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Implementing a patient assessment framework in acute care

Lees L, Hughes T (2009) Implementing a patient assessment framework in acute care. Nursing Standard. 24, 3, 35-43. Date of acceptance: June 26 2009.

Summary
This article describes the secondment of a critical care practitioner to an acute medicine unit. The aim was to develop the acute assessment skills of the units nurses and to implement a new assessment framework. The secondment took place over four months from December 2007 to March 2008 at the Heart of England NHS Foundation Trust, Birmingham. There were several stages to the project, commencing with exploration of existing practice and culminating with evaluation of the projects effect on practice. A review of the multi-professional patient records was conducted six months after the conclusion of the secondment. This revealed that the assessment framework continued to be used in practice. The secondment demonstrated that supporting nurses to embrace new skills resulted in a change in practice. However, a permanent change cannot be assured unless practice is revisited and supported on a continual basis.

College of Physicians 2007). The acute emergency assessment area was merged with the inpatient medical admissions ward and renamed the acute medicine unit (AMU). The new AMU comprises 27 patient-assessment cubicles, ten beds for patients requiring a short stay in acute medicine and ten chest pain assessment beds. A level 1 area has been created for patients at risk of their condition deteriorating, or who are in need of higher levels of care, for example patients with sepsis, chest pain and cardiac failure (Department of Health (DH) and NHS Modernisation Agency 2003, National Institute for Health and Clinical Excellence (NICE) 2007, Higgins et al 2008).

Acute medicine units

An AMU is a specialist area in a hospital that assesses and co-ordinates a high volume of acute medical patient referrals from GPs and the emergency department (Royal College of Physicians 2007). AMUs are staffed by acute physicians, junior doctors, experienced nursing staff and other members of the multidisciplinary team, for example physiotherapists, occupational therapists, speech and language therapists and pharmacists. The length of inpatient stay on an AMU is usually up to 48 hours, after which patients are transferred to appropriate wards or discharged home (DH 2004, Royal College of Physicians 2004).

Authors
Liz Lees, consultant nurse, acute medicine, and Tara Hughes, critical care outreach practitioner, Heart of England NHS Foundation Trust, Heartlands Hospital, Birmingham. Email: liz.lees@heartofengland.nhs.uk

Keywords
Change management, intensive care, nursing: education, patient assessment These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at nursingstandard.rcnpublishing.co.uk. For related articles visit our online archive and search using the keywords.

Purpose of the secondment

THE DIRECTORATE OF ACUTE MEDICINE at the Heart of England NHS Foundation Trust, Birmingham, underwent significant transformation during 2007. This followed a new strategy to manage acute medical patients requiring assessment and admission (Royal NURSING STANDARD In December 2007, an acute medical consultant from the AMU recognised that there was a need for additional clinical expertise among the acute medicine nurses given the increased acuity of the patients (Ryan et al 2008). Early in the development of the AMU, the consultant realised september 23 :: vol 24 no 3 :: 2009 35

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that the units success and the maintenance of patient safety depended on the competence and confidence of the nursing team with regard to assessing and recognising acutely ill patients (National Confidential Enquiry into Patient Outcome and Death (NCEPOD) 2007, NICE 2007, Higgins et al 2008). Initial action taken to remedy the situation and ensure patient safety represented a top-down management approach, whereby change is implemented without necessarily consulting staff about the decisions that have been made. Thereafter, a combination of management approaches was employed (Ryan et al 2008). These included informing consultant physicians and a staff away-day, where changes were communicated. The NCEPOD (2007) reports principal recommendations included implementing improvements across the entire patient pathway, from initial patient assessments and patient transfers, to providing multi-professional training opportunities in practice (NCEPOD 2007). Before the opening of the AMU, acutely ill and unstable medical patients in the trust were assessed and stabilised in the emergency department before being transferred to an appropriate ward or discharged (NICE 2007). The addition of the level 1 area in the new AMU meant that patients at increased risk of deterioration could receive one-to-one nursing care from nurses with enhanced skills in patient assessment (NICE 2007, Higgins et al 2008). An experienced critical care practitioner was seconded to the AMU for four months to help acute medicine nurses develop enhanced clinical expertise. A systematic framework for the assessment of acutely ill patients was used to assist this process. The secondment was structured so that its effect on practice could be measured (Allan et al 2008). The consultant nurse for acute medicine set the objectives and supported the practitioner during the secondment. For example, regular meetings involving the consultant nurse and the critical care practitioner were held throughout the secondment to ensure effective communication and timely resolution of any issues that arose.

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Review of relevant literature

An AMU receives patients with a wide range of medical problems. This variation provides many opportunities for nurses to gain experience in the practice of acute assessment skills. However, the reality of co-ordinating multiple patient admissions and discharges has consequences 36 september 23 :: vol 24 no 3 :: 2009

for the support of learning in the workplace (Hoffman and Donaldson 2004). The volume of patients limits teaching activities in what should be an ideal learning environment. Often, staff can only be freed for mandatory training needs rather than bespoke training promoting new assessment skills. Furthermore, reflective practice and learning from experience, common techniques in nursing, are inhibited because of the speed of patient turnover. Nurses are unable to reflect on what might have been done differently (Johns 1995). Therefore, innovative ways of supporting practice development are required if clinical expertise among nurses is to be developed (Manley and McCormack 2003). Practice educators use the approach of working with staff in a practice setting. Practice-based learning enables students to learn from real clinical experiences (Koh 2002, Fulbrook and Cockerell 2005). Identifying what learning is required and sharing expertise to lead practice changes require a thorough appreciation of the constraints and context of practice (Allan et al 2008). When undertaking work-based learning, if practice is to be affected positively, staff need to feel properly engaged with the learning process (Chapman 2006). The seconded practitioner respected and accommodated the individual needs of learners. To manage the process of change and the dynamics involved in the clinical setting, it was also necessary to appreciate approaches to influencing individual behaviour (Kanter et al 1992). This was achieved by working individually with staff and allowing staff to shadow the practitioner. The principles of transitional management of change, which include a focused and planned approach, underpinned the process adopted for the project (Iles and Sutherland 2001). To bring about a new way of working, an understanding of the stages of change is required (Senge 1990). In this case, the ABCDEfG assessment framework was used (Box 1). While a role model or facilitator can be used to lead the change process, this approach may cause resistance to change, especially if it is construed as a top-down initiative (Ryan et al 2008). Gaining engagement with change also requires managing differing degrees of staff compliance, from non-compliance up to a level of genuine compliance, where staff will do what is asked of them and act in the spirit of the change (Senge 1990). This process and the management of change should be inter-reliant if a real commitment to sustainable change is to be achieved (Kanter et al 1992).

The secondment
Verbal feedback received from the acute medicine nurses indicated that the seconded critical care practitioner was able to stimulate NURSING STANDARD

a new culture of learning in practice (DH and NHS Modernisation Agency 2003, Seymour et al 2003). A structured approach with objectives, skilled facilitation and effective clinical supervision was used to establish a trusting partnership between the seconded critical care practitioner and staff on the AMU (Porter 1998). It was necessary to establish if there was evidence of change in the way nurses assessed patients. This was measured six months after the end of the secondment (Kirkpatrick 1998). A retrospective case note analysis was conducted of the patients notes to assess the extent to which the ABCDEfG assessment framework had been embedded in practice. Assessment of permanent change was not within the scope of the project. Five key stages will be described in this article to demonstrate how the secondment was structured and evaluated in practice, including: 1. Setting objectives. 2. Exploration of existing practices and issues. 3. Devising appropriate methods for managing the process of introducing the assessment framework on the AMU. 4. Introducing the new assessment framework. 5. Evaluating the effect of the secondment on practice. Stage 1: setting the secondment objectives Four main objectives were set to guide the critical care practitioner throughout the secondment: To gain an understanding of practice issues experienced by acute medicine nurses by working with them. To lead by example, encouraging and enabling staff to conduct regular patient reviews by working with nurses in their practice. To instigate regular teaching of nurses about critically ill patients to promote new clinical expertise. To introduce robust systems, protocols and guidance to ensure AMU staff compliance with best practice and national guidelines. Stage 2: exploration of existing practices and issues Before the secondment, all members of the multiprofessional team on the AMU discussed what they felt to be the key issues affecting practice that should be prioritised throughout the secondment. These key issues were: Nurses experience in nursing compared with nursing experience in acute medicine. Experience of practice-based teaching. Knowledge of critical care. NURSING STANDARD

Confidence and support required to gain new skills to care for acutely ill patients. Sense of direction in assessing patients and using a systematic approach. Communication and handover strategies used. To get to know the nurses and the issues affecting their practice reasonably quickly, nurses were given a questionnaire to fill in and then had one-to-one or group discussions with the critical care practitioner. This approach promoted conscious reasoning and awareness of why facilitation needed to take place, and why the practice of not using an assessment strategy could not stay the same. The change management process should be underpinned by actions related to conscious reasoning, and not by emergent change, which is harder to quantify and would have been unachievable during the project. The actions used to manage the change should be planned according to what was said on the questionnaire, including how nurses felt and what support they needed (Iles and Sutherland 2001). The issues identified by the AMUs clinical team were used to develop the survey questions (Box 2). BOX 1 ABCDEfG assessment framework
A = Airway and oxygen therapy. B = Breathing: rate, pattern and oxygen saturations. C = Circulation: blood pressure, pulse and capillary refill time. D = Disability: neurological impairment using the AVPU (awake, verbally responsive, pain responsive, unconscious) score. E = Exposure: general exposure of all limbs to check for oedema and rashes, for example. fG = Not to forget the glucose.
(Smith 2003)

BOX 2 Key survey questions 1. How many years experience do you have as a registered nurse? 2. How many years of that has been spent in acute medicine? 3. Have you completed the ALERT (Acute Life-threatening Events
Recognition and Treatment) course?

4. Do you use an assessment framework to assess acutely ill patients? 5. What qualities do you feel are required to care for acutely ill patients? 6. Do you use a format to hand over acutely ill patients? 7. What changes are needed to improve the care of acutely ill patients? 8. What do you think the benefits will be of the critical care outreach team on
the acute medicine unit?

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At the time of the secondment 52 registered staff were employed on the AMU. Twenty-four members of staff returned the survey, but not all questions were completed. This sample was considered to be representative of the AMU staff. Figure 1 demonstrates that ten staff had less than five years nursing experience, while a further eight staff had between six and ten years nursing experience. When the same staff group was examined in relation to acute medicine, 16 staff had less than five years experience working on an AMU, with a further four staff FIGURE 1 Profile of registered nurses general experience in years
12 10 Number of nurses 8 6 4 2 0 <5 years 6-10 years 10-15 years 15-25 years

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FIGURE 2 Profile of registered nurses demonstrating years of experience in acute medicine

18 16 14 12 Number of nurses 10 8 6 4 2 0

having between six and ten years experience (Figure 2). This demonstrated that the workforce was relatively inexperienced in acute medicine, regardless of the number of years that they were registered. They therefore needed skilled facilitation to promote confidence in patient assessment skills. The Acute Life-threatening Events Recognition and Treatment (ALERT) course was developed by Portsmouth University and is used nationally through a group of trained programme administrators and practitioners (Smith 2003). All nurses working in acute areas should complete this course as it ensures a safe standard of basic competence in caring for acutely ill patients (NICE 2007, Higgins et al 2008). Of the 24 nurses who returned the questionnaire, eight had completed the ALERT course. The14 nurses who had not completed the course comprised: two nurses with 15 years experience; ten nurses with between five and ten years experience; and two nurses with less than five years experience (Figure 3). This demonstrated that the most experienced nurses had not completed the course and enabled the seconded critical care practitioner to target those nurses for training. Two nurses did not answer this question. With regard to question 4: Do you use an assessment framework to assess acutely ill patients?, of the 23 respondents who answered this question, 11 did not use an assessment framework, five used some kind of a framework (although not formally accredited or systematic) and seven used the systematic ABCDEfG framework (Smith 2003) taught on the ALERT course (Figure 4). This indicated that a key part of the work would be to introduce the ABCDEfG framework and standardise assessment practice on the unit. A total of 24 staff responded to question 5: What qualities do you feel are required to care for acutely ill patients?. Key themes were analysed from the responses and used to establish where improvements might be required. The three reoccurring themes were: Good communication skills. Knowledge about patients vital signs. Organising and prioritising. Comments made in addition to the survey questions were that assessing patients is common sense and that the thing they most needed was more time or more nurses. With regard to question 6: Do you hand over acutely ill patients?, responses were received from 24 staff; however, only four nurses categorically said there was an agreed format for handover. Two staff indicated that the format used depended on who was on duty. NURSING STANDARD

<5 years

6-10 years

10-15 years

15-25 years

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Number of nurses

The remaining 18 nurses were not sure whether a format was used or not. At the time of the secondment, the trusts corporate management team was in the process of implementing a verbal communication system known as SBAR (Situation, Background, Assessment and Recommendations) throughout the hospital (Spath 2000, Haig et al 2006). This system aims to produce a uniform approach to communication regarding a patients condition, most commonly but not exclusively via the telephone. This system originated from the Institute for Healthcare Improvement (www.ihi.org/ihi) following an effort to reduce suboptimal verbal communications (Spath 2000). There was much confusion regarding how the ABCDEfG framework worked in conjunction with SBAR system among nurses in the AMU. Extensive explanations with nurses were needed to demonstrate that a critical situation could easily be conveyed using the SBAR system and ABCDEfG framework. Question 7 related to what changes were needed to improve the care of acutely ill patients. The content of the responses was analysed for frequent reoccurrence of key words. These were: staffing, continuity, competency, equipment and time. The context in which they were stated was: Insufficient staff, particularly at busy times. In addition, staff were often loaned to other wards at times of shortages. While this is not a frequent occurrence it continues to happen. Lack of continuity of nursing care was associated with the rapid pace of patient admission and discharge. The competency of night staff because they are less able to access training. This was addressed by the critical care outreach team practitioner working flexibly on a two-shift system. Lack of equipment, for example stethoscopes, patient-weighing scales and tympanic thermometers. This was rectified at the time of the secondment. Lack of protected time for clinical work. This particularly affected band 6 nurses who co-ordinated the unit, a role that took them away from clinical care. Question 8 asked what the nurses thought the benefits would be of the critical care outreach team on the AMU. Most staff viewed this role with enthusiasm. The key themes for this question from the responses were: build confidence, early recognition of acutely ill patients, teaching in practice, support (to ask questions and not feel silly to ask), observing critical care skills in practice, and knowledge. NURSING STANDARD

Stage 3: devising appropriate methods for managing the process of introducing the assessment framework on the AMU These responses and subsequent discussions enabled the critical care outreach team practitioner to have a constructive and comprehensive understanding of the issues affecting practice on the AMU and to decide how to proceed (Kanter et al 1992, Koh 2002). Moreover, understanding the potential for resistance to the proposed change was critical to achieving long-term, not short-term change, which is only evident while the practitioner is working on the unit (Senge 1990, Kanter et al 1992). Some nurses were concerned about their competence to FIGURE 3 Acute medicine unit nurses who had undertaken the ALERTcourse (Dec 2007)
16 14 12 10 8 6 4 2 0 Yes No No reply

FIGURE 4 Systems used to assess acutely ill medical patients

12 10 Number of nurses 8 6 4 2 0 No system System ABCDEfG framework

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function in the new AMU. A wide selection of methods was used to work with staff on the AMU. Examples of these methods are listed in Box 3 (Allan et al 2008). Gaining staff trust by forming a relationship underpinned every interaction, especially while practices were being challenged to stimulate new approaches to acute assessment (Porter 1998). The kinds of facilitation methods used varied, depending on the experience of the nurse and type of interaction. The assessment of what method was required was based on the judgement of the practitioner. While working clinically with the AMU nurses, it was decided that the teaching sessions should be based around the ABCDEfG framework, which is commonly used to assess acutely ill patients (Smith 2003). This framework would also form a new assessment as part of the AMU standard for initial patient observation and assessments. Other more general holistic assessments are and continue to be conducted by nurses on the AMU. These include falls screening, nutritional screening, a modified early warning system, skin inspection and the Waterlow score (Waterlow 1998). In addition, incorporating the ABCDEfG framework in practice was felt to be a practical way of measuring the effect of the critical care outreach team practitioners effect on nursing practice in the AMU. Stage 4: introducing the new assessment framework The ABCDEfG assessment framework is a systematic approach to acute patient assessment (Smith 2003) and forms the basis of advanced/intermediate life support. It is a way of systematically assessing acutely ill patients. It has transferable principles for the assessment and stabilisation of acutely ill medical patients. It is not a new framework, but using it consistently in practice on a large AMU would significantly improve practice (Smith 2003). The ABCDEfG framework is used in conjunction with the Modified Early Warning Score BOX 3 Methods used to introduce the ABCDEfG framework
One-to-one demonstration by the patients bed. One-to-one observed practice. Observations while working as part of the team. Proactive encouragement and motivation of staff through feedback. Demonstration by example in the form of role modelling. Focused short teaching sessions before unit activity became too busy. Prompt cards and the use of new documentation with patients.

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(MEWS) (Higgins et al 2008). This is a simple physiological scoring tool to identify patients at risk of acute deterioration who may require increased levels of care on the AMU or in a high-dependency or intensive care unit (NICE 2007, Higgins et al 2008). A4-size ABCDEfG prompt cards were developed, laminated and fixed prominently in each assessment cubicle as a reminder system. The card outlined what should be documented in each facet of the framework. Reminder systems are considered a pivotal part of the change management process, reinforcing the individual behaviour required (Kanter et al 1992). In addition, the ABCDEfG framework was included in the AMUs nursing documentation, prompting nursing staff to use it to guide their assessment of acutely ill patients. These combined approaches to managing the change were used to ensure a shift from potentially grudging compliance to formal compliance using the ABCDEfG assessment framework (Senge 1990). After the first month, nearly all the A4 prompt cards had been removed from the cubicles because staff had developed a smaller (A5) version, which fitted into their uniform pockets. This demonstrated initial signs of formal compliance as the nurses were keen to use the assessment framework in practice (Senge 1990). When the framework had been in place for a month, a discussion of cases took place to raise awareness of the many aspects of assessment. A worked example of a case using the ABCDEfG framework is illustrated in Box 4. Stage 5: evaluating the effect of the secondment on practice Six months after the end of the secondment, a retrospective case-note analysis was conducted of patients admitted to the AMU over a 48-hour period to assess the extent to which the ABCDEfG framework and learning had been embedded in practice. A total of 34 sets of medical records was surveyed of the AMU beds and trolleys that were occupied. Assessment documentation from day and night shifts was examined. This revealed that in 25 sets of records the ABCDEfG framework had been used successfully. Conversely, in nine sets the systematic framework had not been used, although a narrative description of the patients condition had been documented. On further analysis of these nine sets of notes, two factors were attributed directly to the absence of a systematic framework: the patient had been assessed by members of staff who were new to the AMU and had not been taught to use the ABCDEfG framework; and they had been completed by members of the permanent night staff who were not familiar with the framework. At the time of secondment a recruitment drive was taking place for all staff, NURSING STANDARD

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BOX 4 Example of a patient assessment using the ABCDEfG framework

Situation: A 70-year-old female patient admitted to the acute medicine unit by ambulance with multiple medical problems as a result of a terminal illness. She is: Hypoxic. Dehydrated. Hypoglycaemic. In severe pain. ABCDEfG assessment: A = Airway patent as there is an audible wheeze when respirations are observed. B = Respiratory rate is rapid and shallow and the patient is unable to cough. She is pale and cyanosed centrally. The trachea is not central and abnormality of the ribcage is noted. Widespread crepitating wheeze resulting from aspiration/infection. The patient is unable to talk. Oxygen saturations not recordable. C = Pale and clammy complexion, pyrexia, hypotensive, tachycardia, capillary refill time delayed, dry mucous membranes, extensive skin turgor, sunken eyes, signs of anaemia. Unsure when the patient last passed urine. Arterial blood gas obtained. Electrocardiograph taken. D = (AVPU = awake, verbally responsive, pain responsive, unconscious) Initially only verbally responsive, reduced conscious level was observed and the patient was in a slumped position. Glasgow Coma Score = 11/14, PEARL (pupils equal and reacting to light). E = Emaciated, peripherally cold, no oedema present. Abdomen non-tender/soft. Closed body language, facial grimace because of pain. fG = Blood sugar low. Immediate actions: A = 15 litres oxygen administered via a non-rebreathing oxygen mask, which enables the delivery of high concentrations of oxygen and is recommended for use in patients who are critically ill. B = Repositioning the patient was sat in an upright position to aid lung expansion during breathing and promote comfort, and high-flow oxygen was commenced. C = Obtaining intravenous access and blood samples for laboratory testing and blood sugar analysis. Interpretation of assessment findings and electrocardiography. fG = Discussion of blood glucose with an appropriate doctor to ensure timely administration of prescribed glucose, analgesics and fluids administered as first-line treatment. 35 minutes later: A = Patient was alert and able to converse. B = Her complexion was pink and she appeared to be well oxygenated. Saturations and arterial blood gas analysis later confirmed improvement of acid base status and oxygenation. The patient was able to comply with chest physiotherapy; a sputum specimen was obtained. C = Blood pressure and pulse within acceptable parameters. Diuresis had occurred and a urine specimen was obtained. D = AVPU = patient classified as awake (A). E = Pain free and relaxed. fG = Blood glucose now stable. The patient was stabilised ready for medical review and further care planning. A systematic approach to assessment can help to prioritise and co-ordinate a patients treatment.

which may have accounted for the lack of familiarity on the part of night staff. The 25 sets of patient records were assessed independently by a band 8b nurse in the AMU for level of detail. Four categories were used to quantify the quality of the assessment content: excellent, good, average and poor. The category awarded was selected on the basis of the six key aspects of assessment highlighted in the literature that underpinned this project, including (Smith 2003, NICE 2007, Higgins et al 2008): Evidence of compliance with the ABCDEfG framework. Presence of the MEWS. Whether or not nursing actions were documented. NURSING STANDARD

Evidence of assistance sought regarding concerns raised during assessment of patients. Whether the framework was used for reassessment of patients. Whether the framework was used for nursing handovers of patients. The results were as follows: 15 sets were rated as excellent, eight sets as good, two sets as average and none as poor. A crucial part of patient assessment is reassessment so that deterioration can be recognised and prevented (NICE 2007). The ABCDEfG framework should be used for reassessment of all unstable patients (Smith 2003). Evidence from nursing documentation suggested that the critical care outreach team september 23 :: vol 24 no 3 :: 2009 41

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used the framework consistently for patient reassessments. Using the framework enabled a comprehensive audit trail to be established and timely action to be taken in key areas of concern (Smith 2003). It was difficult to ascertain whether or not the framework was used for staff handovers as there was little documentation in the notes about the handover (Haig et al 2006). SBAR is the ideal system for communicating handover information. However, at the point of the project, the SBAR system was at its inception and had not been embedded in the culture of nurse or clinician patient handovers (Spath 2000).

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Reinforcing good practice at key areas of the patient pathway

Once it was ascertained that the ABCDEfG framework was used for the initial assessment of patients on the AMU, it was introduced in two other key areas of the patient pathway (Figure 5): Patient handovers from the emergency department or GP referrals are now documented in the ABCDEfG framework and a MEWS is noted. This enables the nurses to request further relevant patient information to assure patient safety during transfer to the AMU. Patient transfers from the assessment area to AMU beds and to specialty areas are also now documented in the ABCDEfG format. This has taken careful change management with wards and departments outside the AMU, as the remainder of the hospital inpatient wards use a different format. Adopting this approach ensures that the ABCDEfG framework is used at each key stage of the patient journey before and following transfers (Senge 1990).

conditions to enable nurses to establish quickly and understand if, or when, the patient is deteriorating acutely. Part of the solution to patient assessment and reassessment rests with using a systematic assessment framework and the MEWS. If the assessment of patients is not standardised in practice situations, it is difficult to understand how and why to undertake, or not to undertake, a particular assessment. In addition, there is a risk of missing crucial parts of a patient assessment that may affect the choice of treatment instigated. The SBAR communication tool would have benefited from being introduced after the ABCDEfG. However, the introduction was outside of the control of the critical care outreach team practitioner, who had to address the confusion created by the top-down management approach. Nurses need support and coaching to promote confidence and to encourage them to explore solutions to patient problems (Allan et al 2008). How long and how often staff should be supported is difficult to determine. However, the concern is that if support is not available, nurses may only be able to act in their current sphere of knowledge and may miss vital clinical signs of deterioration. This is especially the case in a busy environment such as an AMU. The availability of time was cited as a prohibitive factor for action learning. Action learning is an educational process whereby the participants study their own actions and experiences to improve performance. However, the use of a systematic method of assessment may save time.

Limitations
The AMU has been in a constant state of evolution for the last 12 months, including recruitment of large numbers of nursing staff and the formation of new medical teams and ways of working. Among the staff changes the number of beds on the unit decreased while the number of assessment trolleys increased. While none of these changes viewed in isolation was problematic, the combined effect was that staff members were continually learning new systems, which may have limited their capacity for learning in other areas, such as assessment practice.

Discussion
Accurate assessment of patients in the AMU depends on a broad knowledge of acute medical FIGURE 5 Use of the ABCDEfG assessment framework on the acute medicine unit (AMU)
Patient handovers from the emergency department Initial assessment and triage in the AMU All patient transfers from the AMU

Conclusion
Introducing the ABCDEfG framework together with the MEWS enabled the nurses to use a systematic, recognised framework for the assessment of acutely ill medical patients. Evidence from the multi-professional documentation suggests the information gathered by using the new assessment framework, in conjunction with the MEWS, focused the NURSING STANDARD

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activities of nursing staff on prioritising and co-ordinating care for acutely ill patients. The ABCDEfG also provided a pivotal tool for communicating key clinical signs with doctors and allied health practitioners in a format that conveyed the urgency or non-urgency of the patients condition. The change has been achieved by introducing the assessment framework systematically at each stage of the patients journey. Nevertheless, organisational factors limit the effectiveness of communicating change and prevent information from filtering through the organisation in the expected way. Hence, the corporate introduction of the SBAR verbal communication system was precipitating too much change and causing confusion. Nonetheless, the critical care outreach team did bring about change in practice. The critical care outreach team practitioner secondment acted as a catalyst for changing the way acutely ill patients were assessed in the AMU. However, the success may be relatively

short lived if practice development is not a continual activity, with adequate staff support systems in place to ensure sustained change. A top-down change management approach alone is not ideal. It needs to be combined with other strategies for change to be successful, for example transitional change. The ABCDEfG framework is now used formally at the point of referral, at initial patient assessment and during handover and patient transfer. This ensures staff members gain confidence and competence in using it. Staff are also able to participate in the continued development of the framework, adapting it as the AMU evolves. The ABCDEfG framework, MEWS and SBAR system all aim to achieve one key goal improving patient safety and patient care through standardised systems and processes. It is intended to re-evaluate the project in 12 months to assess whether the change has been embraced fully or if old patterns of working (without the framework) are being used NS

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