Operational process and staff utilisation changes on the new medical pathway
| Effective twice daily consultant handovers and patient allocation | Morning handover (8.00–9.00am) with patient allocations: daytime admissions cared for by the APs, overnight/twilight admissions managed by GIM consultant (see below), occasional specialty ward admissions managed by specialty ward consultants. Evening handovers (5.00pm) between the daytime AP and twilight/overnight GIM consultant addressed care of unwell patients admitted during the day, bed management, etc. |
| Ambulatory Emergency Care | Ambulatory care delivered by the APs in a new AEC unit enhanced patient flow and early discharge. Initially for 5, but rapidly 7 days a week, from 8.30am–8.00pm. |
| Board rounds 11.30am–12.30pm | Daily ‘standardised’ MDT board rounds, led by senior nursing staff with consultants in attendance, encouraged MDT working, rapid decision making and early discharge. Patient management was reviewed and actioned for all cases on AEC, AAW and specialty wards. |
| Improved consultant rotas | Effective consultant rotas ensured accountability (‘a named responsible consultant’), early patient review, continuity of care (physician of the week/weekend), sustainability, enhanced twilight consultant presence and efficient post overnight ‘take’ ward rounds. |
| Enhanced specialty referral process | Specialty referrals made at morning handover ensured early specialist input and best care. Same day review was mandated if a standardised referral form was completed by 10.00am. Patients remained under the admitting consultant until specialty ward transfer. |
| ‘Frailty’ pathway | Ongoing development of a frailty pathway, with dedicated team, for patients >80 years old. |
| Clinical governance pathways | Introduction of a ‘deteriorating patient’ pathway and clinical governance process to improve patient safety, accountability and learning. |
| Clerking pro forma | Standardisation and simplification of the clerking pro forma. |
| Rapid follow-up facilities | Ongoing development of a ‘hot clinic’ and ‘procedure room’ on the AEC unit, to enhance ambulatory/discharge pathways as these facilities were not readily available elsewhere at MFT. |
| Daytime admissions 8.00am–5.00pm | Admitted and remained under the care of the AP (7 days a week) on AAW/AEC until discharge or transfer to a specialty ward. Continuous rolling ward round throughout the day ensured early review and, when appropriate, rapid discharge. |
| Twilight and overnight admissions 5.00pm–8.00am | Twenty four GIM physicians managed out-of-hours admissions, reviewing twilight cases between 5.00–8.30pm, then on-call for patients admitted overnight (8.30pm–8.00am) followed by a ‘post-take’ ward round the next morning. Patients remained under GIM consultant care whilst on AAWs. |
| Night handover: 9.00pm | Hospital at night handover managed by SNP. Less handover of unclerked patients. |
AAW = acute admission ward; AEC = ambulatory emergency care unit; AP = acute physician; ED = emergency department; GIM = general internal medicine; MDT = multidisciplinary team; MFT = Medway NHS Foundation Trust; SNP = site nurse practitioner; SSW = short stay wards.