acute medicine: the scottish perspective - hse.ie€¦ · acute medicine: the scottish perspective...
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Acute Medicine: The Scottish perspective
Essential actions, flow and a touch of realism
@djbeckett
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“The Scottish Patient Safety Programmemarks Scotland as leader,
second to no nation on earth, in its commitment to reducing
harm to patientsdramatically and continually”
Donald M Berwick, MPPFormer President and CEOInstitute for Healthcare Improvement
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Fill rates
0%
20%
40%
60%
80%
100%
Scotland England
Fill rates, A(I)M, 2015
0%
20%
40%
60%
80%
100%
2013 2014 2015
Acute (Internal) Medicine fill rates, Scotland
Unfilled
Filled
SAM Scotland
• Hosted by RCPE
• Route of entry through SAM UK, initially with no additional cost (regional representation)
• Annual conference (next is December 14th 2018 at FVRH…)
@weeSAMScotland
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2013 2014 2015 2016 2017 2018
Acute (Internal) Medicine fill rates, Scotland
Unfilled
Filled
Scottish Government
• ‘Acute Physicians play a key role in the Unscheduled Care process and we are keen to see a vibrant and representative SAM Scotland work with us and the other key partners to improve patient and staff experience which are inextricably linked’
Alan Hunter, Director of Performance,
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Emergency Access Standard
• The Emergency Department cannot deliver this target alone
• It requires a whole system response to ensure capacity meets demand - by hour of the day and day of the week
• Whole system barometer
Crowding
There is an association between ED crowding and:
• Mortality
• Increased length of stay both in ED and I/P
• Reduced quality of care
• Poor patient experience
• Staff burnout
• Difficulty recruiting and retaining staff
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5.1%
3.6%
5.4%
1.3%
4.6%
2.0%
3.0%
6.1%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
11%
12%
13%
14%
15%0
8/1
1/2
009
22/1
1/2
009
06/1
2/2
009
20/1
2/2
009
03/0
1/2
010
17/0
1/2
010
31/0
1/2
010
14/0
2/2
010
28/0
2/2
010
14/0
3/2
010
07/1
1/2
010
21/1
1/2
010
05/1
2/2
010
19/1
2/2
010
02/0
1/2
011
16/0
1/2
011
30/0
1/2
011
13/0
2/2
011
27/0
2/2
011
13/0
3/2
011
06/1
1/2
011
20/1
1/2
011
04/1
2/2
011
18/1
2/2
011
01/0
1/2
012
15/0
1/2
012
29/0
1/2
012
12/0
2/2
012
26/0
2/2
012
11/0
3/2
012
11/1
1/2
012
25/1
1/2
012
09/1
2/2
012
23/1
2/2
012
06/0
1/2
013
20/0
1/2
013
03/0
2/2
013
17/0
2/2
013
03/0
3/2
013
17/0
3/2
013
31/0
3/2
013
14/0
4/2
013
28/0
4/2
013
12/0
5/2
013
26/0
5/2
013
09/0
6/2
013
23/0
6/2
013
07/0
7/2
013
21/0
7/2
013
04/0
8/2
013
18/0
8/2
013
01/0
9/2
013
15/0
9/2
013
29/0
9/2
013
13/1
0/2
013
27/1
0/2
013
10/1
1/2
013
24/1
1/2
013
08/1
2/2
013
22/1
2/2
013
05/0
1/2
014
19/0
1/2
014
02/0
2/2
014
16/0
2/2
014
02/0
3/2
014
16/0
3/2
014
30/0
3/2
014
13/0
4/2
014
27/0
4/2
014
11/0
5/2
014
25/0
5/2
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08/0
6/2
014
22/0
6/2
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06/0
7/2
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20/0
7/2
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03/0
8/2
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17/0
8/2
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31/0
8/2
014
14/0
9/2
014
28/0
9/2
014
12/1
0/2
014
26/1
0/2
014
Scotland: weekly, self-reported acute inpatient boarding rates, Nov 2009 to Oct 2014Proportion of estimated staffed acute inpatient beds reported occupied by boarded patients, %Sources: (i) SG weekly monitoring submissions; (ii) hospital-level ISD(S)1-derived ISD IR2012-00483 and hospital bed statistics publications
Notes: (i) interpretation of inpatient boarding definition may vary between Health Boards, hence caution should be taken when interpreting trends; (ii) reported measure changed from Mon census in 2009/10
to bed day usage from 2010/11; (iii) data imputed where required, except for Highland Health Board, for which no consistent data are available; (iv) results are intended for management information only
Health Board
variation
2010/11 onwards:
total boarded
bed days
2009/10:
boarder census
at Mon 23.59
Nov 2012 onwards:
continuous collection of
weekly monitoring submissions
Standardised resultsSummary
Multilevel model standardisation
Expected values: Crude rates:
Non-
boarded,
no
sitespec
boarding
Non-
boarded,
site-
specialty
boarding
present
Boarded,
site-
specialty
boarding
present
Non-
boarded,
no
sitespec
boarding
Non-
boarded,
site-
specialty
boarding
present
Boarded,
site-
specialty
boarding
present
Total
Spells 31.6% 59.2% 9.2% 981,798 1,836,546 285,688 3,104,032
days, n 3.2 4.3 5.3 1.7 4.5 9.4 4.1
99% CIlower 3.1 4.2 5.0
99% CIupper 3.4 4.4 5.6
7 days, % 3.7% 4.5% 5.2% 3.3% 4.8% 4.9% 4.3%
99% CIlower 3.6% 4.5% 5.0%
99% CIupper 3.8% 4.5% 5.3%
30 days, % 7.9% 9.5% 10.7% 6.4% 10.3% 11.5% 9.2%
99% CIlower 7.8% 9.4% 10.5%
99% CIupper 8.0% 9.5% 10.8%
7 days, % 2.1% 2.4% 2.6% 1.0% 2.8% 3.7% 2.3%
99% CIlower 2.0% 2.4% 2.5%
99% CIupper 2.1% 2.4% 2.7%
30 days, % 3.0% 3.4% 3.8% 1.5% 4.1% 5.6% 3.4%
99% CIlower 3.0% 3.4% 3.7%
99% CIupper 3.1% 3.5% 3.8%
Spell LoS:
Emergency
readmission
within, of
discharge:
Death within,
of discharge:
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Standardised resultsSummary
Multilevel model standardisation
Expected values: Crude rates:
Non-
boarded,
no
sitespec
boarding
Non-
boarded,
site-
specialty
boarding
present
Boarded,
site-
specialty
boarding
present
Non-
boarded,
no
sitespec
boarding
Non-
boarded,
site-
specialty
boarding
present
Boarded,
site-
specialty
boarding
present
Total
Spells 31.6% 59.2% 9.2% 981,798 1,836,546 285,688 3,104,032
days, n 3.2 4.3 5.3 1.7 4.5 9.4 4.1
99% CIlower 3.1 4.2 5.0
99% CIupper 3.4 4.4 5.6
7 days, % 3.7% 4.5% 5.2% 3.3% 4.8% 4.9% 4.3%
99% CIlower 3.6% 4.5% 5.0%
99% CIupper 3.8% 4.5% 5.3%
30 days, % 7.9% 9.5% 10.7% 6.4% 10.3% 11.5% 9.2%
99% CIlower 7.8% 9.4% 10.5%
99% CIupper 8.0% 9.5% 10.8%
7 days, % 2.1% 2.4% 2.6% 1.0% 2.8% 3.7% 2.3%
99% CIlower 2.0% 2.4% 2.5%
99% CIupper 2.1% 2.4% 2.7%
30 days, % 3.0% 3.4% 3.8% 1.5% 4.1% 5.6% 3.4%
99% CIlower 3.0% 3.4% 3.7%
99% CIupper 3.1% 3.5% 3.8%
Spell LoS:
Emergency
readmission
within, of
discharge:
Death within,
of discharge:
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Six Essential Actions Improvement Approach
Launched in May 2015
Developed in partnership with the Academy of RoyalColleges, NHSScotland and Scottish Government
Aims to improve the patient and staff experience ofUnscheduled Care
Delivery of 95% target for all patients to be admitted,discharged or transferred from the EmergencyDepartment within 4 hours.
Aiming towards a standard of 98%
Ministerial objective
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Clinically Focussed Empowered Leadership Responsive Operational Management
Whole System EscalationTriumvirate Leadership Team
- Site Director, - Chief Nurse, - Chief Doctor
Capacity and Patient Flow Realignment
Determining and utilising appropriate information and trend data for performance improvement
to ensure correct resources are applied to meet demand and
system need
Patient Rather Than Bed Management
Daily Dynamic Discharge Shifting the discharge curve left
Developing a coordinated, multidisciplinary approach to
discharge planning encompassing acute and community resources
Medical and Surgical Processes Aligned for Optimal Care
Designed to pull patients from ED
through assessment and diagnostics process to be
seen at right time, by right person in right place
7 Day Services
To reduce variation in access to all services across
weekend and out of hours. Includes clinical assessment, diagnostics, and access to
Senior Decision Makers. Also support services such as
porters, cleaning and transport
Ensuring Patients Care for at Home
Pathways to reduce attendance, avoid admission and if admission necessary ensure home when ready
Basic Building Blocks
Improve rate of early in day and weekends
Signposting and redirection to appropriate community services
18
Admissions
Discharges
Emergency
admissions
with
ED* LoS
> 4 hr, %
Scheduled
and direct
admissions
Hospital
discharges
with XRI AU
LoS > 24 hr
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Daily Dynamic Discharge
Make sure we align the clinical and therapeutic pathways
Creating the Plan
Dynamic MDT Planning from admission - EDD
Effective Ward Rounds –management planning
Daily Communication of Changes
Dependant tasks considered
Executing the Plan
Rapid Daily Whiteboard Meetings (sick, discharge, new) x 2 per day
Ordered ward rounds (sick, discharge, new)
Non-slip task management
Check, chase, challenge reinforcement
In the moment escalation
Discharging when ready
Following criteria for discharge
Escalation/expediting of delay causing tasks
Discharge lounge?
SHIFT
THE
CURVE
How we DDD on Ward 7CIN THE MORNING:• At 9amWe choose:• A facilitator, task sheet scribe and
ward view updaterWe discuss:• Sick patients/safety issues• Patients for discharge today and
tomorrow• Any relevant others (new patients/
urgent tasks)We agree:• Things that need done TODAY, by
whom, by when (write on task sheet)We summarise:• Bed numbers to be seen firstWe finish:• By copying the task sheet for each
team
IN THE AFTERNOON:• At 3pmWe choose:• A facilitator, task sheet scribe, ward
view updaterWe discuss:• Task sheet from this morning• Plans for all patients – EDD, tasks etcWe agree:• Any new tasks to be added to today’s
sheet (from ward rounds)• Any changes to earlier tasks• Escalations (preventing/possibly
preventing discharge)We summarise:• What ELSE needs done TODAYWe finish:• Agree to mark task sheet off before
leaving/handover to next shift
SIGNED (SCN): SIGNED (CONSULTANT:
MANAGE TODAY
PLAN FOR TOMORROW
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Noon
PRE-NOON
Noon
14% - February 2017
26% - February 2018
12% improvement in one year
PRE-NOON
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2pm
29% - Feb 2017
46% - Feb 2018
17% improvement in one year
PRE-2PM
3pm
60% - Feb 2018
42% - Feb 2017
18% improvement in one year
PRE-3PM
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Variability Methodology
Analyse data to assess
variability in patient flow
Select flow priority based on
opportunities to reduce variation
identified in analysis
Develop standardised clinical processes to identify natural and artificial variation
Implement and monitor standardised
clinical processes. Collect data for
modelling and benefitsConstruct model of improved flow
Use simulation and analysis to identify
appropriate capacity to meet scheduled & unscheduled demand
Select redesign recommendation and implement changes
e.g. cohort homogenous groups
Benefits Realisation
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Variability: Daily Number of Surgical Cases
Elective
UrgentEmergencyNatural
Variation
ArtificialVariation
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UCL
LCL
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
Aug-1
1S
ep-1
1O
ct-
11
Nov-1
1D
ec-1
1Jan-1
2F
eb-1
2M
ar-
12
Apr-
12
May-1
2Jun-1
2Jul-12
Aug-1
2S
ep-1
2O
ct-
12
Nov-1
2D
ec-1
2Jan-1
3F
eb-1
3M
ar-
13
Apr-
13
May-1
3Jun-1
3Jul-13
Aug-1
3S
ep-1
3O
ct-
13
Nov-1
3D
ec-1
3Jan-1
4F
eb-1
4M
ar-
14
Apr-
14
May-1
4Jun-1
4Jul-14
Aug-1
4S
ep-1
4O
ct-
14
Nov-1
4D
ec-1
4Jan-1
5F
eb-1
5M
ar-
15
Apr-
15
May-1
5Jun-1
5Jul-15
Aug-1
5S
ep-1
5O
ct-
15
Nov-1
5D
ec-1
5Jan-1
6F
eb-1
6
Admissions to FVRH AMUPatients
UCL
LCL
75%
80%
85%
90%
95%
100%
Jul-11
Aug-1
1S
ep-1
1O
ct-
11
Nov-1
1D
ec-1
1Jan-1
2F
eb-1
2M
ar-
12
Apr-
12
May-1
2Jun-1
2Jul-12
Aug-1
2S
ep-1
2O
ct-
12
Nov-1
2D
ec-1
2Jan-1
3F
eb-1
3M
ar-
13
Apr-
13
May-1
3Jun-1
3Jul-13
Aug-1
3S
ep-1
3O
ct-
13
Nov-1
3D
ec-1
3Jan-1
4F
eb-1
4M
ar-
14
Apr-
14
May-1
4Jun-1
4Jul-14
Aug-1
4S
ep-1
4O
ct-
14
Nov-1
4D
ec-1
4Jan-1
5F
eb-1
5M
ar-
15
Apr-
15
May-1
5Jun-1
5Jul-15
Aug-1
5S
ep-1
5O
ct-
15
Nov-1
5D
ec-1
5Jan-1
6F
eb-1
6
FVRH compliance with the emergency access standardPercent
80.9%
97.4%
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39
KEEP
CALMAND
MANAGE
VARIABILITY
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0 10 20 30 40 50 60 70 80
WB21 (235)
WA32 (407)
WA31 (501)
WB22 (192)
WA11 (519)
WA12 (574)
WA21 (18)
WB32 (551)
WB12 (776)
Card (421)
WB11 (868)
WA22 (373)
WB23 (111)
WB31 (356)
Average AU LOS (Hours)
Un
it (
Nu
mb
er
of
AU
Ad
mis
sio
ns
to U
nit
)
14. Average AMU LOS by Post-AMU Admitting Unit in Hours with 10th/90th Percentile Error Bars
NHS Forth Valley, [01-Jan-2014 to 30-Jun-2014], All DaysNumbers in parentheses = Total AU admissions to unit
0 10 20 30 40 50 60 70 80
WB21 (235)
WA32 (407)
WA31 (501)
WB22 (192)
WA11 (519)
WA12 (574)
WA21 (18)
WB32 (551)
WB12 (776)
Card (421)
WB11 (868)
WA22 (373)
WB23 (111)
WB31 (356)
Average AU LOS (Hours)
Un
it (
Nu
mb
er o
f A
U A
dm
issi
on
s to
Un
it)
14. Average AMU LOS by Post-AMU Admitting Unit in Hours with 10th/90th Percentile Error Bars
NHS Forth Valley, [01-Jan-2014 to 30-Jun-2014], All DaysNumbers in parentheses = Total AU admissions to unit
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6.0
9.5
8.28.0 7.9
7.5
5.7
7.9
2.9
5.8
4.8
5.6
4.9
4.2
3.0
4.8
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
Sun (1.70) Mon (4.34) Tue (4.54) Wed (4.37) Thu (4.16) Fri (5.18) Sat (2.00) Overall (26.33)
Ave
rage
/ M
edia
n L
OS
(in
day
s)
DOW of Discharge/Transfer-out
LOS by DOW Of Discharge/ Transfer-out (Based on Actual Move Date)NHS FV, Ward B32, Jan'13 - May'15, All Days
Average LOS Median LOS
Note: LOS calculated based on Date & Time
43
43
ADT Criteria
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Downstream Ward Median Discharge Times
2014 2015 2016
Median
Discharge
Time
Median
Discharge
Time
November
A12 16:00 15:07 14:17
A31 16:03 15:00 14:47
B12 16:14 15:38 15:33
B32 16:00 14:34 14:30
Ward
3039 annualised bed days saved
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84
86
88
90
92
94
96
98
100
102
104
106
0
10
20
30
40
50
60
70
80
11/2/15 12/2/15 1/2/16 2/2/16 3/2/16 4/2/16 5/2/16 6/2/16 7/2/16 8/2/16 9/2/16
'Co
re' b
ed
occ
up
ancy
Nu
mb
er
of
bo
ard
ers
FVRH 'core bed' occupancy and number of boarders
Core' bed occupancy Boarders
0
50
100
150
200
250
300
350
400
450
500
FVRH 'wait for AMU bed' breaches, Oct 2014-Sep 2016
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Sustained improvement New Temporary Median of
1.16
Provisional reduction of 54%
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Jan
13
Mar
13
May
13
Jul 1
3
Sep
13
No
v 13
Jan
14
Mar
14
May
14
Jul 1
4
Sep
14
No
v 14
Jan
15
Mar
15
May
15
Jul 1
5
Sep
15
No
v 15
Jan
16
Mar
16
May
16
Jul 1
6
Sep
16
No
v 16
Jan
17
Rat
e p
er
100
0 d
isch
arge
s
Cardiac Arrest RateNHS Forth Valley
FVRH
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Most people in Scotland with any long term condition have multiple
conditions
23
13
7
5
48
31
23
22
18
14
13
9
7
6
3
22
21
17
13
20
23
21
24
19
20
21
16
13
14
9
18
21
20
18
12
16
17
19
17
19
21
19
16
18
14
36
46
56
64
21
29
39
35
47
47
46
56
65
62
74
0% 20% 40% 60% 80% 100%
Depression
Schizophrenia/bipolar
Anxiety
Dementia
Asthma
Epilepsy
Cancer
Hypertension
COPD
Diabetes
Painful condition
Coronary heart disease
Atrial fibrillation
Stroke/TIA
Heart failure
Percentage of patients with each condition who have other conditions
This condition only This condition + 1 other + 2 others + 3 or more others
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Public Finances – Fall in Government Expenditure
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Realism in Healthcare
• Doctors generally choose less treatment for themselves than for patients
• Striving to provide relief from disability, illness and death, modern medicine may have overreached itself – is it now causing hidden harm?
• Focus on unwarranted variation in clinical practice and outcomes
• Multiple conditions – management leading to over-complex medical regimes?
• Clinicians have duty to acknowledge powerlessness at times
JJ Gallo et al. Life-sustaining treatments: what do physicians want and do they express their wishes to others?J Am Geriatr Soc. 2003 Jul;51(7):961-9.
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Value Based Healthcare
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Reducing harm and waste
• Harm in healthcare not just missed diagnoses or under-intervention but ‘hidden harm’ exists in over treatment, excessive interventions and medicalising normality. – This is far harder to measure.
• Focus on better value care – including ‘the gentle art of doing nothing’– This isn’t always in the nature of Acute
Physicians…
Gawande, A. (2014). Being mortal: Medicine and what matters in the end (First edition.). New York: Metropolitan Books.
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Over-investigation and over-diagnosis…
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Doctors and risk
• Managing risk is an inherent part of our role
• There is risk associated with every clinical decision, whether it is to do something or to do nothing
• The importance of positive risk taking –avoidance raises anxiety rather than reduces it
• It is psychologically healthy to stimulate and empower ourselves by taking risks
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So…‘Realistic AcuteMedicine’?
How are we doing?...
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Variation between AMUs
• We all know it exists
• It’s very hard to measure
• Poor coding
• Activity data variably recorded
– Admission vs Attendance vs Ambulatory Care
– In-patient vs Out-patient
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LEM Reid et al (2016).The effectiveness and variation of Acute Medical Units; a systematic review. IJQHC 28; 433-446
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Imison C and Vaughan L (2018) Acute medical care in England: Findings from a survey of smaller acute hospitals. Slide-set resource. www.nuffieldtrust.org.uk/research/acute-medical-care-in-england-findings-from-a-survey-of-smaller-acute-hospitals
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Variation within an AMU
40.0%
45.0%
50.0%
55.0%
60.0%
65.0%
70.0%
A B C D E F G H I J K L M N O P Q R S T U V
Direct discharge rate from FVRH AMU, per consultant physician 2014-2016
Practising Realistic Acute Medicine is hard…
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Where do we start?
• Hunt out the dogma and the pseudoaxioms
• Look for ‘Must’, ‘All’ and ‘Should’…
All admissions to an Acute Medical Unit need a set of baseline bloods
All admissions to an Acute Medical Unit need a baseline ECG
All patients with pneumonic consolidation must have follow up CXR
All patients admitted to an AMU with an overdose must be reviewed by psychiatry before discharge
All patients with ‘CT-negative’ thunderclap headache need a lumbar puncture…
All patients with ‘fast AF’ need to be admitted to hospital…AND on a cardiac monitor…
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drlynndickson
drlynndickson
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‘Right person, right place, right time’
#RightCareEveryTime
Acknowledgements
• Six essential actions (@6EAScot)– [email protected]– [email protected]– [email protected]
• Patient flow program (@patientflowsg)– [email protected]– Institute for Healthcare Optimization
• Realistic Medicine (@RealisticMed)– @drgregorsmith, Deputy CMO– @CathCalderwood1, CMO– @damson29, National Clinical Lead for Realistic Medicine– @ChristineGregs5, ST7 in GIM and ID
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@djbeckett@weeSAMScotland
#RightCareEveryTime