SMJ 2002; 47(5): 103-106
Author
and Correspondence to:
Dr
Alistair Dorward
Consultant
Physician
Medical
Directorate
Royal
Alexandra Hospital
Paisley
PA2
9PN
Email to: alistair.dorward@rah.scot.nhs.uk
Running
Heading: Acute Medical Receiving in Scotland 1996 to 2001
The
purpose of this study was to review changes in working practises of physicians
and hospitals from 1996 to 2001 in the light of rising medical admissions and
published reports into the organisation of acute admissions. Information was
gathered by direct discussion with the appropriate lead doctor for each
hospital’s acute service in February 2001. The results were compared with a
previously published study, which recorded the situation as of October 1996.
The
hospitals which were studied were the twenty seven Scottish hospitals which
admit more than 3000 acute medical patients each year. There has been a 25%
increase in number of consultants carrying out receiving duties. Nearly all
hospitals now have an acute admission unit. Four hospitals have appointed acute
care physicians. Triage of appropriate patients to more specialised ward based
care has increased. There has been a rise in geriatricians’ involvement in
acute receiving from four to fifteen hospitals. New developments include early
discharge for chronic obstructive airway disease, outpatient management of
venous thrombosis, discharge planning and streamlining investigation of chest
pain. Two hospitals have specific
alcohol support services. There continues to be progress and changes within
medical and geriatric services over the last five years stimulated by the
continuing rise in number of medical admissions.
The Scottish Intercollegiate Working Party on Acute Medical Admissions and
the Future of General Medicine was published in April 1998(1) This contained a
review of acute medical receiving practices as they were in Scotland in 1996.
An expanded form was published in the Health Bulletin in 1997.(2) The
intercollegiate report made several recommendations on the processes of acute
medical receiving for the Scottish Health Service. A more recent report has been
issued from the Federation of Medical Royal Colleges, “Acute Medicine – The
Physician’s Role”(3), making further recommendations for physicians, Trusts,
Health Boards and Local Authorities. Since 1996 there have been many changes in
the Scottish Health Service with the formation of new Trusts, but there has been
a continuing rise in acute medical admissions throughout Scotland. This study looks at the modifications in organisation and
patterns of acute medical receiving that have developed since 1996 to see if
these reports have influenced and stimulated change amongst physicians and
geriatricians.
In 1996 twenty-six acute hospitals with an Accident and Emergency
(A&E) department and more than 3000 medical admissions per year were
reviewed. The Western General in Edinburgh was omitted in 1996 because there was
no A&E department, but the number of admissions through that hospital has
risen greatly and it seems appropriate to include this in both the 1996 and 2001
figures.
The author gathered information in February 2001 from each hospital sites
by direct discussion with the appropriate acute care physician, Clinical
Director of Medicine or a consultant with an interest in acute receiving.
Individual hospitals that discharge more than 3000 patients per year were
chosen. (4) The questions asked are documented in Table
1. The results have been
compared with the similar findings of October 1996. (2)
Twenty-seven
hospitals in Scotland fulfil the criteria for the audit and the principal
results are tabulated in the following tables. Table
2 shows the working patterns of consultants, the presence of a triage
system, the presence of an Acute Admissions Unit (AAU) and the number of
discharges per hospital per year to March 1999 which was obtained from ISD
Scotland (4). There were no acute care physicians in Scotland in 1996 but by
2001 there were 5 consultants in four hospitals. The estimated number of
consultants carrying out receiving duties has risen from 248 to 311. The number
of hospitals where consultants take time off other duties to perform acute
duties has risen from six to eleven. The number of hospitals with AAU has risen
from 18 to 24 leaving the three smallest District General Hospitals (DGH)
without an AAU. Patients who are not immediately discharged are triaged to
speciality wards in nine hospitals compared to four in 1996. In five hospitals
(two in 1996) a member of the appropriate specialist team, usually a member of
junior staff, visits the AAU to give advice and arrange transfer of patients.
The length of time each receiving consultant has responsibility for acute
patients is described in Table3.
Only three hospitals have medical High Dependency (HDU) beds but four others mix
these beds with Coronary Care Units.
The
study looked at the relationships between acute medicine and geriatrics. In
February 2001 there were no geriatricians in one hospital site (Stracathro). In
all but two hospitals the geriatricians were managerially part of the same Trust
and in 14 out of 26 they were in the same Directorate. The number of hospitals
where Geriatricians take part in receiving has risen from four in 1996 to
fifteen in 2001. Table 4
describes the main route by which appropriate patient find their way to the care
of the elderly beds. This can be by several methods; by letter or phone referral
or by the geriatricians visiting AAU and taking appropriate patients. Only two
services have retained an age-related policy for admissions but in more
hospitals the patients can be triaged directly from the AAU to geriatric beds.
Table
5 describes the new developments that hospitals have developed in an effort
to try to reduce and manage admissions. These includes outpatient treatment for
venous thrombosis (DVT) with low molecular weight heparins, early discharge for
patients with exacerbations of chronic obstructive pulmonary disease (COPD);
support for alcohol related diseases and employment of a primary care physician
to aid discharge of the elderly patient.
Physicians
have struggled to cope with the rise in acute medical admissions throughout the
1990s. (5) A Scottish intercollegiate paper on physician’s workload (6)
reported their general unhappiness, much of it relating to the processes of
acute receiving. This report showed
that physicians were working longer and more intensive hours, teaching medical
students was being squeezed out of their day, professional development was
suffering and morale was low. As a
result the colleges commissioned a further report looking at acute medical
admissions and the future of general medicine which made many recommendations.
These included setting up an acute admissions unit, establishing effective
discharge planning including bed management and encouraging most physicians and
geriatricians to take part in their acute receiving service.
The subsequent Federation report on the “Physicians Role in Acute
Medicine”(3) made similar suggestions but also advocated that provision should
be made by the on-call physician to cancel conflicting duties such as clinics
and lists. The report did not support the widespread development of the acute
care physician. It was felt physicians who provide acute care should have links
to medical specialities. This study looks to see if some the ideas in these
reports have influenced the working patterns in Scotland over the last five
years.
The
Acute Admission Unit (AAU) allows concentration of acutely ill patients onto one
site. In 1996 in Scotland the AAU was still a new idea for some hospitals and by
2001 six more hospitals have gone on to develop these units. This leaves the
three smallest hospitals in the survey without an AAU. Every AAU had a nominated
person in charge who takes varying amounts of interest in the running of the
unit. By February 2001 four
hospitals had appointed acute care physicians to the AAU. However a number of
hospitals indicated to the author that they were considering appointing such a
person to run their acute service despite the College’s warnings of the
possible negative effects on the overall provision of medical care. It may be
that the appointment of physicians to provide leadership to the AAU to
accelerate delivery of acute medical care should be encouraged, but these posts
should be developed through the enhancement of existing structures. It will be
interesting to see how and if the role of the acute care physician develops in
the next decade.
There
are 25 per cent more consultants carrying out acute receiving duties now
compared with five years ago. This
is partly due to consultant expansion and partly due to the increased number of
geriatricians taking part in receiving. The worry that specialists would opt out
of general medicine has not been founded. Despite encouragement to cancel other
duties to carry out receiving, there is still only a minority of hospitals in
which the consultants take a rest from alternative duties. (Table
2) Of the larger teaching hospitals only Edinburgh Royal Infirmary allow
consultants time off. This may reflect the greater number and seniority of
junior staff in teaching hospitals compared to the DGHs. The “physician of the
week” pattern, as in the “Paisley Pattern” of acute receiving (7), has
only risen from six to eight hospitals. Most consultants are still carrying out
traditional 24 hour consultant on-call shifts with all the attendant problems
this system produces of dealing with a large influx of patients over a short
time period. More hospitals have developed speciality wards where patients
are triaged from the acute receiving ward.
It has also become more popular, in hospitals with large numbers of
junior staff, for a member of the appropriate specialist staff junior team to
visit the AAU to give advice, arrange discharge and sometimes transfer patients
to the speciality wards.
The
efficiency and care with which acute admissions of elderly patients is handled
is vital to the functioning of acute medicine. These patients often have
multiple chronic medical, social and rehabilitative problems. Both college
reports have emphasised the importance of improved liaison between acute
medicine and geriatricians and encouraging geriatricians to participate in the
acute receiving process. The
situation in England, where geriatricians have for a long time been part of
acute medicine is different to Scotland where the pattern of geriatric care has
developed separately with very few geriatric services taking part in acute
receiving. In 1996 I described the
different types of geriatric service based on the British Geriatric Society
compendium document (8). At this time most hospitals had a needs related or
traditional service. Only two
services had an integrated service where general medical and geriatrics were
organised into one department. Four hospitals had some form of age related
policy but this seems less popular now with only two hospitals continuing this
service. This distinction of
different types of geriatric service while useful, does not give a sense of the
relationships between medicine and geriatrics, nor does it tell how the
situation is changing. On this occasion I asked about the commonest way in which
appropriate elderly patients are referred and travel from acute medicine to the
geriatric service. While geographical location has an influence, in general the
more complex the patient transfer the poorer is the integration and commonality
between services. The traditional
route is letter or phoned referral that requires many steps with involvement of
junior, consultant and often secretarial staff and seems designed to be
difficult. The most integrated form is when patients are triaged by the
admitting consultant to the care of the elderly beds.
Table 4 shows how this
process has developed in the last five years.
Letter and phone referrals are less common and geriatricians often either
visit the acute AAU to deal with appropriate patients or allow triage to the
elderly beds. The number of hospitals where geriatricians now take part in the
receiving process has risen from four to fifteen in this short time. It is clear
that Geriatricians have taken on some of the burdens of acute receiving and
there has been a striking change in the working practises of many geriatric
services.
The
Scottish report on Better Critical Care was published in 2000. (9) This report
advocated the development of defined medical high dependency beds. Where
possible these should be integrated into a mixed speciality High Dependency Unit
(HDU) to allow maximum flexibility of bed use and staff. As part of this survey
I asked about the presence of medical HDU beds. Only seven hospitals have
medical HDU beds and these units are of varying types. In four hospitals the HDU
beds are mixed into with coronary care units and in view of the differing nature
of the needs of these patients this is not always ideal. Clearly there is much
scope for the development of medical high dependency beds either in a separate
unit within acute receiving wards or as a combined medical / surgical HDU.
This
paper shows that in the last five years there has much progress in consultant
working practices. A few acute care physicians have been appointed and
leadership has improved in receiving units. There have been new services as
documented in Table 5, in
patients with chronic obstructive airway disease, outpatient management of
venous thrombosis, discharge planning and streamlining investigation of chest
pain. Abuse of alcohol plays a significant role in the rise and number of acute
medical admissions (10,11). As stated in the recent RCPL report on alcohol (12)
the challenge is to move beyond treating the presenting alcohol-related physical
disease to tackling the underlying alcohol problem. It is disappointing that
there is so little support for the very common medical admission whose principal
problem is alcohol related (Table 5).
One
of the most important issues for every medical unit is the number of beds it has
to function effectively. As acute beds have been used more efficiently over the
last decade flexibility has been lost and boarding of patients has risen.
Little work has been carried out on the problems that beset the patient
boarded out of medical beds to other parts of the hospital. These problems
include reduced quality of care, increased length of stay, delay in
investigations, delay in rehabilitation and effects on patients in other
departments. (5) Each boarded person represents a risk not only to the patient,
but also to the doctor in charge, the hospital and the Health Service. When this
review was carried out in February 2001 as a rough estimate there were between
500 and 600 boarded patients throughout the 27 acute hospitals. Despite the many
improvements recorded in this paper the issue of boarding will continue to be
one of the major problems for doctors and managers within the Health Service.
Thanks
The author would like to thank all the throughout Scotland clinicians who gave their time and knowledge to the preparation of this paper.