Editorial

Clinicians working in acute medicine will be familiar with change. The speciality and the environment we work in has changed continually over the past 15 years – I often reflect that no two years have been the same since I started working in the field back in 1999. Change is important, in order to achieve best practice, but sustaining such improvements can be an enormous challenge. The regular turnover of medical staff, local management restructuring and the constantly shifting National goal posts often conspire against us. It is easy for ‘changefatigue’ to set in. Submissions to this journal often describe local audits and service improvement projects which have raised standards: a low baseline may result in a statistically significant improvement from a relatively small intervention – often an education programme or poster campaign to raise awareness of the problem. However, what happens next is far more important: can the improvement be sustained when the key driver behind the project – the enthusiast – moves on, after their 4 month block of acute medicine comes to an end? One year on, we are often back where we started. Two articles in this edition appear to have achieved the Holy Grail of sustainability. In the paper by Joanne Botten from Musgrove Park, door to antibiotic time was improved for patients with neutopaenic sepsis by introducing a system whereby the antibiotics could be administered without waiting for a prescription to be written. The combination of a neutropaenic sepsis alert card and a patient-specific direction empowered the nurses and patients to ensure administration within an hour of arrival in over 90% of cases, a figure which has been sustained for over a year. Sustainable change is often facilitated by modifications in paperwork, but crucially the project’s success was not reliant on a single individual. The value of engaging with the wider team is also shown in Gary Misselbook’s paper describing sustained improvement in the layout and utility of an AMU procedure room. The authors describe how repeated attempts by different registrars had failed to achieve more than temporary reorganisation; the change was only sustained when nursing, infection control and administrative staff became involved in the process. The multiprofessional nature of the AMU is one of its greatest assets – we would all do well to remember this when instigating change. On a similar note, observant readers may have noticed some changes to the editorial board of this journal – I am delighted to welcome Dr Tim Cooksley, acute physician from Manchester and Dr Prabath Nanayakkara from the VUMC in the Netherlands. Tim came through the acute medicine training programme in the North West and his role in the acute oncology service at the Christie Hospital as well as his active involvement in the SAMBA project over recent years brings an important perspective to the editorial team. Prabath has been heavily involved with the development of acute medicine in the Netherlands and co-hosted the successful SAMSTERDAM meeting in 2014. His international perspective will be welcome as we attempt to extend the reach of Acute Medicine to our European neighbours over the coming years. I am very grateful to Nik Patel, Mark Jackson and Ashwin Pinto for their help and support during the past decade and wish them well for the future.