Local clinical governance processes

All AMUs have care pathways, audit programmes and clinical governance procedures. Clinical governance procedures include investigating and responding to critical incidents, morbidity and mortality reviews and answering complaints. AMUs should also carry out patient satisfaction surveys to drive improvements to their service through the experiences and feedback of patients and relatives.

Identifying and managing risk

A key role for AIM is to reduce the risk of threats which may compromise the quality and safety of care provided to patients. By acknowledging that there are risks in many aspects of acute medical care it is possible to take steps to negate them. The RCP has published a series of acute care toolkits to help improve the delivery of acute care. The toolkits look at current problems and suggest a range of recommendations for improving quality. 

Deficiencies in emergency care were highlighted in the National Confidential Enquiry Into Patient Outcome and Death report Emergency Admissions: A journey in the right direction? (opens PDF, 679KB) from 2007. The recommendations of the report reflect AIM’s objective to deliver organised care through an appropriately skilled workforce with senior leadership.

Society for Acute Medicine

The Society for Acute Medicine (SAM) is the specialist body that represents physicians practising AIM. It is committed to providing the very best care for patients. Through SAM, acute physicians have contributed to many important reports, recommendations and guidelines concerning acute medical care. SAM is a stakeholder in the National Institute for Health and Care Excellence (NICE) for guidelines relevant to AIM. SAM works closely with the RCP and plays a pivotal role in developing quality services for acutely unwell medical patients in the UK.


Quality standards

Clinical quality indicators for acute medical units

SAM has published the following clinical quality indicators for acute medical units:

  • All patients admitted to the AMU should have an early warning score measured upon arrival on the AMU.
  • All patients should be seen by a competent clinical decision maker within 4 hours of arrival on the AMU who will perform a full assessment and instigate an appropriate management plan.
  • All patients should be reviewed by the admitting consultant physician or an appropriate specialty consultant physician [senior clinical decision maker] within 14 hours of arrival on the AMU (8 hours for patients arriving between 8am and 6pm).

All acute medical units should collect the following data:

  • hospital mortality rates for all patients admitted via the AMU
  • proportion of admitted patients who are discharged directly from the AMU
  • proportion of patients discharged from the AMU who are readmitted to hospital within 7 days of discharge.

Society for Acute Medicine Benchmark Audit (SAMBA)

SAM’s quality indicators form part of a national annual audit, held over one day in June. During the 24 hours of the audit, all patients presenting to AIM are audited against the quality indicators. Other information is also collected, for example access to diagnostic tests and the frailty of patients. The audit allows units to benchmark their performance against other units and provides a snapshot of AIM in the UK.

Quality care standards

There a number of published quality care standards that provide a blueprint for acute medical services and AMUs. Some recommendations are viewed by service providers as aspirational; however the recommendations clearly define excellence in acute medical care.

Guidelines for sick patients

The RCP’s National Early Warning Score (NEWS) advocates a system to standardise the assessment and response of patients with acute illness.

The NICE guideline Acutely ill patients in hospital: recognising and responding to deterioration is also pertinent to the AMU.

Standards expected of clinical decision makers

The RCP’s Acute medical care: the right person, in the right setting – first time defines the standards expected of clinical decision makers as follows:

A competent clinical decision maker: ‘Has undertaken a period of specific training to use the various tools of clinical assessment combined with appropriate use and interpretation of investigation. This facilitates the development of a rational differential diagnosis followed by prompt, safe and effective treatment of the patient. These skills are subject to assessment by more senior members of the team who have already developed these specific competencies.’

A senior clinical decision maker: ‘Is a medical practitioner who has the competencies and experience to make a prompt clinical diagnosis and decide the need for specific investigations and treatment, the mode of treatment, and the most appropriate setting for that treatment and ongoing care.’

In practice, a competent decision maker is a doctor in training or an appropriately trained advanced nurse practitioner, and a senior clinical decision maker is a consultant physician or a senior specialist registrar.


Accessing data for quality improvement

Acute internal medicine includes many disparate processes which need to work together in the AMU. The AIM quality improvement portfolio is wide-ranging, from simple ward-based projects through to national initiatives.  

As patients experience AMU at the start of their hospital journey, quality initiatives also need to start in the AMU, for example:

  • antibiotic husbandry
  • venous thromboembolism prophylaxis
  • pressure care assessments – in collaboration with nurses
  • medicines reconciliation – in collaboration with pharmacists.

The AMU adopts best practice and guidance from many organisations, for example providing best care for older people as laid out in the 'Silver Book' (opens PDF, 1.12MB), which was developed by a multidisciplinary group of stakeholders. Nationally, and through SAM, AIM is a registered stakeholder with NICE, as well as contributing to reports by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).

Acute hospitals and trusts should support their AMU to run quality improvement projects.Resources should be provided to collect and analyse data. A shared plan between clinicians and managers to prioritise their quality improvement programme will be essential.

Quality care standards are provided by: