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Emergency and acute medical care in over 16s: service delivery and organisation

About

What is covered

This interactive flowchart covers organising and delivering emergency and acute medical care for over 16s in the community and in hospital. It aims to reduce the need for hospital admissions by giving advanced training to paramedics and providing community alternatives to hospital care. It also promotes good-quality care in hospital and joint working between health and social services.

Updates

Updates to this interactive flowchart

6 September 2018 Emergency and acute medical care in over 16s (NICE quality standard 174) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on service delivery and organisation for emergency and acute medical care in over 16s in an interactive flowchart

What is covered

This interactive flowchart covers organising and delivering emergency and acute medical care for over 16s in the community and in hospital. It aims to reduce the need for hospital admissions by giving advanced training to paramedics and providing community alternatives to hospital care. It also promotes good-quality care in hospital and joint working between health and social services.

Updates

Updates to this interactive flowchart

6 September 2018 Emergency and acute medical care in over 16s (NICE quality standard 174) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Emergency and acute medical care in over 16s (2018) NICE quality standard 174

Quality standards

Emergency and acute medical care in over 16s

These quality statements are taken from the emergency and acute medical care in over 16s quality standard. The quality standard defines clinical best practice for emergency and acute medical care in over 16s and should be read in full.

Quality statements

Ambulance services

This quality statement is taken from the emergency and acute medical care in over 16s quality standard. The quality standard defines clinical best practice for emergency and acute medical care in over 16s and should be read in full.

Quality statement

Ambulance services have specialist and advanced paramedic practitioners.

Rationale

Paramedics with an enhanced level of education that is consistent with Health Education England’s multi-professional framework for advanced clinical practice in England can potentially reduce emergency department attendances and hospital admissions. Service delivery models for specialist and advanced paramedics need to take into account local geography, population demographics, and availability of and access to other health and social care services. There are different ways to deploy specialist and advanced paramedics so effective coordination using varied dispatch systems is needed to maximise the benefits these practitioners can provide.

Quality measures

Structure
a) Evidence of ambulance services supporting specialist and advanced paramedic training.
Data source: Local data collection, for example, personal development plans (PDPs), training plans and education and workforce strategies. The College of Paramedics and Health Education England’s Digital career framework includes details on the levels of experience and education required to undertake specialist and advanced paramedic practitioner roles.
b) Evidence of ambulance services having specialist and advanced paramedic practitioners who can respond to 999 calls for suspected medical emergencies.
Data source: Local data collection, for example service protocols and staff rotas.
Outcome
Proportion of incidents resolved without conveyance to an emergency department.
Data source: Local data collection, for example, audit of electronic case records. The National Audit Office report on NHS ambulance services includes details on resolved incidents without conveyance to an emergency department.

What the quality statement means for different audiences

Service providers (ambulance services) have specialist and advanced paramedic practitioners to assess and treat adults with suspected medical emergencies. They should have local arrangements in place to provide education and training for paramedic staff with sufficient post qualification experience to enable these staff to undertake specialist or advanced paramedic practitioner roles. Models of service delivery for paramedic practitioners need to take into account local geography, population demographics, and availability of and access to other health and social care services. They should also have effective coordination and dispatch systems within ambulance services to maximise the benefits of specialist and advanced paramedic practitioners.
Healthcare professionals (specialist and advanced paramedic practitioners) assess selected adults with suspected medical emergencies who need urgent care in the community. They provide enhanced assessment and treatment to decide whether the person can be discharged or needs further treatment and, if so, where they should be taken for further treatment.
Commissioners (clinical commissioning groups) ensure that they commission ambulance services that have specialist and advanced paramedic practitioners to provide enhanced assessment and treatment. They also ensure that effective coordination and dispatch systems are used within ambulance services to maximise the benefits of specialist and advanced paramedic practitioners.

Source guidance

Definitions of terms used in this quality statement

Specialist paramedic practitioner
A paramedic who has undertaken, or is working towards a postgraduate diploma (PGDip) in a subject relevant to their practice. They will have acquired and continue to demonstrate an enhanced knowledge base, complex decision-making skills, competence and judgement in their area of specialist practice.
[The College of Paramedics and Health Education England’s Digital career framework 2017]
Advanced paramedic practitioner
An experienced paramedic who has undertaken, or is working towards a master’s degree in a subject relevant to their practice. They will have acquired and continue to demonstrate an expert knowledge base, complex decision-making skills, competence and judgement in their area of advanced practice.
[The College of Paramedics and Health Education England’s Digital career framework 2017]

Assessment and initial treatment through acute medical units

This quality statement is taken from the emergency and acute medical care in over 16s quality standard. The quality standard defines clinical best practice for emergency and acute medical care in over 16s and should be read in full.

Quality statement

Adults with undifferentiated medical emergencies who need hospital admission are assessed and initially treated in an acute medical unit (AMU).

Rationale

An AMU provides rapid assessment, investigation and treatment for medical emergencies, which are often undifferentiated and may involve multiple medical pathologies. When there is clear pathology and a clear pathway (for example, for treatment of specific conditions such as an acute heart attack or acute stroke), AMU admission may not be appropriate. Assessment in an AMU can reduce mortality rates and length of stay.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that adults with undifferentiated medical emergencies who need hospital admission have an assessment and initial treatment in an AMU.
Data source: Local data collection, for example clinical protocols and agreed pathways.
Process
Proportion of hospital admissions for undifferentiated medical emergencies who were admitted to an AMU.
Numerator – the number in the denominator who are admitted to an AMU.
Denominator – the number of hospital admissions of adults for undifferentiated medical emergencies.
Data source: Local data collection, for example audit of electronic case records.
Outcomes
a) Hospital mortality rates for adults admitted to hospital for undifferentiated medical emergencies.
Data source: Local data collection, for example audit of electronic case records.
b) Length of hospital stay for adults admitted with undifferentiated medical emergencies.
Data source: Local data collection, for example audit of electronic case records.

What the quality statement means for different audiences

Service providers (such as emergency departments, urgent care centres, primary care and ambulance services) ensure that locally agreed referral pathways are in place for adults with undifferentiated medical emergencies who need hospital admission to have an assessment and initial treatment in an AMU. Service providers also ensure that staff are aware that when there is clear pathology and a clear pathway (for example, for resuscitation or treatment of specific conditions such as a heart attack), AMU admission may not be appropriate.
Healthcare professionals (such as acute physician-led multidisciplinary AMU teams) carry out an assessment and initial treatment for adults who have been referred to an AMU with undifferentiated medical emergencies that need hospital admission. The timescale of this assessment and the need for initial treatment is based on the person’s condition.
Commissioners (clinical commissioning groups) ensure that they commission AMUs with sufficient resources and expertise to carry out assessments and initial treatment for adults who have been referred to an AMU with undifferentiated medical emergencies that need hospital admission.
Adults who are referred to hospital with a medical emergency that has no exact known cause have an assessment and their initial treatment in an acute medical unit.

Source guidance

Definitions of terms used in this quality statement

Undifferentiated medical emergencies
Acute medical conditions with no exact known cause and no clear, predetermined clinical pathway, and for which hospital assessment is deemed necessary.
[Expert opinion]
Acute medical unit
An acute medical unit (AMU; also called an acute assessment unit [AAU] or medical admissions unit [MAU]) is an area of an acute hospital where people with undifferentiated medical emergencies who need hospital admission receive rapid assessment, investigation, initial treatment and definitive management. Referral to AMUs is based on locally agreed referral pathways.
[Adapted from the evidence review on assessment through acute medical units for NICE’s guideline on emergency and acute medical care in over 16s: service delivery and organisation, and expert opinion]

Consultant assessment and review

This quality statement is taken from the emergency and acute medical care in over 16s quality standard. The quality standard defines clinical best practice for emergency and acute medical care in over 16s and should be read in full.

Quality statement

Adults admitted with a medical emergency have a timely consultant assessment and review.

Rationale

Having consultants available for timely assessment and review is associated with reduced length of stay for people admitted to hospital with a medical emergency. The frequency of consultant review is based on clinical need. Clinical review should be carried out at least daily, including at weekends and bank holidays.

Quality measures

Structure
a) Evidence of consultant availability during daytime working hours to assess adults who have a medical emergency within 6 hours of the time of admission to hospital.
Data source: Local data collection, for example, from staff rotas and service specifications. For measurement purposes, the first consultant review within a maximum of 6 hours from the time of admission to hospital has been included during the daytime working hours timeframe (normally at least 08.00 to 20.00) based on NHS England (2017) Seven Day Services Clinical Standards.
b) Evidence of consultant availability to assess adults who have a medical emergency within 14 hours of the time of admission to hospital.
Data source: Local data collection, for example, from staff rotas and service specifications. For measurement purposes timeframes have been included based on NHS England (2017) Seven Day Services Clinical Standards and Society for Acute Medicine (2017) Benchmarking audit. These align with the examples of possible considerations in NICE guideline NG94, recommendation 1.2.5.
c) Evidence of consultant availability to review adults daily who have a medical emergency after the initial consultant review is carried out.
Data source: Local data collection, for example, from staff rotas and service specifications. NHS England (2017) Seven Day Services Clinical Standards includes details of ongoing daily consultant review.
Process
a) Proportion of hospital admissions for adults with a medical emergency during the daytime working hours in which a consultant assessment is carried out within 6 hours of the time of admission to hospital.
Numerator – the number in the denominator in which a consultant assessment is carried out within 6 hours of the time of admission to hospital.
Denominator – the number of hospital admissions of adults with a medical emergency during the daytime working hours.
For measurement purposes, the daytime working hours timeframe (normally at least 08.00 to 20.00) of first consultant review within a maximum of 6 hours from the time of admission to hospital has been included based on NHS England (2017) Seven Day Services Clinical Standards.
Data source: Local data collection, for example, audit of electronic case records. NHS Digital (2018) Accident and Emergency Quality Indicators includes information on time to initial assessment.
b) Proportion of hospital admissions for adults with a medical emergency in which a consultant assessment is carried out within 14 hours of the time of admission to hospital.
Numerator – the number in the denominator in which a consultant assessment is carried out within 14 hours of the time of admission to hospital.
Denominator – the number of hospital admissions for adults with a medical emergency.
For measurement purposes, the timeframe of first consultant review within a maximum of 14 hours from the time of hospital admission has been included based on NHS England (2017) Seven Day Services Clinical Standards and Society for Acute Medicine (2017) Benchmarking audit.
Data source: Local data collection, for example, audit of electronic case records. NHS Digital (2018) Accident and Emergency Quality Indicators includes information on time to initial assessment.
c) Proportion of hospital admissions for adults with a medical emergency in which a consultant review is carried out at least once every 24 hours after the initial consultant review.
Numerator – the number in the denominator in which a consultant review is carried out at least once every 24 hours.
Denominator – the number of hospital admissions for adults with a medical emergency in which the person has had the initial consultant review.
Data source: Local data collection, for example local audit of patient records, staff rotas and service specifications. NHS England (2017) Seven Day Services Clinical Standards includes a timeframe for consultant review of at least once every 24 hours after the initial consultant review.
Outcome
Length of hospital stay for adults admitted with a medical emergency.
Data source: Local data collection, for example, local audit of patient records. NHS Digital Hospital episode statistics includes length of stay data.

What the quality statement means for different audiences

Service providers (secondary care providers including emergency departments and acute medical units) ensure that consultants are available to assess adults with a medical emergency within a maximum of 14 hours from the time of hospital admission to determine the care pathway. The frequency of consultant review is based on clinical need. Current local staffing models, the case mix presenting and the severity of illness should be considered to ensure early consultant involvement. Staff rotas may need to be reconfigured to support the timing and frequency of consultant review.
Healthcare professionals (consultants) assess adults with a medical emergency face to face as soon as possible and always within a maximum of 14 hours of the time of hospital admission. During daytime working hours a review should normally occur within a maximum of 6 hours of the time of admission. The frequency of consultant review is based on clinical need. It should be carried out at least daily, including at weekends and bank holidays.
Commissioners (clinical commissioning groups) ensure that they commission services using a service specification that states that there are consultants available to assess adults with a medical emergency within a maximum of 14 hours from the time of hospital admission and to review them daily. Commissioners monitor contracts and seek evidence that service providers have these consultants available.
Adults who are admitted to hospital with a medical emergency are seen by a consultant within 14 hours of admission, and at least once a day while they are in hospital.

Source guidance

Definition of terms used in this quality statement

Medical emergency
A life-threatening emergency, acute exacerbation of chronic illness or routine health problem that needs prompt action. A medical emergency can arise in anyone, for example in people:
  • without a previously diagnosed medical condition
  • with an acute exacerbation of underlying chronic illness
  • after surgery
  • after trauma.
[NICE’s guideline on emergency and acute medical care in over 16s: service delivery and organisation, guideline introduction (glossary)]

Structured patient handovers

This quality statement is taken from the emergency and acute medical care in over 16s quality standard. The quality standard defines clinical best practice for emergency and acute medical care in over 16s and should be read in full.

Quality statement

Adults admitted with a medical emergency have a structured patient handover during transitions of care.

Rationale

Structured patient handovers between the transferring and receiving teams are associated with improvements in patient experience.

Quality measures

Structure
Evidence of structured (verbal and written or electronic) handover processes during transitions of care for adults who have been admitted with a medical emergency.
Data source: Local data collection, for example, ward transfer protocols. NHS England (2017) Seven Day Services Clinical Standards and the Royal College of Physicians (2011) Acute care toolkit 1: handover both include details on patient handover processes.
Process
Proportion of transitions of care for adults admitted with a medical emergency in which a structured handover of care is carried out.
Numerator – the number in the denominator who have a structured handover of care.
Denominator – the number of transitions of care for adults admitted with a medical emergency.
Data source: Local data collection, for example, local audit of patient records.
Outcome
Patient experience of the structured care handover during transitions of care.
Data source: Local data collection, for example local audit of patient records.

What the quality statement means for different audiences

Service providers (primary, secondary and community-based intermediate care) have processes in place to ensure that during transitions of care a structured handover of care (verbal and written or electronic) is carried out for adults who have been admitted with a medical emergency. The current care provider shares complete and up-to-date care information with the new care provider, who documents and acts on this information. Roles and responsibilities between the current and new care providers are also clearly defined at transferral. Service providers ensure that healthcare professionals have training in structured patient handovers and supervision with monitoring of competency.
Health and social care professionals (such as doctors, nurses, advanced clinical practitioners, physiotherapists, mental health teams and pharmacists) work together to deliver a structured handover of care (verbal and written or electronic) during transitions of care for adults who have been admitted with a medical emergency. They share complete and up-to-date information so that patient safety is not compromised. Roles and responsibilities between the current and new care providers are also clearly defined at transition of care.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that enable coordination and continuity of care, and sharing of information, during transitions of care for adults who have been admitted with a medical emergency.
Adults who have been admitted to hospital with a medical emergency and whose care is being transferred to a different healthcare setting have information about their condition and any special needs passed on to their new care provider. They are given information about their condition and encouraged to be involved in making decisions about their care.

Source guidance

Definitions of terms used in this quality statement

Medical emergency
A life-threatening emergency, acute exacerbation of chronic illness or routine health problem that needs prompt action. A medical emergency can arise in anyone, for example in people:
  • without a previously diagnosed medical condition
  • with an acute exacerbation of underlying chronic illness
  • after surgery
  • after trauma.
[NICE’s guideline on emergency and acute medical care in over 16s: service delivery and organisation, guideline introduction (glossary)]
Structured patient handover
A handover of care that uses the approach outlined in the SBAR (situation–background–assessment–recommendation) tool to facilitate efficient handover of patients between transferring and receiving teams. It includes:
  • a summary of the stay, including diagnosis and treatment
  • a monitoring and investigation plan
  • a plan for ongoing treatment, including drugs and therapies, nutrition plan, infection status and any agreed limitations of treatment
  • a discharge plan
  • physical and rehabilitation goals
  • mental health, psychological and emotional needs
  • specific communication or language needs
  • tasks still to do.
The plan also needs to be communicated to the person or their next of kin.
[Adapted from NICE's guideline on acutely ill adults in hospital, recommendation 1.15, the NHS Institute for Innovation and Improvement’s Safer care SBAR implementation and training guide and expert opinion]

Equality and diversity considerations

When adults admitted with a medical emergency are being transferred to a different healthcare setting they should be provided with handover information that they can easily read and understand themselves, or with support from their next of kin if appropriate. This can help them to communicate effectively with healthcare services. Information should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and be culturally and age-appropriate. People should have access to an interpreter or advocate if needed.
For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

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Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Offer advance care planning to people in the community and in hospital who are approaching the end of life and are at risk of a medical emergency. Ensure that there is close collaboration between the person, their families and carers, and the professionals involved in their care. See NICE's recommendations on end of life care for people with life-limiting conditions.

Glossary

critical care outreach teams

Paths in this pathway

Pathway created: March 2018 Last updated: September 2018

© NICE 2018. All rights reserved. Subject to Notice of rights.

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