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Acute medicine: making it work for patients A blueprint for organisation and training


Medicine, nursing, physiotherapy, OT, SALT, dietetics. Patient focused care ... Nursing, physiotherapy or OT backgrounds. Postgraduate Diploma in Health Care Practice ... – PowerPoint PPT presentation

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Title: Acute medicine: making it work for patients A blueprint for organisation and training

Acute medicine making it work for patientsA
blueprint for organisation and training
  • A working party report from the Royal College of
    Physicians of London 2004

Traditional model for acute care
  • gt 80 medical admissions are emergencies,
    presenting through AE
  • A team of junior doctors deliver the service
  • Almost all Consultant physician practice Acute
    Medicine alongside an organ based specialty
  • No specific time assigned to provide acute care
  • Emergency work fitted around elective activities
    like OPD, procedures etc

Problems Acute Care
  • Increasing numbers acute admissions
  • Aging population
  • Reduction in number of acute beds
  • Increasing organ based specialisation
  • Competing demands for specialty work and Acute
  • Difficulties in keeping skills up to date
  • Increasing public expectations

Problems Acute Care
  • Changing patterns of junior doctors working
  • Reduction in working hours
  • Structured training and education
  • Data suggesting sub-optimal care of severely ill
    medical patients
  • Poor recognition of physiological deterioration
    (BMJ 1998 JCRPL 1999)
  • Lack of senior medical input at initial

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Future Patterns of Care by General and Specialist
PhysiciansReport of a Working Party RCPL 1996
  • Care by Physicians with specialty interest
  • A new type of physician with specific
    responsibility for the care of acute medical
    emergencies A radical proposal requires

Acute Medical Admissions and the Future of
General MedicineScottish Intercollegiate Working
Party RCPE 1998
  • Creation of Acute medical admission wards
  • Dual Accreditation in G(I)M and specialty
  • Care by physicians with speciality interest
  • Study interface Medicine and AE
  • Hospitals consider appointing physicians in
    acute care medicine

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Acute Medicine the Physicians role. Proposals
for the futureFederation of Medical Royal
Colleges.RCPL 2000
  • Dual accreditation
  • Care by physicians with specialty interest
  • Ensure twice daily senior ward round
  • Adequate consultant time for emergency care
  • Allocate time to supervise and develop Medical
    Admission/Assessment units
  • appointment of physicians solely to provide
    acute care without links to a specialty should be
    actively discouraged

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The interface between acute general medicine and
critical careA working party report RCPL 2002
  • Early involvement of senior physicians is crucial
  • Consultant physicians need to keep up their
    practical skills
  • Rapidity of decision making and prompt
    resuscitation more important than precise
  • Need to provide critical care without walls

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The Interface of Accident and Emergency and Acute
MedicineA Working Party Report RCPL 2002
  • Improve the interface between AE and Acute
  • Appoint consultant physicians to provide strong
    leadership for acute medical care
  • Sound assessment and management of acutely ill
    patients require specific skills

Acute Medicine A new medical specialty
  • In July 2003 Specialist Training Authority
    recognised Acute Medicine as a sub-speciality of
    General (Internal) Medicine
  • Emphasis on skills and training in rapid
    assessment and treatment of acute medical

Acute medicine making it work for patientsA
blueprint for organisation and training
  • A working party report from the Royal College of
    Physicians of London 2004
  • Focuses on Acute Medicine as a new specialty

Acute Medicine
  • part of General (Internal) Medicine concerned
    with the immediate and early specialist
    management of adult patients with a wide range of
    medical conditions who present to hospitals as
  • Acute medicine differs from Emergency medicine
    as it does not deal with surgical conditions,
    trauma and minor injuries or paediatric

Consultant Physicians in Acute Medicine
  • Have expertise in rapid assessment, diagnosis and
    management of patients with acute medical
  • Manage Acute Medicine services
  • Lead Acute Medicine Units (AMUs)
  • Lead multidisciplinary clinical teams
  • Educate trainees as well as consultants in other
  • Support colleagues in AE, HDU and general wards

Raising the profile in Acute MedicineSociety for
Acute Medicine and RCPL
  • Consultant physician in Acute Medicine as lead
    clinician in every Trust
  • Regional Specialty Advisor (RCP and SAM)
  • National Director of Acute Medicine (DoH)
  • Committee for Acute and General Internal Medicine
  • Secure an academic and research base

Education and Training in Acute Medicine
  • Dedicated undergraduate training
  • 2 year Foundation Training
  • Improve exposure Primary Care and AE
  • 2-3 years Basic Medical Training
  • Rotations through AMUs
  • Blocks of 1-4 months
  • Wide ranging experience in medical specialties

Education and Training in Acute Medicine
  • Subspecialty training in acute medicine
  • HST in G(I)M plus one extra year
  • Mandatory experience in AMUs, CCUs, ITUs, HDUs,
    AE depts and geriatric medicine
  • RCP IMPACT course
  • Ill medical patients Acute Care and Treatment
  • Acute Medicine Curriculum
  • Clinical, management, organisational skills

Workforce Requirements in Acute Medicine
  • Currently physicians with specialty interest
    deliver most acute care
  • Require increase in training posts
  • Contributions across the interfaces
  • At least THREE consultants in Acute Medicine by

Job Plans and Career Paths
  • Flexible according to local need
  • Acute Medicine with no specialty interest
  • 5 DCC PA in acute medicine on AMU
  • 1.5 DCC PA other acute related activity, HDU/ICU,
    speciality or emergency clinics or procedures
  • 1 PA AMU development
  • Acute Medicine with additional specialty
  • 4 DCC PA in acute medicine
  • 3.5 speciality interest

Maintaining Standards of Care
  • Assessment and management plan within 4 hours
  • SpR or equivalent in medicine (MRCP) present at
    all times in all units, covering AMU, case review
  • 1 hour for junior medical staff to assess and
  • Consultant Review within 24 hours - FIFTEEN
    minutes per patient

Maintaining Standards of Care
  • 15 minutes 16 new patients in 4 hour PA
  • Allows Clinical Directors to calculate consultant
    time required for Acute Medicine
  • Medium Term
  • Physician in Acute Medicine on site 08-22.00
  • Long Term
  • Physician in Acute Medicine 24/7 - matched by
    support services

The Emergency DepartmentMedicine and Surgery
InterfaceProblems and Solutions
  • Professor Carol Black RCP
  • Sir Peter Morris RCS
  • Sir George Alberti DoH
  • Dr Alaistair McGowan FEM
  • Dr Martin Shalley BAEM

Reforming Emergency CareProblems
  • Competing needs challenges balancing elective
    and emergency workloads
  • Demands of teaching and academic medicine
  • Lack of integration of hospital ED with wider
    health and social care community
  • Patient care delayed by professional barriers

Reforming Emergency Care Problems
  • 5. Patient care delayed by poor management of
    clinical information
  • 6. Shortages of consultants in many acute medical
    and surgical specialities
  • 7. Use of most junior of team as first contact
  • 8. Time for speciality teams to see ED referrals
  • 9. Inability of ED seniors to admit directly

Reforming Emergency Care Problems
  • 10. Patient care delayed by over
    compartmentalised hospital
  • 11. EWDT
  • 12. Absence of Acute Assessment Units and
    Observations Units
  • 13. Lack of funding for Acute Physician posts
  • 14. Delays in radiology and lab. investigations
  • 15. Time taken common, less complex cases

Reforming Emergency CareSolutions
  • Separate elective and emergency work
  • Increase consultants in acute specialities
  • SpR medicine to be based in AE or AMU
  • 3 Physicians in Acute Medicine in every trust by
  • Investigations and support 24/7
  • Protocols for multidisciplinary management and

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Skillmix and the Hospital DoctorNew Roles for
the Health Care Workforce
  • Extended roles and working flexibly across
    professional boundaries
  • Suggested new post of Health Care Practitioner
  • possible dutiesadmin, technical, communication,
    treatment, limited prescribing.

The Terminology is a MUDDLE
  • Physicians Assistants
  • Health Care Practitioners HCP
  • Assistant HCP
  • Emergency Care Practitioners ENP
  • Medical Support Workers
  • Medical Technicians

Whatever they are called.
  • Need for proper career structure
  • Qualification to enable nationwide recognition /
    transferability of skills
  • Need for statutory Register of competent

Physician Assistant in USA / Canada / Netherlands
  • What we have in the UK
  • Clinical workforce shortage

Physician Assistant in USA
  • highly qualified health professionals who are
    prepared, through a demanding academic and
    clinical curriculum, to provide health care
    services under physician supervision
  • Master of Physician Assistant Studies (MPA)
  • Master of Science in Health Sciences (MSHS)
  • Master in Public Health (MPH)

National Commission on Certification of Physician
  • On graduation with Masters degree PA must pass
    national certifying exam
  • Complete 100 hours of CME every two years
  • Pass a recertifying exam every 6 years
  • NCCPA- independent accrediting agency assures
    the public that NCCPA credentialed PAs meet
    established standards of knowledge and skills on
    entry and throughout their careers

  • Accreditation Review Commission on Education for
    the Physician Assistant
  • Evaluates PA programmes and awards accreditation
    based on compliance with guidelines in the
    Educational Standards for Physician Assistant
  • Established by American Medical Association

Physicians Assistants in USA
  • Standardised training
  • Common qualification (Masters degree)
  • National Accreditation NCCPA
  • Regulation through NCCPA
  • Mandatory CME and re-examination
  • Recertification / revalidation
  • Professional Support American Academy of
    Physicians Assistants
  • Personal indemnity

Medical Support Workers in the UK
  • Crisis development
  • Lots of good practice (CWP)
  • Variable around UK
  • More limited roles
  • Unregulated
  • No career structure
  • Indemnity unresolved

Medical Support Workers
  • 6 surgical HCAs Salford
  • Venous bloods, cannulation, blood cultures, ecg,
    Clerical support, filling in forms, organising
    tests, result chasing.
  • TWO week intensive training programme
  • 7 Medical Assistants Winchester
  • DoH pilot site
  • 10 day intensive training
  • Support Junior Doctors

Physicians Assistants Addenbrookes
  • 20 PA in Medical Services
  • 3 week induction programme
  • NVQ level 3 Direct Care
  • Tasks and administration
  • Overwhelmed in the rush 50 not clinical
  • No limit to procedures
  • Indemnity is the problem (de-skilling is not)

(No Transcript)
CWP Role Redesign
  • 16 pilot sites
  • Design and test new roles /ways of working
  • Progress report Spring 2003
  • Kingston HCP
  • Warwick Emergency Care Practitioners
  • Portsmouth University Medical Technicians
  • GMWDC Work, Earn and Learn
  • Share and disseminate good practice

Kingston Hospital and St Georges Medical School
  • Changing Workforce programme
  • Health Care Practitioners (and Assistants)
  • Training lasts one year
  • Elements of many professions
  • Medicine, nursing, physiotherapy, OT, SALT,
  • Patient focused care

Kingston HCP and HCPA
  • Need not be health care background
  • Nursing, physiotherapy or OT backgrounds
  • Postgraduate Diploma in Health Care Practice
  • Modular, problem based learning, case studies,
    tutorials, practical sessions, supernumerary
    clinical placement

Kingston HCPSeven defined disease states
  • Seven modules
  • Asthma, COPD
  • Acute coronary syndrome
  • Upper GI bleed
  • Stroke
  • Pneumonia, UTI
  • Follow Integrated Care Pathways
  • Deliver assessment, care and treatment of
    selected group medical inpatients on MAU

Kingston 13 HCP, 14 HCPA
  • Clerks patient, provisional diagnosis, orders and
    interprets tests, initiates treatment, provides
    basic physio, OT, SALT, nursing care, patient
  • Discusses with doctor on post take ward round
    and routine ward rounds
  • HCP perceived as very successful by majority
    (though not all) Consultant Physicians
  • Project closing early (unrelated to roles)

Portsmouth UniversityFoundation degree in
Applied Medical Technology
  • 2 year course
  • Defined Curriculum
  • Tasks and underpinning knowledge
  • Do what the doctor requires
  • University course
  • Not registered practitioners
  • Regulation unclear

Greater Manchester Workforce Development
Confederation Work, Earn and Learn
  • Need 2000 more clinical staff by 2004
  • Assistant Practitioners
  • Two year foundation degree course (3yr PT)
  • 1st year generic nursing skills
  • NVQ level 3
  • 2nd year specialised different modules
  • Diploma in Health and Social Care

Greater Manchester Workforce Development
  • Work, earn and learn learning through doing
  • 1 day university, 4 days at Trust
  • Help deliver service - WDC pay 1 day education
  • Initially conversions existing Health Care roles
  • Now new recruits female, 30-50, post family,
    life skills but low educational attainment, not
    registered unemployed, keen for career in Health
    and social care

Greater Manchester Workforce Development
  • Started Sept 02, second intake Jan 03
  • Current numbers 387 trainees
  • Attrition 6
  • Aim recruit 500 new each year till 05/06
  • Skills for Health
  • Quite basic skills..

Modernisation AgencySkills for Health
  • National occupational standards for health
  • Developing competency frameworks for long term
    conditions and emergency care
  • Developing new roles
  • Service / team/ organisational development
  • Personal and career development

  • NHS
  • Modernisation Agency
  • Changing Workforce Programme
  • Extended Roles
  • Professional Boundaries
  • Fluidity of stages
  • Flexible Workforce
  • Life Long Learning
  • Additional skills and competencies allows Career

CWP - Mapping CareersAn enabling career framework
  • Skills escalator approach - Stages 1-9
  • 1-4 Nonregistered / regulated workforce
  • 5-9 Registered and regulated workforce
  • Facilitate moves between stages and staff groups
  • Encourage life long learning
  • Level 4 support staff, undertaking new roles -
    clinical duties previously reserved for
    registered staff

Physicians Assistants in UK
  • No agreed curriculum or standardisation of
  • No central register or agreed qualification
  • Professional Staff
  • Current registration and codes of conduct
  • Non registered staff undertaking new roles with
    direct clinical care
  • Regulation?

Modernisation Agency New Ways of
WorkingProgramme Board
  • Diagnostic Practitioner Primary Care
  • Physician Practitioner Acute Care
  • Development of core curriculum
  • Training and Practice Framework with associated
  • Regulation Health Professionals Council