Position Statements

Interface between acute medicine and critical care

After wide consultation, and as used in JRCPTB documentation the agreed definition of Acute Medicine ‘is that part of general (internal) medicine concerned with the immediate and early specialist management of adult patients suffering from a wide range of medical conditions who present to, or from within hospitals requiring urgent or emergency care’. The acute medical unit is the specialised area of an acute hospital where patients suffering from acute medical illness can be assessed and initially managed.

There has been rapid change in the organisation and delivery of care for patients with medical illnesses over the last decade and more recently since the Acute Medicine sub specialty curriculum was established in 2005. The continued growth of this area of care has been reflected by the large number of reports and recommendations that have been produced the most recent of which include The Acute Medicine Task Force Report, RCPL and the UK Consensus Conference on Acute Medicine from the RCPE.   Both provide a framework that may be used to improve care for patients with acute medical problems. These include prompt assessment by a competent senior decision maker, facilitated access to investigations, accurate diagnosis and prompt instigation of treatment wherever it may be required. In addition these documents outline the required facilities and the need for close working with other specialties, in particular Critical Care and Emergency Medicine. As a minimum AMU’s must have dedicated monitoring facilities to provide level 1 care and for larger units the need for level 2 facilities is recognized with the defined level of staffing. Acute hospital physicians and those practicing acute medical care should be equipped by training, experience and the available facilities to provide this level care for patients with acute medical problems.

The Acute Internal Medicine (AIM) curriculum reflects the need for physicians who are dedicated to providing prompt, high quality and effective management of patients who present with acute medical illness. Working within the multi-professional team and with adequate facilities it is possible for such clinicians to improve patient care and outcomes. Even given the increasing number of patients with complex and long term medical problems and associated acute exacerbations. Trainees in Acute Internal medicine need to acquire competences relevant to:

  • the prompt practical management of acute presentation of medical illness,
  • the management of medical patients in an in-patient setting,
  • the development of new patient pathways to maximise safe, effective care in the community
  • the provision of leadership skills within an acute medical unit,
  • the development of multi-professional systems to promote optimal patient care,
  • the management of patients requiring more intensive levels of care

Critical care is essential to support acute medical admissions as medical patients numerically represent the most seriously ill subgroup of patients presenting to acute hospitals with a recognised hospital mortality of between 4-5%.

The recommendations from the reports referenced above suggest that in future level 3 facilities should be co-located with the AMU and ED, i.e. within the emergency floor, especially for larger acute hospitals. Close working relationships between AIM and critical care is, therefore, essential. All AMUs require an area that provides augmented care (Level 1–2 see below) and staff with competences to deliver this level of care. In some cases level 2 facilities are already embedded within the AMU to ensure provision of the higher level of care often required for many acute medical patients at the point of entry and need. Staff working in AMUs with HDU facilities must have the necessary critical care competences relevant to their local working environment and policies.

The AMTF report recommended that AMUs develop an augmented care area (up to level 2 care) and staff with competences to deliver this level of care. Safe transfer arrangements should be in place to ensure level 3 care is accessed when required. Staff in smaller hospitals (ideally based on the AMU) will still need competences in the assessment and stabilisation of critically ill patients prior to transfer to larger critical care units.

To ensure the appropriate skills in critical care are acquired the AIM curriculum requires that acute medical trainees are competent in the recognition and management of common medical problems including shock and respiratory failure and have the associated clinical skills in haemodynamic monitoring, non-invasive ventilations, CVP line and arterial line insertion etc). Training in AIM also specifies a placement within critical care to support training in these areas. Although some critical care training maybe acquired during CMT or ACCS training the society feels that this should be supplemented by further training as an AIM speciality trainee. The development of an acute medical syllabus for nursing is planned to ensure that the multi-professional team has the necessary skills to manage level 1 and level 2 patients frequently and competently.

It is important that the Society for Acute Medicine, the professional body for AIM, continues to work closely with Critical Care to ensure that the care to patients with higher level of need is coordinated and delivered to the highest standard.

Levels of care

Level 0

Patients whose needs can be met through normal ward care in an acute hospital

Level 1

Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care whose needs can be met on an acute ward with additional advice and support from the critical care team.

Level 2

Patients requiring more detailed observation or intervention including support for a single failing organ system or postoperative care, and those stepping down from higher levels of care.

Level 3

Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level included all complex patients requiring support for multi-organ failure

References

Royal College of Physicians of Edinburgh. UK Consensus Statement on Acute Medicine. BJHS 2009;70:56–7.

Royal College of Physicians. Acute medical care. The right person, in the right setting—first time. Report of the Acute Medicine Task Force. London: RCPL, 2007.

The Society of Acute Medicine (UK). Recommendations for Medical Assessment (admission) Units. Edinburgh: SAM (UK), 2003.

Effectiveness of acute medical units in hospitals: a systematic review. International Journal for Quality in Health Care 2009; Volume 21, Number 6: pp. 397–407

Mayor S. Acute medical units reduce deaths and stays in hospital. BMJ 2008;337:a1865. (Report of: 2nd International Conference of the Society for Acute Medicine, London, 2008).

McNeill G, Brahmbhatt DH, Prevost AT et al. What is the effect of a consultant presence in an acute medical unit? Presentation at: First International Conference of the Society for Acute Medicine, Glasgow, 2007.

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