Acute medical units: The way to go? A literature review

Interventions to minimise hospital winter pressures related to discharge planning and integrated care: a rapid mapping review of UK evidence

Background

Winter pressures are a familiar phenomenon within the National Health Service and represent the most extreme of many regular demands placed on health and social care service provision. This review focuses on a part of the pathway that is particularly problematic: the discharge process from hospital to social care and the community. Although studies of discharge are plentiful, we identified a need to focus on identifying interventions and initiatives that are a specific response to 'winter pressures'. This mapping review focuses on interventions or initiatives in relation to hospital winter pressures in the United Kingdom with either discharge planning to increase smart discharge (both a reduction in patients waiting to be discharged and patients being discharged to the most appropriate place) and/or integrated care.

Methods

We conducted a mapping review of United Kingdom evidence published 2018-22. Initially, we searched MEDLINE, Health Management Information Consortium, Social Care Online, Social Sciences Citation Index and the King's Fund Library to find relevant interventions in conjunction with winter pressures. From these interventions we created a taxonomy of intervention types and a draft map. A second broader stage of searching was then undertaken for named candidate interventions on Google Scholar (Google Inc., Mountain View, CA, USA). For each taxonomy heading, we produced a table with definitions, findings from research studies, local initiatives and systematic reviews and evidence gaps.

Results

The taxonomy developed was split into structural, changing staff behaviour, changing community provision, integrated care, targeting carers, modelling and workforce planning. The last two categories were excluded from the scope. Within the different taxonomy sections we generated a total of 41 headings. These headings were further organised into the different stages of the patient pathway: hospital avoidance, alternative delivery site, facilitated discharge and cross-cutting. The evidence for each heading was summarised in tables and evidence gaps were identified.

Conclusions

Few initiatives identified were specifically identified as a response to winter pressures. Discharge to assess and hospital at home interventions are heavily used and well supported by the evidence but other responses, while also heavily used, were based on limited evidence. There is a lack of studies considering patient, family and provider needs when developing interventions aimed at improving delayed discharge. Additionally, there is a shortage of studies that measure the longer-term impact of interventions. Hospital avoidance and discharge planning are whole-system approaches. Considering the whole health and social care system is imperative to ensure that implementing an initiative in one setting does not just move the problem to another setting.

Limitations

Time limitations for completing the review constrained the period available for additional searches. This may carry implications for the completeness of the evidence base identified.

Future work

Further research to consider a realist review that views approaches across the different sectors within a whole system evaluation frame.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130588) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 31. See the NIHR Funding and Awards website for further award information.

Effects of a medical admission unit on in-hospital patient flow and clinical outcomes

BACKGROUND

the burden of acute complex patients, increasingly older and poli-pathological, accessing to Emergency Departments (ED) leads up hospital overcrowding and the outlying phenomenon. These issues highlight the need for new adequate patients' management strategies. The aim of this study is to analyse the effects on in-hospital patient flow and clinical outcomes of a high-technology and time-limited Medical Admission Unit (MAU) run by internists.

METHODS

all consecutive patients admitted to MAU from Dec-2017 to Nov-2019 were included in the study. The admissions number from ED and hospitalization rate, the overall in-hospital mortality rate in medical department, the total days of hospitalization and the overall outliers bed days were compared to those from the previous two years.

RESULTS

2162 patients were admitted in MAU, 2085(95.6%) from ED, 476(22.0%) were directly discharged, 88(4.1%) died and 1598(73.9%) were transferred to other wards, with a median in-MAU time of stay of 64.5 [0.2-344.2] hours. Comparing the 24 months before, despite the increase in admissions/year from ED in medical department (3842 ± 106 in Dec2015-Nov2017 vs 4062 ± 100 in Dec2017-Nov2019, p<0.001), the number of the outlier bed days has been reduced, especially in surgical department (11.46 ± 6.25% in Dec2015-Nov2017 vs 6.39 ± 3.08% in Dec2017-Nov2019, p=0.001), and mortality in medical area has dropped from 8.74 ± 0.37% to 7.29 ± 0.57%, p<0.001.

CONCLUSIONS

over two years, a patient-centred and problem-oriented approach in a medical admission buffer unit run by internists has ensured a constant flow of acute patients with positive effects on clinical risk and quality of care reducing medical outliers and in-hospital mortality.

A multivariable analysis to predict variations in hospital mortality using systems-based factors of healthcare delivery to inform improvements to healthcare design within the English NHS

Over the last decade, the strain on the English National Health Service (NHS) has increased. This has been especially felt by acute hospital trusts where the volume of admissions has steadily increased. Patient outcomes, including inpatient mortality, vary between trusts. The extent to which these differences are explained by systems-based factors, and whether they are avoidable, is unclear. Few studies have investigated these relationships. A systems-based methodology recognises the complexity of influences on healthcare outcomes. Rather than clinical interventions alone, the resources supporting a patient's treatment journey have near-equal importance. This paper first identifies suitable metrics of resource and demand within healthcare delivery from routinely collected, publicly available, hospital-level data. Then it proceeds to use univariate and multivariable linear regression to associate such systems-based factors with standardised mortality. Three sequential cross-sectional analyses were performed, spanning the last decade. The results of the univariate regression analyses show clear relationships between five out of the six selected predictor variables and standardised mortality. When these five predicators are included within a multivariable regression analysis, they reliably explain approximately 36% of the variation in standardised mortality between hospital trusts. Three factors are consistently statistically significant: the number of doctors per hospital bed, bed occupancy, and the percentage of patients who are placed in a bed within four hours after a decision to admit them. Of these, the number of doctors per bed had the strongest effect. Linear regression assumption testing and a robustness analysis indicate the observations have internal validity. However, our empirical strategy cannot determine causality and our findings should not be interpreted as established causal relationships. This study provides hypothesis-generating evidence of significant relationships between systems-based factors of healthcare delivery and standardised mortality. These have relevance to clinicians and policymakers alike. While identifying causal relationships between the predictors is left to the future, it establishes an important paradigm for further research.

The First Observational Study of Acute Medical Unit in Qatar

Background  Acute medical unit (AMU) is a dedicated facility to treat patients with acute medical conditions requiring a short hospital stay (< 72 hours) with the support of a multidisciplinary team led by a medical consultant. We aim to present a study of the AMU model of care from Qatar to provide insight into its effects on patient care and management. Methods  Retrospective data from AMU facility at Hamad General Hospital (HGH), Doha, Qatar, was collected from January 2019 to December 2020 from the electronic patient record. The data were analyzed for demographic characteristics of the patients, length of stay (LOS), readmission rate, and postdischarge follow-up. The effectiveness of the AMU system was studied closely from this data. An extensive literature search was also performed for comparative results analysis in other AMU facilities outside Qatar. Results  Total admissions under the AMU facility were 8,371 from january2019 to December 2020. The 28 days readmission rate was 10.25 and 9.9% in 2019 and 2020, respectively. The average LOS was approximately 3.2 days. Around 88.7% of the patients were discharged home, 7.8% were admitted to medical wards due to longer stays, and 0.5% left against medical advice. Most of the patients admitted under AMU were 18 to 60 years old. The top primary diagnoses of admissions were minor stroke, transient ischemic attack, chest infection, urinary tract infections, and gastrointestinal and liver diseases. The most common comorbidities were hypertension, diabetes, acute kidney injury, and chronic kidney disease. A total of 2,858 patients were booked for a follow-up visit in the postdischarge clinic on discharge from the AMU for the year 2019 and 2020. The analysis of these followed up patients showed 73% of patients were discharged from clinic after first visit while the readmission from clinic was on only 1% (28 patients for year 2019 and 2020). Conclusion  Attentive patient care under AMU with a designated multidisciplinary medical team led by an internal medicine consultant is the cornerstone for the success of the AMU unit. This unit has proven very helpful for the smooth disposition of patients from the emergency department with reduced LOS, readmission rate, and overall mortality.

Impact of hospitalist care model on patient outcomes in acute medical unit: a retrospective cohort study

OBJECTIVE

To assess a newly introduced, hospitalist-run, acute medical unit (AMU) care model at a tertiary care hospital in the Republic of Korea.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care hospital in the Republic of Korea.

PARTICIPANTS

We evaluated 6391 medical inpatients admitted through the emergency department (ED) from 1 June 2016 to 31 May 2017.

INTERVENTIONS

The study compared multiple outcomes among medical inpatients from the ED between the non-hospitalist group and the AMU hospitalist group.

OUTCOME MEASURES

In-hospital mortality (IHM), intensive care unit (ICU) admission rate, hospital length of stay (LOS), ED-LOS and unscheduled readmission rates were defined as patient outcomes and compared between the two groups.

RESULTS

Compared with the non-hospitalist group, the AMU hospitalist group had lower IHM (OR: 0.43, p<0.001), a lower ICU admission rate (OR: 0.72, p=0.013), a shorter LOS (coefficient: -0.984, SE: 0.318; p=0.002) and a shorter ED-LOS (coefficient: -3.021, SE: 0.256; p<0.001). There were no significant differences in the 10-day or 30-day readmission rates (p=0.974, p=0.965, respectively).

CONCLUSIONS

The AMU hospitalist care model was associated with reductions in IHM, ICU admission rate, LOS and ED-LOS. These findings suggest that the AMU hospitalist care model has the potential to be adopted into other healthcare systems to improve care for patients with acute medical needs.

Acute assessment services for patient flow assistance in hospital emergency departments

BACKGROUND

Emergency departments (EDs) are facing serious and significant issues in the delivery of effective and efficient care to patients. Acute assessment services have been implemented at many hospitals internationally to assist in maintaining patient flow for identified groups of patients attending the ED. Identifying the risks and benefits, and optimal configurations of these services may be beneficial to those wishing to utilise an acute assessment service to improve patient flow.

OBJECTIVES

To assess the effects of acute assessment services on patient flow following attendance at a hospital ED.

SEARCH METHODS

We searched MEDLINE, CENTRAL, Embase and two trials registers on 24 September 2022 to identify studies. No restrictions were imposed on publication year, publication type, or publication language.

SELECTION CRITERIA

Studies eligible for inclusion were randomised trials and cluster-randomised trials with at least two intervention and two control sites. Participants were adults (as defined by study authors) receiving care either in the ED or the acute assessment service, where both were based in the hospital setting. The comparison was hospital-based acute assessment services with usual, ED-only care. The outcomes of this review were mortality at time point closest to 30 days, length of stay in the service (in minutes), and waiting time to see a doctor (in minutes).

DATA COLLECTION AND ANALYSIS

We followed the standard procedures of Cochrane Effective Practice and Organisation of Care for this review (https://epoc.cochrane.org/resources).

MAIN RESULTS

We identified a total of 5754 records in the search. Following assessment of 3609 de-duplicated records, none were found to be eligible for inclusion in this review.

AUTHORS' CONCLUSIONS

At present there are no randomised controlled trials exploring the effects of acute assessment services on patient flow in hospital-based emergency departments compared to usual, ED-only care.

Continuous monitoring of patients in and after the acute admission ward to improve clinical pathways: study protocol for a randomized controlled trial (Optimal-AAW)

BACKGROUND

Because of high demand on hospital beds, hospitals seek to reduce patients' length of stay (LOS) while preserving the quality of care. In addition to usual intermittent vital sign monitoring, continuous monitoring might help to assess the patient's risk of deterioration, in order to improve the discharge process and reduce LOS. The primary aim of this monocenter randomized controlled trial is to assess the effect of continuous monitoring in an acute admission ward (AAW) on the percentage of patients who are discharged safely.

METHODS

A total of 800 patients admitted to the AAW, for whom it is equivocal whether they can be discharged directly after their AAW stay, will be randomized to either receive usual care without (control group) or with additional continuous monitoring of heart rate, respiratory rate, posture, and activity, using a wearable sensor (sensor group). Continuous monitoring data are provided to healthcare professionals and used in the discharge decision. The wearable sensor keeps collecting data for 14 days. After 14 days, all patients fill in a questionnaire to assess healthcare use after discharge and, if applicable, their experience with the wearable sensor. The primary outcome is the difference in the percentage of patients who are safely discharged home directly from the AAW between the control and sensor group. Secondary outcomes include hospital LOS, AAW LOS, intensive care unit (ICU) admissions, Rapid Response Team calls, and unplanned readmissions within 30 days. Furthermore, facilitators and barriers for implementing continuous monitoring in the AAW and at home will be investigated.

DISCUSSION

Clinical effects of continuous monitoring have already been investigated in specific patient populations for multiple purposes, e.g., in reducing the number of ICU admissions. However, to our knowledge, this is the first Randomized Controlled Trial to investigate effects of continuous monitoring in a broad patient population in the AAW.

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT05181111 . Registered on 6 January 2022. Start of recruitment: 7 December 2021.

Development of an acute medical unit to optimize patient flow and early discharges in a tertiary care hospital in the United Arab Emirates

BACKGROUND

Hospitals worldwide are seeing an increased number of acute admissions, with resultant emergency department (ED) crowding and increased length of stay (LOS). Acute Medical Units (AMUs) have developed throughout the United Kingdom and other Western countries to reduce the burden on EDs and improve patient flow. Limited information is available on AMUs in the Middle East. The purpose of this study is to describe the development of the first AMU in the United Arab Emirates (UAE) for general medical patients and its impact on LOS, early discharges, ED boarders, and readmission rates.

METHODS

We established a consultant-led AMU in a tertiary hospital in the UAE. A retrospective comparative review of all general medical admissions to the AMU between August 1, 2020 and December 31, 2020 and all admissions to the traditional medical wards between August 1, 2019 and December 31, 2019 was conducted.

RESULTS

The average LOS reduced from 10 to 5 days (95% CI [4.14-6.25], p < 0.001) after the introduction of AMU. Early discharges increased by 22%. The number of outliers and number of patients boarding in ED reduced significantly (111 in 2019 vs. 60 in 2020, p < 0.05; 938 in 2019 vs. 104 in 2020, p < 0.001 respectively), with a decrease in ED waiting time from 394 min to 134 min (95% CI [229.25-290.75], p < 0.001). There was no increase in 30-day readmission rates.

CONCLUSION

Restructuring the system of care can reduce LOS, overcome discharge barriers and improve patient flow. Similar units can be developed in hospitals throughout the UAE and the region to reduce LOS and improve patient flow through acute care units.

Nurse staffing levels within acute care: results of a national day of care survey

Introduction

The relationship between nurse staffing levels and patient safety is well recognised. Inadequate provision of nursing staff is associated with increased medical error, as well as higher morbidity and mortality. Defining what constitutes safe nurse staffing levels is complex. A range of guidance and planning tools are available to inform staffing decisions. The Society for Acute Medicine (SAM) recommend a ‘nurse-to-bed‘ratio of greater than 1:6. Whether this standard accurately reflects the pattern and intensity of work on the Acute Medical Unit (AMU) is unclear.

Methods

Nurse staffing levels in AMUs were explored using the Society for Acute Medicine Benchmarking Audit 2019 (SAMBA19). Data from 122 acute hospitals were analysed. Nurse-to-bed ratios were calculated and compared. Estimates of the total nursing time available within the acute care system were compared to estimates of the time required to perform nursing activities.

Results

The total number of AMU beds across all 122 units was 4997. The mean daytime nurse-to-bed ratio was 1:4.3 and the mean night time nurse-to-bed ratio was 1:5.2. The SAM standard of a nurse to bed ratio of greater than 1:6 was achieved in 99 units (81.9%) during daytime hours and achieved by 74 units (60.6%) at night.

The estimated time required to deliver direct clinical care was 35,698 h. A deficit of 4128 h (11.5% of time required) was estimated, representing the time difference between the total number of nursing hours available with current staffing and the estimated time needed for direct clinical care across all participating units.

Conclusion

This UK-wide study suggests a significant proportion of AMUs do not meet the recommenced SAM staffing levels, particularly at night. A difference was observed between the total number of nursing hours within the acute care system and the estimated time required to perform direct nursing activities. This suggests a workforce shortage of nurses within acute care at the system level.

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.

Admission criteria for a cardiovascular short stay unit: a retrospective analysis on a pilot unit

Rapid intensive observation (RIO) units have been created to guarantee high standards of care in a sustainable health-care system. Within short stay units (SSUs), which are a subgroup of RIOs, only rapidly manageable patients should be admitted. Physicians are unable to predict the length of stay (LOS) as objective criteria to make such a prediction are missing. A retrospective observational study was carried out to identify the objective criteria for admission within a cardiovascular care-oriented SSU. Over a period of 317 days, 340 patients (age 69.4 ± 14.7 years) were admitted to a pilot SSU within our internal medicine department. The most frequent diagnoses were chest pain (45.9%), syncope (12.9%), and supraventricular arrhythmias (11.2%). The median LOS was 4 days (quartile 1:3; quartile 3:7). Predictors of LOS ≤ 96 h were age < 80, hemoglobin > 115 g/L, estimated glomerular filtration rate > 45 mL/min/1.73 m², Charlson Comorbidity Index < 3, Barthel Index > 40, diagnosis of chest pain, syncope, supraventricular arrhythmias, or acute heart failure. The HEART (history, ECG, age, risk factors, troponin) score was found to be excellent in risk stratification of patients admitted for chest pain. Blood tests and anamnestic variables can be used to predict the LOS and thus SSU admission. The HEART score may help in the classification of patients with chest pain admitted to an SSU.

A Swift and Dynamic Strategy to Expand Emergency Department Capacity for COVID-19

Emergency departments (EDs) worldwide struggled to prepare for coronavirus disease 2019 (COVID-19) patient surge and to simultaneously preserve sufficient capacity for “regular” emergency care. While many hospitals used costly shelter facilities, it was decided to merge the acute medical unit (AMU) and the ED. The conjoined AMU-ED was segregated into a high-risk and a low-risk area to maintain continuity of emergency care. This strategy allowed for a feasible, swift, and dynamic expansion of ED capacity without the need for external tent facilities. This report details on the technical execution and discusses the pearls and potential pitfalls of this expansion strategy. Although ED preparedness for pandemics may be determined by local factors, such as hospital size, ED census, and primary health-care efficacy, the conjoined AMU-ED strategy may be a potential model for other EDs.

Interventions in overcrowding of emergency departments: an overview of systematic reviews

OBJECTIVE

To present an overview of systematic reviews on throughput interventions to solve the overcrowding of emergency departments.

METHODS

Electronic searches for reviews published between 2007 and 2018 were made on PubMed, Cochrane Library, EMBASE, Health Systems Evidence, CINAHL, SciELO, LILACS, Google Scholar and the CAPES periodicals portal. Data of the included studies was extracted into a pre-formatted sheet and their methodological quality was assessed using AMSTAR 2 tool. Eventually, 15 systematic reviews were included for the narrative synthesis.

RESULTS

The interventions were grouped into four categories: (1) strengthening of the triage service; (2) strengthening of the ED’s team; (3) creation of new care zones; (4) change in ED’s work processes. All studies observed positive effect on patient’s length of stay, expect for one, which had positive effect on other indicators. According to AMSTAR 2 criteria, eight revisions were considered of high or moderate methodological quality and seven, low or critically low quality. There was a clear improvement in the quality of the studies, with an improvement in focus and methodology after two decades of systematic studies on the subject.

CONCLUSIONS

Despite some limitations, the evidence presented on this overview can be considered the cutting edge of current scientific knowledge on the topic.

Quality improvement at an acute medical unit in an Asian Academic Center: A mixed methods study of nursing work dynamics

BACKGROUND

The acute medical unit (AMU) provides early specialist care to emergency department patients before inpatient admission. The workflows and skills for successful AMU nursing comprise a hybrid of internal and emergency medicine.

PURPOSE

To understand nursing work dynamics in the AMU.

METHODS

AMU at a 1,250-bed tertiary academic center in Singapore with 14,000 ED presentations monthly. Retrospective mixed methods study using focus group discussions and surveys. Fifteen nurses across three focus group discussions. Thirty-two physicians and 54 nurses responded to a validated questionnaire.

FINDINGS

Focus group discussions transcripts content analyzed by two researchers. Survey items factor analyzed and attitudinal differences between AMU physicians and nurses, and among nurses compared using Student's t- and one-way ANOVA tests.

DISCUSSION

AMU nursing staff faced obstacles of inadequate patient information, emergency department onboarding, unbalanced workload, and coworker conflicts, which led to them to develop processes and checklists to manage patient information, patient expectations, and teamwork.

CONCLUSION

AMU nursing requires a combination of specialist internal medicine and emergency medicine skills. Training should familiarize nurse workforce with managing patient expectations and multidisciplinary teamwork.

A multistage mixed methods study protocol to evaluate the implementation and impact of a reconfiguration of acute medicine in Ireland's hospitals

BACKGROUND

To address deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established in 2010 to optimise the management of acutely ill medical patients in the hospital setting, and to ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure patients receive timely treatment in the most appropriate setting. It does so primarily via the development of Acute Medical Assessment Units (AMAUs) for the rapid assessment and management of medical patients presenting to hospitals, as well as streamlining the care of those admitted for further care. This study will examine the impact of this programme on patient care and identify the factors influencing its implementation and operation.

METHODS

We will use a multistage mixed methods evaluation with an explanatory sequential design. Firstly, we will develop a logic model to describe the programme's outcomes, its components and the mechanisms of change by which it expects to achieve these outcomes. Then we will assess implementation by measuring utilisation of the Units and comparing the organisational functions implemented to that recommended by the NAMP model of care. Using comparative case study research, we will identify the factors which have influenced the programme's implementation and its operation using the Consolidated Framework for Implementation Research to guide data collection and analysis. This will be followed by an estimation of the impact of the programme on reducing overnight emergency admissions for potentially avoidable medical conditions, and reducing length of hospital stay of acute medical patients. Lastly, data from each stage will be integrated to examine how the programme's outcomes can be explained by the level of implementation.

DISCUSSION

This formative evaluation will enable us to examine whether the NAMP is improving patient care and importantly draw conclusions on how it is doing so. It will identify the factors that contribute to how well the programme is being implemented in the real-world. Lessons learnt will be instrumental in sustaining this programme as well as planning, implementing, and assessing other transformative programmes, especially in the acute care setting.

[Pre-hospitalization unit: A simple organization and a place for internists to improve the non-scheduled hospitalization stream from emergencies]

INTRODUCTION

The adult emergency department at Rouen University hospital (CHU) welcomes over 100.000 patients per year. In order to streamline unscheduled hospital admissions from the emergency room (ER), a 20-bed pre-hospitalization unit and a centralized bed management system (bed manager, bed manager software, dedicated beds) have been put into place.

PATIENTS AND METHODS

Emergency admissions have increased by (+3.5% between 2017 and 2018) with 20% direct hospitalization from the ER to other conventional units (2/3 in medicine, 1/3 in surgery). In 2018, 3450 patients, of which 54% aged over 75 years have been admitted in the pre-hospitalization unit with an average length of stay of 1.3±1.4 days: 35.4% stayed less than 24hours and 34.8% more than 48hours of which 5.2% stated more than 4 days, 132 patients (3.8%) died, 805 patients (23.3%) were discharged at home, 220 (6.4%) transferred to another facility, and 2287 (66.3%) were secondarily hospitalized in another hospital unit: more than 9 times out of 10 in a medicine unit (internal medicine 30%, geriatrics 27.9%, respiratory medicine 12.2%). This unscheduled emergency hospitalization allowed a daily hospitalization of 50 short stay inpatients beds. It has to be noted that the number of available inpatient beds clearly decreases during the week-ends. The main pathologies were respiratory infections (14.2%), heart diseases (9.7%), metabolic disorders (3.9%), and urinary tract infections (13.6%).

CONCLUSION

This pre-hospitalization unit associated with a centralized bed management system has clearly improved the unscheduled hospital admissions, in particular concerning the emergency medical sector. The lack of inpatient beds at the week-end and the management of epidemic periods still remain a challenge that has to be taken up.

Association entre mortalité et attente aux urgences chez les adultes à hospitaliser pour étiologies médicales

Introduction : Notre objectif principal est de comparer, dans un centre hospitalier universitaire (CHU) français et chez les patients hospitalisés pour étiologies médicales à partir de la structure des urgences (SU), le taux de mortalité intrahospitalière entre ceux qui n’attendent pas faute de place en service et ceux en attente (boarding).

Méthode : Il s’agit d’une étude quasi expérimentale, monocentrique, observationnelle, rétrospective, par recueil d’informations à partir des dossiers patients informatisés. Nous avons appliqué un score de propension pour ajuster les critères de jugement aux variables mesurées dans les deux groupes, c’est-à-dire les données : 1) démographiques (âge et sexe) ; 2) médicales (niveau de triage) ; 3) biologiques (numération leucocytaire, hémoglobinémie, natrémie, kaliémie, taux sérique de CRP, créatininémie) ; 4) d’imageries (réalisation ou non de radiographie, d’échographie, d’imagerie par résonance magnétique, de tomodensitométrie).

Résultats : En 2017, la SU du CHU a admis 60 062 patients adultes. Sur les 15 496 patients hospitalisés après admission en SU, 6 997 l’ont été pour une étiologie médicale, dont 2 546 (36 %) sans attente et 4 451 (64 %) après une attente. Après pondération, le taux de mortalité intrahospitalière était plus important dans le groupe en attente : 7,8 vs 6,3 % ; p < 0,05. De même, la durée médiane d’hospitalisation était plus importante dans le groupe en attente : 7,6 [4,7– 12,0] vs 7,1 j [4,3–11,5] ; p < 0,01.

Discussion : Les taux de mortalité et de la durée de séjour intrahospitaliers sont plus importants chez les patients étudiés qui attendent en SU faute de place en service. Nos résultats sont concordants avec la littérature internationale. Il est nécessaire de trouver des solutions pour réduire cette surmortalité.

Acute medical unit: experience from a tertiary healthcare institution in Singapore

Singapore's healthcare system is under strain from the rising demands of an increasing and ageing population, resulting in delayed specialist care for patients presenting to the emergency department and requiring admission. Acute assessment units have been developed elsewhere but are not well established in local healthcare. Our institution extended our acute medical team to form an acute medical unit (AMU), in which focused internist-led teams are stationed on site to rapidly assess and re-triage patients. All patients (excluding those with very complex conditions) are admitted to the AMU and managed by internists who provide holistic, patient-centric care with better ownership, improved efficiency and less fragmentation. Patients can receive timely access to medical interventions and stable patients can benefit from early supported discharge, anchored by the nursing, allied health and transitional care teams. Given the ageing patient population with multiple comorbidities, this integrated model with exceptional outcomes is highly suitable for Singapore.

Emergency Department Ceiling Collapse: Response to an Internal Emergency

Hospital disaster resilience is often conceived as the ability to respond to external disasters. However, internal disasters appear to be more common events in hospitals than external events. This report describes the aftermath of a ceiling collapse in the emergency department of VieCuri Medical Center in Venlo, the Netherlands, on May 18, 2017. By designating the acute medical unit as a temporary emergency department, standard emergency care could be resumed within 8 hours. This unique approach might be transferrable to other hospitals in the developed world. In general, it is vital that hospital disaster plans focus on both external and internal disasters, including specific scenarios that disrupt vital hospital departments such as the emergency department. (Disaster Med Public Health Preparedness. 2019;13:829-830).

Acute care nurses' views on family participation and collaboration in fundamental care

AIMS AND OBJECTIVES

To understand the beliefs, attitudes and perceptions of nurses regarding family participation and collaboration in the care of their hospitalized adult relative.

BACKGROUND

Family participation in care is known to enhance the quality of patient care. Nurses are uniquely placed to support such participation, including the delivery of fundamental care. However, nurses' attitudes and beliefs may help or hinder participation.

DESIGN

A mixed methods approach with an exploratory sequential design was used.

SETTING

A regional referral hospital in Australia.

PARTICIPANTS

Nurses were eligible to participate in the study if they were permanent staff of the hospital, and who in their day-to-day work had direct contact with adult patients and their families on acute care wards.

METHODS

Observer-as-participant observation data and semi-structured interviews were undertaken. 30 hr of observational data were gathered, and 14 nurses were interviewed. Data collection occurred between September and December 2016. Following separate analysis, data were triangulated.

RESULTS

Analysis uncovered two contrasting categories: (i) enacting family participation (four themes); and (ii) hindering family participation (five themes).

CONCLUSION

The findings of our study demonstrated that the practices of nurses do not always align with healthcare policies, and strategies to support nurses to enact patient- and family-centred practices are needed.

RELEVANCE TO CLINICAL PRACTICE

Nurses can use these findings to make informed evidence-based changes to the way they practice and communicate with families to ensure fundamental care is delivered.

Prognostic value of early warning scores in the emergency department (ED) and acute medical unit (AMU): A narrative review

BACKGROUND

A wide array of early warning scores (EWS) have been developed and are used in different settings to detect which patients are at risk of deterioration. The aim of this review is to provide an overview of studies conducted on the value of EWS on predicting intensive care (ICU) admission and mortality in the emergency department (ED) and acute medical unit (AMU).

METHODS

A literature search was conducted in the bibliographic databases PubMed and EMBASE, from inception to April 2017. Two reviewers independently screened all potentially relevant titles and abstracts for eligibility.

RESULTS

42 studies were included. 36 studies reported on mortality as an endpoint, 13 reported ICU admission and 9 reported the composite outcome of mortality and ICU admission. For mortality prediction National Early Warning Score (NEWS) was the most accurate score in the general ED population and in those with respiratory distress, Mortality in Emergency Department Sepsis score (MEDS) had the best accuracy in patients with an infection or sepsis. ICU admission was best predicted with NEWS, however in patients with an infection or sepsis Modified Early Warning Score (MEWS) yielded better results for this outcome.

CONCLUSION

MEWS and NEWS generally had favourable results in the ED and AMU for all endpoints. Many studies have been performed on ED and AMU populations using heterogeneous prognostic scores. However, future studies should concentrate on a simple and easy to use prognostic score such as NEWS with the aim of introducing this throughout the (pre-hospital and hospital) acute care chain.