SMJ 2002 47(5): 99
Dr Graham R Nimmo MD
FRCP Edin FFARCSI
Consultant Physician
Medicine and Intensive Care, Clinical Sub Dean (Teaching) WGH, LUHT and
University of Edinburgh
The
number of patients admitted to hospital as medical emergencies continues to
increase while available in-patient beds decrease (1, 2).
Although the number of patients and available beds are important to plan
services more emphasis must be placed on case mix and illness severity
assessment of patients. Equally, predicted length of stay linked to the case mix
and the impact of age must be determined. Work intensity is increasing for all
staff and services and the paper by Dorward et al highlights the changes in the
working practices of physicians and acute hospitals in Scotland between 1996 and
2001 (3). A number of useful points are highlighted by the results of this
survey.
Of
the 27 acute hospitals in Scotland which receive over 3000 acute medical
patients each year nearly 90% have developed an acute admission unit. This
should facilitate the prompt assessment and treatment of medical emergencies.
However to be effective they must provide a 24 hour service 365 days per year.
They must be adequately staffed (numbers and skill mix) and resourced.
Interestingly only 4 of the hospitals surveyed (15%) had appointed an Acute
Physician. Staffing requirements not only include appropriate medical and
nursing staff but also a seven day service from PAMS (particularly physiotherapy
and occupational therapy) as well as dedicated clerical support. Diagnostic and
other support services within the hospital need to understand the changing
pattern of patient care in order to respond effectively.
The
involvement of specialists for advice and to take over the care of sicker or
more complex cases has increased across the country during the study period.
This is in line with the shift in emphasis to admitting a patient to the
appropriate bed (specialty) at the appropriate time rather than indiscriminate
admissions to any available bed (4).
Novel
services aimed at rapid diagnosis and out-patient management in suspected DVT
and exacerbations of COPD have been successfully introduced in 55% and
41% of hospitals respectively.
One
finding of the study which is of great concern is the patchy availability of
high dependency facilities for medical patients. These were present in 7
hospitals (26%) and in four hospitals (15%) HDU patients were admitted to
Coronary Care beds.
It is likely that some medical patients requiring HDU are accommodated
within intensive care.
Following
publication of Better Critical Care in 2000 with recommendations on the
development of specifically defined mixed medical and surgical HDUs it is clear
that much work needs to be done to achieve this in Scottish acute hospitals (5).
This must be a priority for the Critical Care Delivery Groups in each trust.
Training
is another issue which is raised by this paper. Although Acute Physician posts
are being developed and advertised there is no core curriculum for these posts
and no defined training regarded as essential, other than MRCP and the CCST in
G(I)M. This is not a criticism as this is a new and developing field. However we
must now begin to define the appropriate training requirements both at SpR
and SHO level. The introduction of competency based training and
assessment in Anaesthetics and by the Intercollegiate Board for Intensive Care
Medicine provides a template which might be adopted for Acute Medicine training
(6).
It
seems likely that we are in a transition from General Medicine to Acute
Medicine. Times are changing and the requirement for rapid, hands-on, senior
medical input for a wide range of medical emergencies is here. To help
facilitate the passage through this transition period, and ultimately develop
and improve the management of medical emergencies, the Society for Acute
Medicine (UK) has been set up. The aims are to help develop standards for
medical assessment or acute admissions units, give direction on training and
education and to encourage communication with specialties including A&E,
Intensive Care and Diagnostic services.
Much
remains to be done but the paper by Dorward shows that advances are being made
already. We should face the continuing challenge of medical emergencies with
optimism: there is a bright future for Acute Medicine.
1. Forgac I. Caring for and about general medicine. The service is under stress. BMJ 1999; 318:73-74.
2. Scottish health statistics 1989-97. Information
Statistics Division.
3. Dorward AJ et al. Changing patterns of acute
medical receiving in Scotland 1996-2001. Current journal.
4. Tackling NHS emergency admissions: policy into
practice. 1997, The NHS Confederation.
5. Better critical care. Report of the short life
working group on intensive care and high dependency care. Scottish Executive
Health department July 2000.
6. The CCST in Intensive Care Medicine.
Competency-based training and assessment. The Intercollegiate Board for Training
in Intensive Care Medicine 2001.