Emergency Admissions— A time for action and improving patient outcomes

The report Emergency Admissions: A journey in the right direction? was recently published by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). ¹ This report analysed 1800 medical and surgical patients who were admitted acutely to hospital over seven days in February 2005 and who subsequently died or were transferred to critical care within seven days of admission or died within seven days of discharge. This study, by its nature, analyses the most seriously ill subgroup of patients and, therefore, may underestimate the true extent and nature of problems that may affect care adversely. These include, for example, deficits in care provision that increase the risk of healthcare-acquired infection and result in increased length of hospital stay.

The report makes ten principal recommendations which can broadly be divided into issues of competency or process of care—important factors in patient care which have been apparent for many years and were, indeed, highlighted by Hippocrates. In essence, the recommendations state that acutely unwell patients should be seen promptly by a competent clinician, that documentation throughout the patient journey should be accurate and clear, that there should be diagnostic support available 24 hours per day, that patients’ physiology should be monitored and that patient transfers should be minimized.

The report highlights that in most of these areas the majority of patients in this severely ill group received adequate care, but in specified areas an unacceptably high proportion received suboptimal care.

How will this report help improve clinical outcomes in acute care? Most, if not all, of the recommendations have been published before in a variety of previous reports.^{2, 3} For example, one of the earliest reports, published almost a decade ago, highlighted the need for 24-hour/seven-day per week provision of diagnostic services to support acute medical admissions. ² The more recent of these reports ³ covered all of the NCEPOD recommendations, with the exception of physiological monitoring which has been covered in other reports.^{4, 5}

The NCEPOD report ¹ highlights that in most of these areas of patient care, progress in implementing the recommendations has been, at best, slow. Before addressing why progress has been slow, we should consider whether the recommendations are themselves sufficient and which areas the report has not covered.

In examining the care delivered in the acute setting, perhaps we should apply the close relative test: what would we as healthcare professionals wish to happen for a close relative? The report shows that only 60% of patients had been seen by a consultant within 12 hours and this was most likely to have occurred within an assessment unit (acute medical or surgical unit) or an inpatient ward. Within 24 hours of admission, 8% had not been seen. This clearly is not acceptable, especially as the report relates to patients who, by definition, were likely to have poor outcomes. We would argue, however, that even 12 hours is too long to wait for input from a senior professional and that we should aspire to higher standards. How can this be achieved? The current levels of medical manpower would not permit a 24-hour consultant presence in the acute setting throughout the UK. We can, however, improve consultant input by working extended hours within the acute units and by ensuring that consultants are informed of all cases of clinical concern. This would require that physiological scoring is implemented uniformly, that we as consultants encourage contact by junior members of staff throughout 24 hours and, as the report reiterates, that job planning must reflect the needs of the large number of patients requiring acute care. In relation to early warning scoring systems, it is key that these are linked to clear actions and escalation policies if outcomes are to improve at point of entry to care.^{6, 7}

Acute medical and acute surgical units must be seen as defined training areas for both undergraduate and postgraduate healthcare professionals in order to ensure that competencies relevant to the acute care of patients are achieved. This report covers a large number of areas but predominantly looks at the medical components of care. The delivery of high-quality acute care requires a multi-professional approach, and the roles of nursing staff and allied health professionals in both detecting and treating acute illness must be recognized and promoted. As such, staffing levels in the acute units and the level of monitoring equipment must also be adequate,^{8, 9} but in reality they vary throughout the country. The report does not address these issues, but they are essential for all involved in assessing or redesigning acute services.

The report therefore highlights that much work still requires to be done and essentially reveals that previous national recommendations have not been uniformly adopted.

Why is this the case? The reasons are multifactorial and include that, until recent years, there has been little focus on acute care despite the fact it accounts for the vast majority of both medical and surgical hospital admissions. Other reasons include tensions in prioritization between unscheduled and scheduled care and between acute and specialist care. In addition, many clinicians feel uncomfortable in managing the acutely unwell and this must dictate the need for improved training programmes. Finally, staff are often required to work within systems that are inadequate and poorly organized. This reflects the lack of emphasis on acute care by both healthcare professionals and senior managers.

Programmes like the Emergency Services Collaborative and the Unscheduled Care Collaborative have helped emphasize the importance of improving the timeliness and quality of acute care, but this work needs to continue with an even greater emphasis on patient experience and outcomes. ¹⁰ The forthcoming acute medical task force document ⁹ re-emphasizes the recommendations of this NCEPOD report but is broader-ranging and takes a more prescriptive, whole-system approach designed to improve the care for all patients requiring acute care. We must now implement the recommendations and ensure that progress is monitored. How can this be done?

First we must recognize that there is wide variation in clinical outcomes for patients in relation to the time and place that they access acute services.^{11, 12} This is despite the fact that they may be suffering from similar illness and disease severity. We can do better. Improved care could be delivered at a local level (Trust or Health Board) if it is given the correct emphasis. Or does it require another national programme to coordinate this delivery, with quality and outcomes in acute care as the main focus?

In summary, the NCEPOD report ¹ supports the recommendations of previous reports but perhaps could have gone further, with greater emphasis given to specific components of the recommendations. It does highlight current deficiencies and serves as a useful baseline for the necessary improvement. The importance of the report is that it serves as a timely reminder to us all. However, we must now move into an era of delivery of improved acute care with demonstrable improvement in patient out-comes—in other words it is time for action, not further reports.