The patient population

Patients presenting to acute internal medicine (AIM) are, by definition, unscheduled or emergency admissions, although there are some exceptions, eg discharged patients returning to an early follow-up clinic. AIM patients are adults (aged 16 or over) and they present with a wide range of medical problems. AIM physicians treat patients on the basis of their physical, psychological and social needs.

The population of patients presenting to AIM is complex because:

  • patients usually present with symptoms or signs as opposed to a clear diagnosis
  • the level of acuity or disease severity varies significantly between acute medical patients
  • an increasing number of patients are frail and/or older. Frequently, older patients do not describe symptoms but present with a frailty syndrome such as falling or confusion
  • lifestyle-related illnesses are increasing, especially alcohol-related disease
  • patients nearing the end of their life are referred to AIM
  • AIM is the default specialty for patients who need admission but are deemed unsuitable by another specialty, eg patients with abdominal pain deemed non-surgical.

Taking all these factors into account, AIM and acute medical units (AMUs) need to provide a wide range of services to a diverse patient population.

In terms of service provision, there are significant implications for acute hospitals and trusts. It is important for the AIM service to be properly run and appropriately resourced. Getting things right at the start of a patient’s hospital stay will help to ensure quality and safety, as well as improving efficiency through safe early discharge and reduced readmissions.

Prevention of disease

Caring for a diverse group of patients puts AIM in a position to influence health promotion and prevention. Some initiatives can be run by the AIM team alone, while others will require collaborative working with other specialties or teams. These intiatives include:

  • stopping smoking – counselling and prescribing nicotine substitutes
  • alcohol – counselling and referral to alcohol prevention services, including a hospital-based alcohol team
  • obesity – measuring body mass index, screening for diabetes mellitus and referral to obesity service
  • hyperlipidaemia – treatment for patients with a cardiovascular event
  • HIV – screening is recommended in all general medical admissions if the local disease prevalence exceeds two in 100 of the population, in accordance with the British HIV Association’s UK National Guidelines for HIV Testing 2008
  • venous thromboembolism prevention – prescribing low molecular weight heparin and/or compression stockings
  • functional assessments and social care packages for older, frail patients
  • alerting public health bodies of notifiable diseases
  • screening for dementia.

This list is not exhaustive and a preventive measure of some sort will be a component in the care of many patients, eg hypertension and cardiovascular risk or advice about flu and pneumococcal vaccination in patients with pneumonia.

Provision of advice on stopping smoking and reducing or cutting out alcohol is particularly important to AIM, as there is probably no better time to educate patients than when their lifestyle choice has caused an acute illness. While AIM can play a significant role in identifying patients, its input will usually be transient. Therefore, AIM services need to develop clear lines of communication with GPs to continue health promotion interventions following discharge from hospital.

Planning effective services

The design of an AIM service is specified in the RCP report, Acute medical care: the right person, in the right setting – first time.

Standards for AIM are described in the following documents:

Services should audit themselves against the Society for Acute Medicine’s (SAM) Clinical Quality Indicators for Acute Medical Units, and participate in the Society for Acute Medicine Benchmark Audit (SAMBA).

The main challenge in establishing an AIM service is staff recruitment and nurse staff retention. SAM has led a national campaign, Take AIM, to promote the specialty to trainee doctors. Many hospitals and trusts offer ‘golden handshakes’ to attract senior doctors. Many well-established units have been championed by established consultants who moved from their parent specialty to AIM.