Examination of acute medical care in Scottish hospitals
Reid, Lindsay Eleanor Margaret
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Acute medical patients constitute the single largest group of patients in hospitals. The processes by which they are cared for in the United Kingdom (UK) have changed over the past few decades and now the majority of acute medical care is delivered within acute medical units (AMUs). The AMU model is also increasingly being adopted outside of the UK, including in Ireland, Australasia and Europe. AMUs emerged as a result of local service innovations and there is evidence to suggest that care within AMUs varies across settings. Although there are published recommendations for care delivery, empirical evidence is lacking. In this thesis I aim to examine the concept of the AMU model with regard to the literature; its definition; its components; and how these components are delivered across Scottish sites. This is with the aim of informing service provision and contributing to the development of an evidence base relating to AMUs. Firstly, I undertook a systematic review of the evidence relating to the effectiveness of and variation in the AMU model. I found limited, observational and possibly confounded evidence that the AMU model was associated with reductions in hospital length of stay and mortality compared to other models of care in European and Australasian settings. I also found variation in the admission criteria, entry sources, functions and staff work patterns across the 12 AMUs described in the literature. Given this finding that AMUs do not operate in a uniform way, I undertook a second systematic review to assess the published evidence evaluating different methods of delivery of care within AMUs. I identified nine studies of ten interventions. From this I concluded that there was little discerning evidence pertaining to how best to deliver care in AMUs. This led me to undertake a qualitative descriptive study of all the AMUs in Scotland with the aim of further delineating the AMU model. During a visit to each AMU, I collected data through semi-structured interviews with healthcare professionals working in the units. This totalled 171 interviews of 275 participants across 29 sites. I used this data to provide a report detailing how care was delivered in each AMU. I then thematically analysed these reports using framework analysis. There were three principal findings from this qualitative study. Firstly, I found that acute medical care was delivered in acute medical services rather than single AMUs. Secondly, I identified a framework of 12 key components of AMU care that were integral to the functioning of the AMU irrespective of the setting. Examples include nurse staffing and the physical areas contained within the AMU. Lastly, I described how these components were delivered across Scottish AMUs and, where possible, identified distinct models of care delivery. For example, I identified 13 models of AMU functions and seven models of consultant work patterns. In summary, I found that care in Scottish AMUs is delivered variably. The reasons for the variation are unclear. The findings of this thesis are the first in-depth study into AMUs. They provide a useful foundation for discussions and onward planning of resources, capacity and standards of care at both a national and local level. These findings are also an impetus for further research to delineate how best to deliver care in AMUs, and form an essential precursor to such work.