Quality Improvement

Improving Communication and Coordination in Medical Ward Rounds: A Quality Improvement Initiative in an Acute Teaching Hospital

Original Articles, Volume 24, Issue 1, Pages 1 – 60 (2025)

Background: Medical ward rounds are essential to support care delivery, however a lack of multi-disciplinary team rounding may have a knock-on effect on care coordination and may lead to delayed discharges and increased length of stays.
Methods: The aim of this study was to improve patient outcomes by improving communication and coordination surrounding medical ward rounds through bringing disciplines together during medical ward rounds or at post-round operational huddles. The primary outcome measure was to improve the number of patients discharged by noon.
Results: At the end of the study there was no impact on our primary outcome measure. Efforts for improvement were redirected from the micro- to the meso- and macrosystem of the organisation.
Conclusion: While developing this complex project, we found reforms at a macrosystem of how care is provided are needed including ward-based care. Reforms must balance system resilience and efficiency while ensuring ‘slack’ in the system to support communication, relationship building and coordination of care.

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Improving Telemetry use in the Acute Assessment Unit

Original Articles, Volume 23, Issue 1, Pages 1 – 52 (2024)

Background and Aims: Despite published guidelines, telemetry use is inappropriate in 25-43% of cases. This impacts patient safety and telemetry effectiveness. QI methodology was used to review telemetry in a hospital acute medical unit with the aim of reducing inappropriate use and addressing alarm fatigue.
Methods: A ‘Telemetry Indication Form’ was created. Eight weeks of baseline data was collated before introducing the ‘Indication Form’. Four plan-do-study-act cycles were conducted. At each cycle, data was analysed using statistical process control charts.
Results: Inappropriate telemetry use significantly reduced from 32% to 4%. Total telemetry use also fell. Unfortunately, interventions to address alarm rates did not result in significant reduction in false alarms.
Conclusions: A ‘Telemetry Indication Form’ has significant potential to improve patient safety through reducing inappropriate use.

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Acute Medicine: How will we grow? – An analysis of organisational capabilities for quality improvement, research & education from SAMBA 2021

Volume 22, Issue 3, Pages 109 – 168 (2023)

Background: Education, research, and Quality Improvement (QI) are key enablers for high quality care. We aimed to map the capability of Acute Medical Units (AMUs) to facilitate excellence in these areas.
Methods: AMUs were surveyed in an organisational questionnaire within the Society for Acute Medicine Benchmarking Audit 2021.
Results: 143 units participated. 80 units had a QI lead, 24 had a research lead and 99 had a medical education lead. 15 units had all three leadership roles. Most QI work considered service structure rather than changes in processes or care outcomes.
Conclusion: The organisational capability of AMUs in the strategic areas considered is variable. Improving leadership and disseminating learning could help build a strategic foundation for acute medicine to grow.

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Developing priorities for quality improvement in acute medicine using a modified Delphi method
A consensus process hosted by the Society for Acute Medicine Quality Improvement Committee (SAM-QI)

Original Articles, Volume 21, Issue 2, Pages 65-120 (2022)

Introduction: The SAM Quality Improvement Committee (SAM-QI), set up in 2016, has worked over the last year to determine the priority Acute Medicine QI topics. They have also discussed and put forward proposals to improve QI training for Acute Medicine professionals.
Methods: A modified Delphi process was completed over four rounds to determine priority QI topics. Online meetings were also used to develop proposals for QI training.
Results: Same Day Emergency Care (SDEC) was chosen as the priority topic for QI work within Acute Medicine.
Conclusion: The SAM-QI group settled on SDEC being the priority topic for Acute Medicine QI development. Throughout the Delphi process SAM-QI has also developed proposals for QI training that will help Acute Medicine professionals deliver coordinated meaningful improvements in care.

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Developing priorities for quality improvement in acute medicine using a modified Delphi method
A consensus process hosted by the Society for Acute Medicine Quality Improvement Committee (SAM-QI) Read More

Quality: What does it mean in Acute Medicine and how do we measure it?

Clinical Reviews, Volume 20, Issue 2, Pages 89-156 (2021)

Acute Medicine is a specialty that is not defined by a single organ system and sits at the interface between primary and secondary care. In order to document improvements in the quality of care delivered a system of metrics is required.

A number of frameworks for measurements exist to quantify quality of care at the level of patients, teams and organisations, such as measures of population health, patient satisfaction and cost per patient. Measures can capture whether care is safe, effective, patient-centred, timely, efficient and equitable. Measurement in Acute Medicine is challenged by the often-transient nature of the contact between Acute Medicine clinicians and patients, the lack of diagnostic labels, a low degree of standardisation and difficulties in capturing the patient experience in the context.

In a time of increasing ecological and financial constraints, reflecting about the most appropriate metrics to document the impact of Acute Medicine is required.

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Usability of a Web-based Software Tool for History Taking in the Emergency Department

Original Articles, Volume 19, Issue 3, Pages 113 – 172 (2020)

Medical history taking is an important step within the diagnostic process. This study aims to assess the quality and usability (effectiveness, satisfaction, efficiency) of a web-based medical history taking app in the emergency department.

During three weeks, patients and junior physicians filled out study questionnaires about the app. Senior physicians rated the quality of medical histories taken by junior physicians and app.

In 241 patients, the studied app showed excellent usability with patients not in need of immediate medical attention.

Senior physicians rated medical histories as more complete when app was used by patients in comparison to conventional history taking alone (p<0.01). Current app could not substitute medical history taking by physicians, but could definitely rather be used to gather ancillary information.

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Identifying avoidable switchboard delays in England’s NHS hospitals: phase one of the national SWITCH project

Original Articles, Volume 18, Issue 4, Pages 205 – 264 (2019)

Background: Inter-hospital communication frequently requires mediation via a switchboard. Identifying and eliminating switchboard inefficiencies may improve patient care.

Methods: All 175 acute hospital switchboards in England were contacted six times. Call contents and duration were recorded. No clinician calls or bleeps were connected.

Results: The mean delay before contacting a switchboard operative was 55±46 seconds. 115 hospitals (66%) used automated switchboards; 34 of these (30%) had infection control messages. Robot operators introduced an additional 40 second delay versus humans (mean 70.3±28 versus 29.8±23 seconds, p<0.0001). Multivariate analysis identified robot operators (HR 5.1, p<0.0001) and infection control messages (HR 2.9, p=0.003) as predictors of delays over 60 seconds. Conclusions: There are significant avoidable delays in contacting switchboard operatives across England. Quality improvement is underway.

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Effective acute care handover to GP: optimising the structure to improve discharge documentation

Original Articles, Volume 17, Issue 2, Pages 57 – 116 (2018)

Abstract

Time and resource constraints have often led to the use of assessment records as discharge communications from acute and emergency departments. However, whether this addresses the primary care needs has not been demonstrated. This study examined the optimal structure that can impart key discharge information effectively using feedback from general practitioners (GP). We implemented an electronic assessment template that focused on the most relevant headings. Prespecified process measures were examined and qualitative thematic analysis of free-text comments from GP surveys were conducted to optimise the document. Our findings suggest that the structure of a discharge summary can influence the quality of information, users’ compliance and readers’ perceptions of the length of the letter.

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Improving acute care for older people at scale – the Acute Frailty Network

Research Audit and Clinical Practice, Volume 15, Issue 4, Pages 165 – 220 (2016)

Older people form a growing proportion and volume of those accessing urgent care. Non-specific presentations, multiple comorbidities and functional decline make assessment and management of this cohort challenging. Comprehensive Geriatric Assessment offers an evidence based framework to assess and mange older people, especially those with frailty. In this article we describe the CGA approach, underpinned by specific examples illustrating some of the key competencies required, and describe the role of the Acute Frailty Network (AFN). The AFN is a national improvement collaborative designed to support hospitals in delivering evidence based care for older people with frailty and urgent care needs. We describe the principles underlying the approach of the AFN, derived from working with over 20 hospitals, and some of the early successes.

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A simple intervention to improve patient safety, save time and improve staff experience in the AMU procedure room

Research Audit and Clinical Practice, Volume 15, Issue 1, Pages 1 - 48 (2016)

Abstract

Over the last decade, operating theatres and Intensive Care Units (ICUs) have established systematic methods for performing procedures on patients that have been shown to reduce complications and improve patient safety. Whilst the use of procedure rooms on Acute Medicine Units (AMUs) is highly recommended by patient safety groups and Royal College publications, they are not universally available or appropriately utilised. In this article we discuss a quality improvement project that was undertaken on an AMU at a large university teaching hospital in the United Kingdom, highlighting its successes and challenges.

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