Enhanced care for patients who need more than routine ward care
Acute Medical Enhanced Care provides closer monitoring, enhanced nursing support and appropriate treatments for acutely unwell adults whose needs exceed routine ward provision but do not require Level 2 or Level 3 critical care.
Delivered through the Acute Medical Unit (AMU) and in close partnership with critical care, it helps ensure patients receive the right intensity of care with clear pathways for deterioration, escalation and recovery.
Enhanced care complements critical care. It must never be used to deny or delay critical care when that is indicated.
This is a clinical continuum, not a mandatory sequence of transfers.
Understanding Acute Medical Enhanced Care
Enhanced Care is defined by the patient's need, the skills of the team and the available monitoring and treatment, not solely by a bed label or a physical room.
What an Acute Medical ECU provides
- Focused care for medical patients at significant risk of clinical deterioration.
- Closer physiological monitoring and more frequent clinical reassessment than routine ward care.
- Skilled nursing, senior medical review and timely multidisciplinary input.
- Locally agreed treatments supported by appropriate equipment, staffing and competencies.
- Direct collaboration with critical care and its outreach service.
What it must not become
- A substitute for Level 2/3 critical care when critical care is required.
- An ordinary ward renamed without increasing staffing, monitoring and clinical capability.
- An ungoverned location for interventions beyond local staff competency.
- An overflow area that routinely displaces appropriate enhanced-care patients.
- A service without agreed admission, transfer, deterioration and escalation pathways.
Across the UK: SAM's acute medical guidance and the FICM framework are relevant to service development in all four nations. Detailed implementation, commissioning and reporting should follow each nation's arrangements and the organisation's approved policies.
The guidance underpinning Acute Medical Enhanced Care
The central document is the joint SAM–Intensive Care Society guidance. Read the full document alongside the broader hospital Enhanced Care framework developed by FICM.
SAM–ICS: Enhanced Care Units within Acute Medicine
Published November 2022 and endorsed by the Royal College of Nursing. Covers patient cohorts, clinical leadership, bed spaces, monitoring, staffing, physiotherapy, pharmacy, safety, escalation and working with critical care.
FICM: Enhanced Care in the hospital setting
The overarching, multi-specialty framework from May 2020, developed with the Royal Colleges of Physicians and with SAM involvement. Supports locally appropriate models with clearly defined governance and critical care collaboration.
Guidance review status: The SAM–ICS document names November 2025 as its review date. Until a revised edition is formally published, link to the existing document and verify its status with SAM and ICS before describing any individual recommendation as newly updated.
Which patients benefit — and how should the pathway work?
The right patient for an ECU needs enhanced observation or treatment but does not need, or may not be suitable for, critical care. Every admission requires an individual assessment and an agreed ceiling of treatment.
Patients at risk of deterioration
Acutely unwell medical patients needing intensive clinical observation or treatment beyond what is reliably deliverable in routine ward care.
Patients requiring enhanced monitoring
For example, patients needing continuous monitoring, frequent review or monitoring following selected time-critical therapies.
Selected patients needing respiratory support
Where a dedicated respiratory support unit is not the appropriate or available pathway, and locally agreed staffing, equipment and critical care support are in place.
Recognise risk, initiate treatment and use agreed ECU referral criteria.
Confirm suitability, responsibilities and treatment escalation goals.
Provide appropriate staff, monitoring, interventions and timely senior review.
Reassess rapidly and involve critical care/outreach when clinically needed.
Move to critical care, a ward or another appropriate destination when safe.
Illustrative process only. Local SOPs should define referral, inclusion and exclusion criteria, review and escalation responsibilities, treatment ceilings, and transfer arrangements.
Developing an Acute Medical Enhanced Care Unit
A practical starting framework for teams planning an ECU, expanding an existing service or reviewing whether their current clinical capability matches patient acuity.
Understand local demand
Review acuity, deterioration events, higher-dependency needs, critical care referrals and current gaps in the acute medical pathway.
Agree clinical scope
Define patient cohorts, exclusions, permitted therapies, operating hours, referral routes and escalation arrangements with critical care.
Design staffing
Set appropriate nursing ratios and skill mix, senior physician cover, education, pharmacy, physiotherapy and wider MDT access.
Plan the environment
Provide suitable bed spaces, continuous monitoring, oxygen and suction, access to blood gases, ultrasound and urgent diagnostics.
Establish governance
Agree a multidisciplinary operational policy, training, safety huddles, incident review, M&M processes and shared critical care governance.
Evaluate and improve
Review patient outcomes, escalation delays, ward transfers, staffing and service capability. Use findings to revise pathways and resources.
Build from experience: SAM's members-only Enhanced Care database contains real unit examples, SOPs, admission criteria, facilities information and clinical contacts. Open the member database →
Workforce, capability and clinical review
The joint SAM–ICS document contains useful benchmarks, which must be interpreted alongside acuity, case mix, competencies and the agreed treatment model.
In the 2022 SAM–ICS guidance, adjusted for individual dependency and local service requirements.
Where specified therapies such as non-invasive respiratory support or vasopressors are used, or for side-room needs.
The guideline recommends availability to assess patients following ECU admission or deterioration.
At least two per day, with one by a consultant or equivalent, as recommended in the guidance.
The multidisciplinary team
In addition to acute medical and nursing staff, the guideline calls for named physiotherapy and pharmacy leads, seven-day input from both disciplines, and access to microbiology, palliative care and other relevant services according to need.
Competency-based nursing development
SAM endorses the NOrF–CC3N competency framework for Level 1 patients and Enhanced Care areas. Build local supervision, education and documented competency into workforce planning.
Figures above are recommendations in the SAM–ICS 2022 document, not universal statutory staffing rules. They do not replace acuity-based assessment, professional judgement, employer obligations or later applicable guidance.
Safety, escalation and partnership with critical care
Good enhanced care relies on governance as much as the physical bed space. Collaboration must be embedded in the model before higher-acuity patients are admitted.
Safety and clinical leadership
- Named medical, nursing, physiotherapy and pharmacy leads.
- Written admission, discharge, staffing and escalation policies.
- Structured safety briefings and robust morbidity and mortality review.
- Documented treatment escalation plans and personalised goals of care.
- Review of deterioration, incidents, medication safety and care outcomes.
Boundaries that must remain clear
- Critical care consultation and a transfer route must be available at all times.
- Patients who require critical care should not be retained in an ECU because of capacity pressure.
- Higher-risk interventions require explicit protocols, training and critical care agreement.
- Local capability should reflect staffing, monitoring and infrastructure, not merely a procedure list.
- Ceilings of treatment must be individualised and reviewed with the patient where appropriate.
Clinical treatments: The SAM–ICS guidance discusses non-invasive respiratory support and, where appropriate, invasive blood pressure monitoring or peripheral vasopressors. Their inclusion in a guidance document does not make them mandatory ECU services. Local critical care agreement, training, staffing and safety protocols are essential wherever these treatments are offered.
National standards and related clinical guidance
A selected reference library for service leaders, nursing teams and clinicians. These documents serve different purposes: ICU standards do not automatically become ECU standards.
Learning from practice and improving Enhanced Care
Use structured service evaluation and shared examples to develop safe, sustainable provision. There is a need for more research and national benchmarking specifically addressing acute medical Enhanced Care.
What should an ECU review?
- Referral source, case mix, acuity and admission suitability.
- Timeliness of senior review and physiological monitoring.
- Staffing, competency, occupancy and capacity-related exclusions.
- Clinical deterioration, critical care referrals and transfer delays.
- Incidents, mortality review, length of stay and patient experience.
- Consistency with the local operational policy and escalation plan.
Suggested domains for local QI, not newly approved national quality indicators.
Examples and practical tools
SAM already hosts a members-only Enhanced Care database with example SOPs, admission criteria, unit information and contacts. This resource should be the practical companion to the publicly accessible guidance.
Open members-only ECU database →
Have an established ECU? Share or update your unit information by emailing administrator@acutemedicine.org.uk .
Enhanced Care belongs within a joined-up acute medical pathway
Safe services are designed around patient need, genuine workforce capability and close collaboration with critical care. Explore the related SAM guidance and share experience with the wider Acute Medicine community.
Resources reviewed October 2026. This page supports service development and does not replace patient-specific clinical decisions or locally approved operating policies.