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Introduction to Acute Medicine

Glenn Matfin and Nick Murch

 KEY POINTS

• Acute Medicine (or Acute Internal Medicine) is the specialty concerned with the initial assessment, investigation, diagnosis and management of adult patients with urgent medical needs.
• There is a broad spectrum of clinical work within the specialty, including the immediate management of life‐threatening medical emergencies, the initial treatment (generally first 48–72 hours) of all presenting general medical ailments, and the provision of ambulatory care. More recently, acute medical care within the patient’s home via telemedicine, Hospital at Home service and ‘virtual wards’ has also been implemented.
• The delivery of Acute and Internal Medicine care is dependent on the close working and interrelationship between members of the multidisciplinary team.
• Most physician trainees now receive much of their training in the care of acutely unwell medical patients while working in the Acute Medicine service.
• As Acute Medicine is an evolving specialty, and many acute medical services have a varied configuration and staffing model, the role of the Acute Medicine clinician varies across the UK.

Introduction

Acute Medicine (or Acute Internal Medicine) is the specialty concerned with the immediate and early specialist initial assessment, investigation, diagnosis and management of adult patients requiring urgent or emergency care for one or more of a wide range of medical conditions.

Acute Medicine evolved to provide patients suffering from a wide range of medical conditions who present to, or from within, hospitals requiring urgent or emergency management with the best quality care, in the right environment. These patients are often treated on distinct wards called acute medical units (AMUs) and patient care is generally led by consultant physicians, trained or with an interest in Acute Medicine. A patient admitted to the AMU will receive care that will include the necessary investigations and management required until the patient is discharged, transferred downstream to an internal medicine or specialty ward, or escalated to a higher level of care.

Acute Medicine and AMUs are relatively new innovations aimed at improving care given to patients with acute medical illness. Acute Internal Medicine was formally recognised as a specialty with defined training programmes in 2009, having previously been a subspecialty of General Medicine (now known as Internal Medicine) since 2003. The creation of Acute Medicine as a specialty has been a success in improving care for patients with an acute medical illness.

Despite its relative youth, the specialty of Acute Medicine has good support and advocacy from clinical professional bodies, such as Royal Colleges and the Society of Acute Medicine (SAM). This organisation and specialisation mean that most physician trainees now receive much of their training in the care of acutely unwell medical patients while working in the Acute Medicine service.

There is a broad spectrum of clinical work within the specialty, including the immediate management of life‐threatening medical emergencies, the initial treatment (generally the first 48–72 hours) of all presenting general medical ailments, and the provision of ambulatory care. AMUs may be co‐located with the emergency department (ED) and same‐day emergency care (SDEC) areas. More recently, acute medical care within the patient’s home via telemedicine, Hospital at Home service and ‘virtual wards’ has also been implemented.

Given the variety of patient presentations to Acute Medicine services, medical specialty in‐reach or co‐location with cardiology, medicine for care of the older person, stroke medicine and respiratory medicine is common. Ready availability of advice and management pathways from the other medical specialties is also critical. Some of this workload is performed by Acute Medicine physicians with subspecialty expertise. As well as medical specialties, Acute Medicine services need to work closely with other disciplines, for example surgical specialties, obstetrics and gynaecology, and psychiatry. Access to higher level care is also important – Acute Medicine specialists work closely with colleagues in high‐dependency, intensive care and coronary care units. There has been a trend to having higher level of care provided on AMUs in enhanced care areas.

It is imperative to explore ways of incentivising doctors to work in the most challenging and in‐demand areas of medicine, such as Acute Medicine. The rapid growth of hospitalists in the USA is a good example of attracting clinicians to an area of unmet clinical need. Bob Wachter (Chair, Department of Medicine, University of California, San Francisco) coined the term ‘hospitalist’ in 1996, more than 25 years ago. In naming a physician whose practice is dedicated to caring for a patient during the entirety of their hospital stay, he and his esteemed colleague (Lee Goldman) started a new movement. Hospitalists usually care for all medical inpatients and, in some organisations, every single inpatient, 24 hours a day, seven days a week. Hospitalists now number more than 50 000 in the USA and are more numerous than any subspecialty of Internal Medicine (the largest of which is cardiology with 22 000 physicians).

Hospital Medicine and Acute Medicine share a lot in common, both having core expertise in managing the clinical problems of acutely ill, hospitalised patients. However, the key lesson for the continued growth of Acute Medicine lies not in hospitalism as a suggested model of care, but in the process of how it became so successful – right leadership, financial impetus, workforce capacity and buy‐in from other hospital specialties (e.g. offering co‐management service, especially perioperative care).

As Acute Medicine is an evolving specialty, and many acute medical services have a varied configuration and staffing model, the role of the Acute Medicine clinician varies across the UK. However, it is critical that there is a multiprofessional approach to providing all the relevant knowledge and skills that the acutely ill medical patient may require.

The roles of the Acute Medicine physician include the following.

• Stabilise acutely ill patients, and then either discharge or transfer these individuals, when stable and if required, to the most appropriate acute care setting for their needs.
• Minimise length of stay by delivering safe and effective care for short‐stay patients.
• Fully differentiate the presenting complaint or problem.
• Risk‐stratify the cause of admission (i.e. ‘assess to admit’) to determine the best place for ongoing care and management (e.g. ambulatory, inpatient, home).
• Improve hospital patient flow, including reducing ED overcrowding.
• Provide leadership and guidance for the medical acute take.

In the UK, there is a shift from the terms General Medicine or General Internal Medicine to the more commonly used international term of Internal Medicine. Internal Medicine is the specialty that encompasses the care, investigation, diagnosis and management of all medical needs, including acute medical problems, of both inpatients and outpatients.

Where is acute medical care administered?

The challenge for Acute Medicine is to provide a range of high‐quality services to a heterogeneous group of patients across the acute care setting. In time‐sensitive conditions where early intervention is paramount – such as sepsis, diabetic ketoacidosis and acute kidney injury – Acute Medicine clinicians can make a real difference to outcomes for patients.

In addition to the assessment and admission of adult patients, Acute Medicine clinicians also have an important role in developing services to enable the safe delivery of care in outpatient and home settings (Figure 1.1). Many patients previously admitted to hospital for investigation or treatment of conditions such as deep vein thrombosis, pulmonary embolism and cellulitis can now be treated safely as outpatients with the help of Acute Medicine‐led SDEC services and follow‐up clinics. Rapid‐access (‘hot’) medical clinics also allow unwell patients access to specialist clinicians and rapid diagnostics without admission to hospital. Acute medical care within the patient’s home via telemedicine, Hospital at Home service and ‘virtual wards’ is rapidly evolving.

Figure 1.1 Changing landscape of Acute Medicine services. The circle in the middle of the figure represents the patient – who should be at the centre of all we do (i.e. person‐centred care). The solid blue arrows represent the different directions of travel of possible patient journeys throughout the acute medical care setting. The solid orange boxes represent the major bases for the Acute Medicine team. On the left side of the figure, the patient can be managed by the Acute Medicine team at home, either in person by the Hospital at Home team or digitally via the virtual ward or telemedicine. On the right side, patients traditionally entered the hospital ‘front door’ – the point of arrival/entry to hospital – via the emergency department (ED). However, this leads to ED crowding. Front‐door...