), Irish Association of the Directors of Nursing and Midwifery (IADNAM) and the Therapy Professions Committee (TPC).

• Has been informed by the Health Services Patient Charter and has benefitted from the involvement of patient advocates in the design of the programme

The programme targets and key performance indicators (KPIs) include:

•  95% of all medical patients attending should spend less than 6 hours from registration to discharge in AMU/AMAU/MAU

•  All patients will be seen by a senior clinical decision maker within 1 hour of arrival

•  Implementation of the National Early Warning Score (NEWS) and iSBAR

•  Access to same day diagnostics and reporting for Acute Medical urgent patients

•  25% of admissions should receive appropriate care without an overnight hospital stay

•  31% acute medical admissions should spend no more that 1-2 nights in hospital

•  33% of AMAU admissions should require LOS of between 3 – 14 days

•  11% or less of AMAU admissions will require no more than 14 days. 

The Programme Key Performance Indicator (KPIs) metrics
KPISourceData Available
Total number admissions to AMAUVaried across servicesYes
% with total medical assessment time <6 hours (Registration to discharge AMAU/AMU/MAU)Varied across servicesYes
% of patients with LOS=0 HIPE/NQAIS ClinicalYes
 % of patients with LOS 1-2 daysHIPE/NQAIS ClinicalYes
 % of patients with LOS >2 daysHIPE/NQAIS ClinicalYes
 % of patients with LOS >14 daysHIPE/NQAIS ClinicalYes
AvLOS for those staying >2 daysHIPE/NQAIS ClinicalYes
Overall AvLOS for medical patient HIPE/NQAIS ClinicalYes
30 day re-admission rateHIPE/NQAIS ClinicalYes
Clinical Strategy and Programmes Division