DOCSLIB.ORG

Model of Care for Acute Surgery National Clinical Programme in Surgery

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Model of Care for Acute Surgery National Clinical Programme in Surgery Model of Care for Acute Surgery National Clinical Programme in Surgery Model of Care for Acute Surgery National Clinical Programme in Surgery Forward The National Clinical Programme in Surgery is delighted to publish the Acute Surgery Model of Care. The aim of the Surgery Programme is to provide a framework for the delivery of more timely, accessible, safer, cost effective and efficient care for the acute surgical patient. This follows on from the Elective Surgery Model of Care which is currently being rolled out across Ireland. While understanding the difficulties facing healthcare delivery at the present time, we believe that the principles laid out in this document represent best practice that will, in the long term, fundamentally improve surgical care. Change of this magnitude will clearly take time to implement and will impact all care providers and the organisations within which they work. We also acknowledge that the patient care that is provided by surgeons and anaesthetists cannot be delivered without the support of a wide range of other professional and ancillary groups. Finally, we welcome the collaboration with the other programmes charged with the delivery of acute patient care. This final document could not have been completed without the widespread input and suggestions that we have received from our own team, the surgical and healthcare community as well as patients themselves. We would like to express our sincere gratitude and appreciation to one and all. Professor Frank Keane, Joint Lead Mr Ken Mealy, Joint Lead National Clinical Programme in Surgery National Clinical Programme in Surgery Model of Care for Acute Surgery 2013 2 | P a g e Table of Contents Forward ................................................................................................................................................... 1 1.0 Executive Summary ..................................................................................................................... 6 2.0 Glossary of Terms .............................................................................................................................. 8 3.0 Background and Objectives ............................................................................................................ 10 3.1 Scope of the Document ............................................................................................................... 12 4.0 Surgical Activity and Bed Occupancy – Acute and Elective ............................................................ 16 4.1 Introduction ................................................................................................................................. 16 4.2 Methodology ............................................................................................................................... 17 4.3 Results ......................................................................................................................................... 17 4.4 Discussion .................................................................................................................................... 30 5.0 The Way Forward ............................................................................................................................ 34 5.1 Core Principles ............................................................................................................................. 35 5.1.1 Quality Assured Acute Surgical Care..................................................................................... 35 5.1.1.1 Standards of Care for Acute Surgery............................................................................. 35 5.1.1.2 Knowing the Risk ........................................................................................................... 36 5.1.1.3 Communicating with Patients ....................................................................................... 37 5.1.1.4 Consent and Patient Safety ........................................................................................... 37 5.1.1.5 Consultant-delivered Service ........................................................................................ 38 5.1.2 Recognition of Acute vs. Elective Pathways ......................................................................... 39 5.1.3 Networked Solutions ............................................................................................................ 42 5.1.3.1 Hospital Groups............................................................................................................. 42 5.1.3.2 Hospital Models ............................................................................................................ 43 5.2 Strategies ..................................................................................................................................... 45 5.2.1 Efficient Patient Flow - Access & Discharge .......................................................................... 45 5.2.1.1 Importance of Access and Facilities .............................................................................. 45 5.2.2 Acute Surgical Assessment Units (ASAUs) ............................................................................ 46 5.2.2.1 Diagnostic Services ........................................................................................................ 50 5.2.3 Designated Theatres ............................................................................................................. 51 5.2.4 Manpower/Resource Optimisation ...................................................................................... 52 5.2.4.1 The Surgical Team ......................................................................................................... 52 5.2.4.2 The Need for Innovative Roles ...................................................................................... 54 5.2.4.3 Efficient use of Resources ............................................................................................. 56 Model of Care for Acute Surgery 2013 3 | P a g e 5.2.5 Capacity Planning .................................................................................................................. 57 5.2.5.1 Predicting Flows into Unscheduled Surgical Care ......................................................... 57 5.2.5.2 Critical Care Capacity Planning ..................................................................................... 62 5.2.5.3 Discharge Planning ........................................................................................................ 62 5.2.5.4 Acute Surgical Inpatients who do not have a surgical procedure ................................ 63 5.2.6 Key Performance Indicators ................................................................................................. 65 5.2.6.1 Data, Outcomes and Quality Indicators ........................................................................ 65 5.2.6.2 Audit (IASM, INOR and Critical Care audit) ................................................................... 66 5.3 Key Considerations ...................................................................................................................... 69 5.3.1 Governance ........................................................................................................................... 69 5.3.2 Surgical Specialties – Their Role in Acute Care ..................................................................... 71 5.3.3 Integration with other Stakeholders & Clinical Programmes ............................................... 72 5.3.3.1 Acute Medicine Programme ......................................................................................... 72 5.3.3.2 Emergency Medicine Programme ................................................................................. 73 5.3.3.3 Transport Medicine Programme ................................................................................... 74 5.3.3.4 Critical Care Programme ............................................................................................... 76 5.3.3.5 National Cancer Control Programme ............................................................................ 78 5.3.4 Information and Communication Technology support (ICT) ................................................ 79 5.3.5 Trauma .................................................................................................................................. 79 5.3.6 Paediatric Surgery ................................................................................................................. 81 6.0 Standards for Acute Surgical Care................................................................................................... 85 6.1 Generic Standards for Acute Surgical Care ................................................................................. 86 6.2 Surgical Specialty Standards for Acute Surgical Care .................................................................. 90 6.2.1 Cardiothoracic Surgery ......................................................................................................... 90 6.2.2 General Surgery .................................................................................................................... 91 6.2.3 Neurosurgery ........................................................................................................................ 94 6.2.4 Oral and Maxillofacial Surgery (OMFS) ................................................................................
Load more

Recommended publications
  • Acute Medical Assessment Units: a Literature Review
    Acute Medical Assessment Units: A Literature Review 2013 1 This report was prepared by Dr Elyce McGovern SpR in Public Health Medicine on behalf of The National Acute Medicine Programme 2013. 2 Table of Contents List of Tables 5 List of Figures 6 Acknowledgements 7 Abbreviations 8 Chapter 1 Introduction 9 Background 10 History of Acute Medicine in Ireland 11 History of Acute Medicine Internationally 12 Rationale for the Acute Medicine Programme in Ireland 13 Aims and Objectives 18 Chapter 2 Methodology 20 Search Strategy 23 Search Results 26 Critical appraisal Techniques 29 Chapter 3 Results 32 Critical Appraisal of studies which examined AMAU Outcomes 35 Critical Appraisal of studies which examined AMAU Processes 39 Critical Appraisal of studies which examined AMAU Structure 42 Critical Appraisal of studies which examined AMAU Alternatives 45 Critical Appraisal of additional AMAU Studies 49 Country of Origin of Research 51 Impact of Medical Assessment Unit on Length of stay 52 Impact of Medical Assessment Unit on Readmission Rates 55 Impact of Medical Assessment Unit on Trolley Time 57 Impact of Medical Assessment Unit on Mortality 58 Impact of Medical Assessment Unit on Hospital Beds 60 Impact of Medical Assessment Unit on Waiting Times for 61 Unit Diagnostics and Procedures Impact of Medical Assessment Unit on seeing a Doctor Soon 63 Impact of Medical Assessment Unit on Disposition Decision 64 within Six Hours Patient Satisfaction Surveys regarding Acute Patient Assessments 65 3 in an Acute Hospital Assessment Evidence for proposed
    [Show full text]
  • BFI Press Release: Missing Believed Wiped Bumper Christmas Stocking
    For Immediate Release: Tuesday 7 November 2017, London. The BFI’s Missing Believed Wiped returns to BFI Southbank this December to present British television rediscoveries, not seen by audiences for decades, since their original transmission dates. The exciting, bespoke line-up of TV gems feature some of our most-loved television celebrities and iconic characters including Alf Garnett in Till Death Us Do Part: Sex Before Marriage, Cilla Black in her eponymous BBC show featuring Dudley Moore , Jimmy Edwards in Whack-O!, a rare interview with Peter Davison about playing Doctor Who and a significant screen debut from a young Pete Postlethwaite. Lost for 50 years and thought only to survive in part, Till Death Us Do: Sex Before Marriage, originally broadcast on 2 January, 1967 on BBC1, sees Warren Mitchell’s Alf Garnett rail against the permissive society, featuring guest star John Junkin alongside regular cast members Dandy Nichols, Anthony Booth and Una Stubbs. Although the existence of this missing episode from the 2nd series has been known for some years, previous attempts to screen the episode had been refused with the print in the hands of a private collector. Having recently changed hands, MBW is delighted that access has been granted for this special one off screening, for one of 1960s best known and controversial UK television characters. Following last year’s successful screening of a previously lost episode of Jimmy Edwards’s popular 1950s BBC school-themed comedy romp Whack-O!, this year’s MBW programme includes a 1959 episode entitled The Empty Cash Box. Written by Frank Muir and Dennis Norden and starring Jimmy Edwards as the cane-happy headmaster, this episode was originally broadcast on the BBC on 1st December 1959.
    [Show full text]
  • The Acute Medical Unit Model: a Characterisation Based Upon the National Health Service Scotland
    REID, L.E.M., PRETSCH, U., JONES, M.C., LONE, N.I., WEIR, C.J. and MORRISON, Z. 2018. The acute medical unit model: a characterisation based upon the National Health Service Scotland. PLoS ONE [online], 13(10), article ID e0204010. Available from: https://doi.org/10.1371/journal.pone.0204010. The acute medical unit model: a characterisation based upon the National Health Service Scotland. REID, L.E.M., PRETSCH, U., JONES, M.C., LONE, N.I., WEIR, C.J. and MORRISON, Z. 2018 This document was downloaded from https://openair.rgu.ac.uk RESEARCH ARTICLE The acute medical unit model: A characterisation based upon the National Health Service in Scotland 1,2,3 2 2 3 Lindsay E. M. ReidID *, Ursula Pretsch , Michael C. Jones , Nazir I. Lone , Christopher J. Weir3,4, Zoe Morrison5 1 Development and Delivery Department, Ko Awatea Health Systems Innovation and Improvement, Auckland, New Zealand, 2 Quality, Research and Standards, Royal College of Physicians of Edinburgh, a1111111111 Edinburgh, United Kingdom, 3 Usher Institute of Population Health Sciences and Informatics, University of a1111111111 Edinburgh, Edinburgh, United Kingdom, 4 Edinburgh Clinical Trials Unit; University of Edinburgh, Edinburgh, a1111111111 United Kingdom, 5 Business School, University of Aberdeen, Aberdeen, United Kingdom a1111111111 * [email protected] a1111111111 Abstract OPEN ACCESS Background Citation: Reid LEM, Pretsch U, Jones MC, Lone NI, Weir CJ, Morrison Z (2018) The acute medical unit Acute medical units (AMUs) receive the majority of acute medical patients presenting to model: A characterisation based upon the National hospital as an emergency in the United Kingdom (UK) and in other international settings.
    [Show full text]
  • Radio 4 Listings for 14 – 20 April 2012 Page 1 of 16 SATURDAY 14 APRIL 2012 Richard Adams in Watership Down
    Radio 4 Listings for 14 – 20 April 2012 Page 1 of 16 SATURDAY 14 APRIL 2012 Richard Adams in Watership Down . Development is now Produced by Alan Hall planned in Sandleford near Newbury . A Falling Tree production for BBC Radio 4. SAT 00:00 Midnight News (b01fjz4z) A planning application to build 2,000 homes has met with The latest national and international news from BBC Radio 4. opposition from the local community. However West Berkshire Followed by Weather. Council says it needs to build more due to a housing shortage. SAT 11:00 Beyond Westminster (b01g4dnc) To explore the issues and mark the 40th anniversary of the Vying for Asian Voters book’s publication Helen retraces the landscape that follows the SAT 00:30 Book of the Week (b01g6pwc) Berkshire/Hampshire border. For both Labour and the Conservatives achieving an outright Double Cross majority in the Westminster Parliament will require winning over many voters who have not previously supported their Episode 5 SAT 06:30 Farming Today (b01g4ddz) causes. In particular, both parties need to do more to win over Farming Today This Week voters among Britain's ethnic communities and especially voters Written by Ben Macintyre. with an Asian heritage. Caz Graham investigates how the UK dairy industry compares It is June 1944 and the Allies prepare for the landings in internationally, from how farmers look after their cows to the Labour, shocked by its recent defeat in the Bradford West by- Normandy, taking the Germans by surprise, thanks to the work price of a pint. election, needs to reconnect with these voters it has too often of the double agents working for the British secret service.
    [Show full text]
  • Acute Medical Care in England
    Acute medical care in England Findings from a survey of smaller acute hospitals Candace Imison and Dr Louella Vaughan Background and methods • The Nuffield Trust conducted a survey to determine the current state of acute medical care in smaller hospitals in England as part of a larger NIHR-funded project exploring models of medical generalism in smaller hospitals. • Using a semi-structured interview schedule, we interviewed medical directors and/or lead clinicians for acute/emergency medical care between August 2016 and February 2017. • We used the definition used by Monitor for smaller hospitals: that is, trusts with an annual turnover of less than 300 million. • The survey covered 48 trusts (accounting for 70% of smaller NHS acute trusts) across 50 hospital sites: two trusts ran two acute hospitals. • The interviews with acute trusts were recorded and transcribed. The responses were then codified and entered into SurveyMonkey to support a structured analysis. How this report is structured • The first section draws on our survey data to explore the staffing of acute medical services in smaller hospitals. It shows the huge challenges faced by smaller acute trusts in England, particularly in maintaining sufficient numbers of medical staff, and the stark variation that exists across medical specialties. • For the skill-mix element of the staffing analysis, we also draw upon NHS Digital data to analyse skill mix across all 68 smaller acute hospital trusts in England. Where data sources draw upon this data it is clearly marked. • The second section explores the configuration of acute medical services in smaller hospitals. This uses the survey data to illustrate the increasingly fragmented and complex nature of acute medical services, and the huge variation that exists across small acute trusts.
    [Show full text]
  • Adult Rapid Tranquillisation in the Emergency Department (A&E) and Acute Medical Unit
    WAHT-A&E-033 It is the responsibility of every individual to ensure this is the latest version as published on the Trust Intranet ADULT RAPID TRANQUILLISATION IN THE EMERGENCY DEPARTMENT (A&E) AND ACUTE MEDICAL UNIT This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance. INTRODUCTION Patients presenting to either the emergency department (ED) or other acute care areas such as the medical assessment unit (MAU) requiring rapid tranquillisation for their own safety represent a high risk group of patients. Requirement for rapid tranquillisation may be due to psychiatric illness, diseases such as encephalitis, injury (traumatic brain injury) or due to the ingestion of drugs. The confusion / violence / aggression / agitation that may accompany such illnesses presents many challenges to those who have to manage the patient not least the undifferentiated nature of the underlying disease. The decision to undertake emergency Rapid Tranquillisation (RT) should only be done if it is the patient’s best interests and all other avenues to gain patient co-operation have been exhausted. THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS : Medical practitioners qualified to administer and prescribe tranquillising drugs. Qualified Nurse / Practitioner trained to administer tranquillising drugs. Medical
    [Show full text]
  • The Acute Medical Unit Model: a Characterisation Based Upon the National Health Service in Scotland
    RESEARCH ARTICLE The acute medical unit model: A characterisation based upon the National Health Service in Scotland 1,2,3 2 2 3 Lindsay E. M. ReidID *, Ursula Pretsch , Michael C. Jones , Nazir I. Lone , Christopher J. Weir3,4, Zoe Morrison5 1 Development and Delivery Department, Ko Awatea Health Systems Innovation and Improvement, Auckland, New Zealand, 2 Quality, Research and Standards, Royal College of Physicians of Edinburgh, a1111111111 Edinburgh, United Kingdom, 3 Usher Institute of Population Health Sciences and Informatics, University of a1111111111 Edinburgh, Edinburgh, United Kingdom, 4 Edinburgh Clinical Trials Unit; University of Edinburgh, Edinburgh, a1111111111 United Kingdom, 5 Business School, University of Aberdeen, Aberdeen, United Kingdom a1111111111 * [email protected] a1111111111 Abstract OPEN ACCESS Background Citation: Reid LEM, Pretsch U, Jones MC, Lone NI, Weir CJ, Morrison Z (2018) The acute medical unit Acute medical units (AMUs) receive the majority of acute medical patients presenting to model: A characterisation based upon the National hospital as an emergency in the United Kingdom (UK) and in other international settings. Health Service in Scotland. PLoS ONE 13(10): They have emerged as a result of local service innovation in the context of a limited evi- e0204010. https://doi.org/10.1371/journal. pone.0204010 dence base. As such, the AMU model is not well characterised in terms of its boundaries, patient populations and components of care. This makes service optimisation and develop- Editor: Saravana Kumar, University of South Australia, AUSTRALIA ment through strategic resource planning, quality improvement and research challenging. Received: December 19, 2017 Aim Accepted: August 31, 2018 This study aims to evaluate a national set of AMUs with the intent of characterising the AMU Published: October 3, 2018 model.
    [Show full text]
  • Collaborative Approach to Reducing Cardiac Arrests in an Acute Medical Unit
    Open Access BMJ Quality Improvement Report BMJ Open Qual: first published as 10.1136/bmjoq-2017-000026 on 12 November 2017. Downloaded from Collaborative approach to reducing cardiac arrests in an acute medical unit Calum McGregor,1 Sanjiv Chohan,2 Jonathon O’Reilly3 To cite: McGregor C, Chohan S, ABSTRACT BACKGROUND O’Reilly J. Collaborative Cardiac arrests are often preceded by a period of Cardiac arrests are often preceded by approach to reducing cardiac physiological deterioration. Preventing potentially arrests in an acute medical 8–12 hours of physiological deterioration, avoidable cardiac arrests therefore depends on reliable unit.BMJ Open Quality detectable by measurement of patients’ vital 2–4 2017;6:e000026. doi:10.1136/ recognition of, and response to, those deteriorations. Our signs. Moreover, patients’ prognosis deteri- bmjoq-2017-000026 hospital’s acute medical unit had one of the highest rates orates with increasing numbers of abnormal of cardiac arrest in our organisation at baseline. The aim physiological parameters.5 Inadequate clin- was to reduce our unit’s cardiac arrest rate by over 50%. Received 16 February 2017 ical monitoring and failure to act on deteri- Revised 11 July 2017 Pareto chart analysis identified unreliable processes in the recognition and response to deteriorating patients. Process oration has been found to be associated with Accepted 21 September 2017 6 7 mapping exercises were performed, then the model for preventable deaths in hospital. Previous 8 9 improvement and rapid cycle tests of change were used to studies of hospital patients, National develop standardised processes for clinical observations, Reporting and Learning System data7 and recognising deteriorating patients and responding to National Confidential Enquiry into Patient hypoxia.
    [Show full text]
  • The Role of Acute Internal Medicine Service in Handling Burden of Medical Access Block in a Tertiary Hospital, Hospital Melaka Experience
    12-The role00127_3-PRIMARY.qxd 12/31/20 7:06 PM Page 64 ORIGINAL ARTICLE The role of acute internal medicine service in handling burden of medical access block in a tertiary hospital, Hospital Melaka experience Nida’ Ul-Huda Adznan, MRCP, Chye Lee Gan, MRCP Department of Internal Medicine, Hospital Melaka, Ministry of Health Malaysia where patients who have been assessed in the emergency ABSTRACT department (ED) are unable to leave the department due to a Introduction: Access block is a major problem faced by most lack of capacity in the downstream system.1 The causes for hospitals. It has led to congestions in emergency this congestion vary in different regions ranging from departments (ED) leading to sub-optimal or delayed shortage of acute medical inpatient beds, financial treatment. Inevitably the spotlight falls on medical restrictions on service provision to the availability of staff.2 department, being accountable for the highest proportion of Effects on patient care include delays in being assessed and access block in ED. receiving the required care, reduced patient satisfaction, increased complaints, increased inpatient length of stay, Materials and Methods: This is a retrospective study looking increased cost of treatment and poorer outcomes.3,4 Delays at data collected during office hours on 79 working days, are also associated with waiting for the relevant medical excluding weekends and public holidays in Hospital Melaka, team to assess an acute medical patient in ED. Malaysia. Details on all medical access block cases that were reviewed were recorded including their locations, In 2017, there were a total of 39,378 admissions through ED diagnosis, disposition decisions and if they received in Hospital Melaka (HM) and 48% were medical patients.
    [Show full text]
  • Rethinking Acute Medical Care in Smaller Hospitals
    Research report October 2018 Rethinking acute medical care in smaller hospitals Dr Louella Vaughan, Nigel Edwards, Candace Imison and Ben Collins About this report Across England, millions of people rely on smaller hospitals as their first recourse in an emergency, their first source of expertise when conditions worsen, and their first choice for planned operations. But these hospitals are facing increasing challenges in delivering effective acute medical services in the context of growing patient numbers, an increasingly complex mix of cases arriving for care, workforce shortages, changing societal expectations and severe restrictions in funding growth. The Nuffield Trust was asked by NHS England to develop a better understanding of the problems associated with acute medicine in smaller hospitals and to find possible solutions. This report brings together what we have learnt from a review of the literature, discussions with experts from a number of health systems in other countries and interviews with senior clinicians and managers in England, Scotland and Wales, many of whom have already developed partial solutions to the problems associated with smaller and rural hospitals. We also draw on insights from other ongoing research at the Nuffield Trust. The report is intended to be a stimulus for local innovation and to dissuade the thought that the reconfiguration of services is the only solution to staffing and other challenges posed by running smaller hospitals in an increasingly complex health care landscape. Find out more online at:
    [Show full text]
  • Acute Medical Unit: Experience from a Tertiary Healthcare Institution in Singapore
    Singapore Med J 2018; 59(10): 510-513 Commentary https://doi.org/10.11622/smedj.2018124 Acute medical unit: experience from a tertiary healthcare institution in Singapore Wei-Ping Goh1, MBBS, MBA, Hui Fen Han2, BSc(Hons), Uma Chandra Segara3, BSc, Geraldine Baird1, MSN, Aisha Lateef1,4, MRCP, FAMS ABSTRACT Singapore’s healthcare system is under strain from the rising demands of an increasing and ageing population, resulting in delayed specialist care for patients presenting to the emergency department and requiring admission. Acute assessment units have been developed elsewhere but are not well established in local healthcare. Our institution extended our acute medical team to form an acute medical unit (AMU), in which focused internist-led teams are stationed on site to rapidly assess and re-triage patients. All patients (excluding those with very complex conditions) are admitted to the AMU and managed by internists who provide holistic, patient-centric care with better ownership, improved efficiency and less fragmentation. Patients can receive timely access to medical interventions and stable patients can benefit from early supported discharge, anchored by the nursing, allied health and transitional care teams. Given the ageing patient population with multiple comorbidities, this integrated model with exceptional outcomes is highly suitable for Singapore. Keywords: acute medical unit, internist-led, Singapore INTRODUCTION and shorter length of stay were noted in the AMT patients, who Healthcare systems worldwide are seeing an increasing number were also more likely to be admitted into a ward specialising in of patients who require hospitalisation, largely due to ageing their condition and have a smaller bill size compared to non- populations with multiple comorbidities as well as rising AMT patients.
    [Show full text]
  • The Expected Effects of an Acute Medical Unit on the Amount and Type of Acute Patients Admitted to the General Medical Wards and the Experienced Workload of Nurses
    The expected effects of an Acute Medical Unit on the amount and type of acute patients admitted to the general medical wards and the experienced workload of nurses Evelien W. van der Maas, BSc. Master’s Thesis 0 The expected effects of an Acute Medical Unit on the amount and type of acute patients admitted to the general medical wards and the experienced workload of nurses November, 2011 Health Sciences School of Management and Governance University of Twente Author External Supervisor E.W. van der Maas, BSc. Drs. M.I. Brilleman Master student Health Sciences Deventer Ziekenhuis [email protected] Centrale Stafdienst Supervisor University Second Supervisor University Dr. C.J.M. Doggen Dr. Ir. E.W. Hans University of Twente University of Twente School of Management and Governance School of Management and Governance Health Technology & Services Research Operational Methods for Production and Logistics 1 Abstract Introduction. The establishment of Acute Medical Units (AMUs) in hospitals is growing in popularity as a solution for the problem of bed shortages. An AMU can be seen as a buffer between the emergency department and the general medical wards. Patients can stay for a maximum of 24, 48 or 72 hours at the AMU. Deventer Hospital is currently considering to implement an AMU at their hospital. It wants to stabilize the process of arrival of new acute patients to the medical wards, lower the experienced workload of nurses, shorten the length of hospital stay and reduce the amount of admission stops and patients at a ‘second best’ or even inappropriate ward. The hospital wants to determine whether this is established by implementing an AMU.
    [Show full text]