Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Emergency and acute medical care in the community

Recommendations for commissioners and providers of health and social care in the community

Providing emergency and acute medical care in the community can reduce the need for hospital admissions. The recommendations in this section cover the first points of contact with healthcare services, and services that provide alternatives to hospital care or permit earlier discharge back to the community.

The evidence reviews contain the methods and evidence that were used to develop these recommendations, and a summary of the guideline committee's reasoning for making the recommendations. Each recommendation includes a link to the relevant evidence review on the NICE website.

First points of contact with healthcare services

1.1.1 Provide specialist and advanced paramedic practitioners who have extended training in assessing and treating people with medical emergencies. [See the evidence review on paramedics with enhanced competencies.]

1.1.2 Provide point-of-care C-reactive protein testing for people with suspected lower respiratory tract infections. [See the evidence review on GP access to laboratory investigations.]

1.1.3 For people who are at increased risk of developing a medical emergency:

  • provide advanced community pharmacy-based services

  • consider providing advanced pharmacist services in general practices. [See the evidence review on community-based pharmacists.]

1.1.4 For people at risk of an acute medical emergency, do not commission pharmacists to conduct medication reviews in the home unless needed for logistical or clinical reasons. [See the evidence review on community-based pharmacists.]

Alternatives to hospital care

1.1.5 Provide nurse-led support in the community for people at increased risk of hospital admission or readmission. The nursing team should work with the team providing specialist care. [See the evidence review on community nursing.]

1.1.6 Provide multidisciplinary intermediate care as an alternative to hospital care to prevent admission and promote earlier discharge. Ensure that the benefits and risks of the various types of intermediate care are discussed with the person and their family or carer[1]. [See the evidence review on alternatives to hospital care.]

1.1.7 Provide a multidisciplinary community-based rehabilitation service for people who have had a medical emergency. [See the evidence review on community rehabilitation.]

1.1.8 Provide specialist multidisciplinary community-based palliative care as an option for people in the terminal phase of an illness. [See the evidence review on community palliative care.]

1.1.9 Offer advance care planning to people in the community and in hospital who are approaching the end of life and are at risk of a medical emergency[2]. Ensure that there is close collaboration between the person, their families and carers, and the professionals involved in their care. [See the evidence review on advance care planning.]

Recommendations for research

The guideline committee made recommendations for research in the following areas:

  • clinical call handlers

  • remote decision-support technologies for paramedics

  • extended access to GP services

  • primary care-led assessment models for suspected medical emergencies

  • GP access to same-day plain X-ray radiology or ultrasound

  • extended access to community nursing

  • extended access to social care services.

For the full list of research recommendations see recommendations for research.

1.2 Emergency and acute medical care in hospital

Recommendations for commissioners, providers and healthcare professionals in secondary care

Optimising the quality of care in hospitals can improve the flow of patients from admission to discharge. The recommendations in this section address hospital services for emergency and acute care.

The evidence reviews contain the methods and evidence that were used to develop these recommendations, and a summary of the guideline committee's reasoning for making the recommendations. Each recommendation includes a link to the relevant evidence review on the NICE website.

Managing hospital admissions

1.2.1 Use validated risk stratification tools to inform clinical decisions about hospital admission for people with medical emergencies. [See the evidence review on standardised criteria for hospital admission.]

1.2.2 Assess and treat people who are admitted with undifferentiated medical emergencies in an acute medical unit. [See the evidence review on assessment through acute medical units.]

1.2.3 Provide access to liaison psychiatry services for people with medical emergencies who have mental health problems. [See the evidence review on liaison psychiatry.]

1.2.4 Start discharge planning at the time of admission for a medical emergency. [See the evidence review on discharge planning.]

Timing and frequency of consultant reviews

1.2.5 For people admitted to hospital with a medical emergency, consider providing the following, accompanied by local evaluation that takes into account current staffing models, case mix and severity of illness:

  • consultant assessment within 14 hours of admission to determine the person's care pathway

  • daily consultant review, including weekends and bank holidays

  • more frequent (for example, twice daily) consultant review based on clinical need.

    [See the evidence reviews on early versus late consultant review and frequency of consultant review.]

Providing services within the hospital

1.2.6 Provide coordinated multidisciplinary care for people admitted to hospital with a medical emergency. [See the evidence review on multidisciplinary team meetings.]

1.2.7 Include ward-based pharmacists in the multidisciplinary care of people admitted to hospital with a medical emergency[3]. [See the evidence review on pharmacist support.]

1.2.8 Provide access to physiotherapy and occupational therapy 7 days a week for people admitted to hospital with a medical emergency. [See the evidence review on enhanced inpatient access to physiotherapy and occupational therapy.]

1.2.9 Consider providing access to critical care outreach teams (CCOTs) for people in hospital who have, or are at risk of, acute deterioration, accompanied by local evaluation of the CCOT service. [See the evidence review on critical care outreach teams.]

Organising ward rounds, handovers and transfers

1.2.10 Use standardised and structured approaches to ward rounds, for example with checklists or other clinical decision support tools. [See the evidence review on structured ward rounds.]

1.2.11 Use structured handovers during transitions of care and follow the recommendations on transferring patients in the NICE guideline on acutely ill patients in hospital. [See the evidence review on structured patient handovers.]

1.2.12 Use standardised systems of care (including checklists, staffing and equipment) when transferring critically ill patients within or between hospitals. [See the evidence review on standardised systems of care for intra- and inter-hospital transfers.]

Recommendations for research

The guideline committee made recommendations for research in the following areas:

  • emergency department opening hours

  • GPs located in or near emergency departments

  • minor injury units, urgent care centres and walk-in centres

  • hospital diagnostic radiology services

  • specialised units for older people

  • the role of 'physician extenders'

  • integrated patient information systems

  • standardised criteria for hospital discharge

  • post-discharge early follow-up clinics.

For the full list of research recommendations see recommendations for research.

1.3 Planning emergency and acute care services

Recommendations for commissioners and providers of health and social care

The recommendations in this section cover hospital bed capacity and escalation policies, and the development of integrated care models.

The evidence reviews contain the methods and evidence that were used to develop these recommendations, and a summary of the guideline committee's reasoning for making the recommendations. Each recommendation includes a link to the relevant evidence review on the NICE website.

1.3.1 Healthcare providers should:

  • monitor total acute hospital bed occupancy, capacity, flow and outcomes in real time, taking account of changes in a 24-hour period and the occupancy levels and needs of specific wards and units

  • plan capacity to minimise the risks associated with occupancy rates exceeding 90%. [See the evidence review on bed occupancy.]

1.3.2 Health and social care systems should develop and evaluate integrated care pathways. [See the evidence review on integrated care.]

Recommendation for research

The guideline committee made a recommendation for research on hospital escalation policies. For the full list of research recommendations see recommendations for research.



[2] NICE is developing a guideline on end of life care for adults in the last year of life.

[3] NICE's guideline on medicines optimisation includes recommendations on medicines-related communication systems when patients move from one care setting to another, medicines reconciliation, clinical decision support, and medicines-related models of organisational and cross‑sector working.

  • National Institute for Health and Care Excellence (NICE)