Consultant physicians working with patients 5th edition - FSEM

Medical Task Force recommended that there should
be a single such system across the NHS and the RCP
has supported work to develop the NHS Early
Warning Score (NEWS) system.
� The initial care of all patients should be dictated by
their clinical need and the severity of their illness at
presentation.
� When a patient is found to be seriously ill, their care
should be directly provided by the most senior
doctor readily available. This should be a consultant
or specialty registrar (StR) and possession of the
membership of the RCP, MRCP(UK), should be the
minimum qualification for this task.
� A severely ill patient may require resuscitation and
immediate care before a formal clerking can be
carried out.
� The RCP recommends that a foundation or core
medical training (CMT) doctor should be allowed
one hour to complete their formal assessment of a
patient presenting to hospital with an acute medical
problem. 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 venous
thromboembolism
– assessing the patient’s risk of acute kidney injury
– carrying out a diagnostic synthesis and deriving
differential diagnoses
– drawing up an appropriate care plan including a
clear monitoring plan specifying the
physiological observations to be recorded and
their frequency
– initiating treatment where appropriate
– reporting the case to an appropriate senior
doctor.
� All patients should have their formal assessment
completed within four hours of their admission. 2
� Amoreseniordoctorwithappropriateskillsinacute
medicine should be based in the AMU at all times.
This should be an StR 3+,orequivalent
middle-grade doctor, who should have the
MRCP(UK) qualification and at least two years’
recent experience of managing acutely ill patients.
When working on the AMU, they should have no
other scheduled commitments. 1,2
� There must always be consultant supervision of the
medical team on call and the identity of the
supervising consultant should always be known to
the medical staff on call and to other relevant staff.
There should be clear mechanisms in place to
2 Specialties Acute medicine
involve the consultant at an early stage in the care
of patients who are particularly unwell.
� During the extended working day, the consultant on
call should review patients as soon as possible after
their formal assessment has been completed –
‘rolling review’. As a minimum standard, the
consultant on call should review all acute
admissions within 12 hours of completion of their
formal assessment.
� In addition to the review of newly assessed patients,
the consultant on call should also review all patients
who remain on the AMU. These tasks will require a
consultant-led post-take ward round at least twice a
day, seven days a week.
� All patients admitted into the hospital from the
AMU should have been reviewed by the consultant
on call, who should agree or modify the care plan
proposed at the patient’s formal assessment.
Exceptionally, a senior StR could deputise for the
consultant on call in this role.
� Planning for the patient’s discharge should start as
soon as possible after admission.
� Any patient leaving the AMU, or remaining there
over a change of shift, should have details of their
situation passed on to the clinicians assuming
responsibility for their continuing care. This
handover of information and responsibility is vital
for good patient care. The handover process
therefore should be robust, clearly understood and
regularly audited. 16,17
Maintaining and improving the quality of care
Education and training
The acute medical intake provides a unique forum for
training medical and other staff and students involved
in the care of the acutely ill patient. Consultants are
expected to ensure that learning opportunities are taken
up whenever possible. The General Medical Council
(GMC) has approved a variety of assessment tools for
junior medical staff, particularly the Acute Care
Assessment Tool (ACAT), which can be carried out in
the context of the acute medical intake. Senior StRs
approaching the end of their training should have the
experience of leading the post-take round under the
supervision of the consultant on call. Detailed
recommendations for education and training are
included in the RCP report Acute medical care. 2
Continuing professional development
It is clearly important that all consultants involved in the
supervision of the acute medical intake are familiar with
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