Consultant physicians working with patients - Royal College of ...

2 Specialties Acute internal medicine and general internal medicineThe initial care of all patients should be dictated by theirclinical need and the severity of the illness atpresentation.When a patient is found to be seriously ill, his or hercare should be directly provided by the most seniordoctor readily available. This should be a consultant orspecialty registrar (StR) and possession of themembership of the RCP, MRCP(UK), should be theminimum qualification for this task.A severely ill patient may require resuscitation andimmediate care before a formal clerking can be carriedout.The RCP recommends that a foundation or coremedical training (CMT) doctor should be allowed oneand a half hours to complete the formal assessment of apatient presenting to hospital with an acute medicalproblem. This would include: carrying out a clinical assessment documenting that assessment arranging appropriate investigations gathering the results of those investigations assessing the patient’s risk of venousthromboembolism assessing the patient’s risk of acute kidney injury carrying out a diagnostic synthesis and derivingdifferential diagnoses drawing up an appropriate care plan including aclear monitoring plan specifying the physiologicalobservations to be recorded and their frequency initiating treatment where appropriate reporting the case to an appropriate senior doctor.All patients should have their formal assessmentcompleted within 4 hours of their admission. 2Amoreseniordoctorwithappropriateskillsinacutemedicine should be based in the AMU at all times. Thisshould be an StR 3+, or equivalent middle-gradedoctor, who should have the MRCP(UK) qualificationand at least 2 years’ recent experience of managingacutely ill patients. When working on the AMU, theyshould have no other scheduled commitments. 1,2There must always be consultant supervision of themedical team on call and the identity of the supervisingconsultant should always be known to the medical staffon call and to other relevant staff. There should be clearmechanisms in place to involve the consultant at anearly stage in the care of patients who are particularlyunwell.During the extended working day, the consultant on callshould review patients as soon as possible after theirformal assessment has been completed – ‘rolling review’.As a minimum standard, during the working day thisreview should take place within 6–8 hours of thepatient’s admission to the AMU. Patients admittedovernight should receive a consultant review within 14hours. 15In addition to the review of newly assessed patients, theconsultant on call should also review all patients whoremain on the AMU. These tasks will require aconsultant-led post-take ward round at least twice a day,7daysaweek.All patients admitted into the hospital from the AMUshould have been reviewed by the consultant on call,who should agree or modify the care plan proposed atthe patient’s formal assessment. Exceptionally, a seniorStR could deputise for the consultant on call in this role.Planning for the patient’s discharge should start as soonas possible after admission.Any patient leaving the AMU, or remainingthere over a change of shift, should have details ofhis or her situation passed on to the clinicians assumingresponsibility for their continuing care. This handoverof information and responsibility is vital for goodpatient care. The handover process should thereforebe robust, clearly understood and regularly audited asdescribed in the RCP Acute care toolkit 1: Handover. 16–18Patients transferred out of AMU should receive promptreview on their new ward, with a consultant reviewwithin 24 hours of the transfer, 7 days a week. Thisshould be a priority duty in the first hour of theworking day – ‘golden hour’ review. 19Maintaining and improving the quality of careEducation and trainingThe acute medical intake provides a unique forum fortraining medical and other staff and students involved inthe care of the acutely ill patient. Consultants are expectedto ensure that learning opportunities are taken upwhenever possible. The General Medical Council (GMC)has approved a variety of assessment tools for juniormedical staff, particularly the Acute Care AssessmentTool (ACAT), which can be carried out in the contextof the acute medical intake. Senior StRs approachingC○ Royal College of Physicians 2013 19