Published: 22/07/2004, Volume II4, No. 5915 Page 29

Admitting patients straight to the medical admissions unit can relieve pressure on hospital beds, as Nigel Jowett and Hywel Evans explain

More than 90 per cent of patients in acute medical wards present as emergencies. The increasing caseload is putting pressure on consultant physicians at a time of reduced service hours and greater training requirements for junior doctors. There is also increased expectation by patients and their relatives for early consultant involvement.

In 2002, the Royal College of Physicians highlighted the need for prompt assessment and continuing review of acutely ill medical patients by senior physicians, noting there are too few consultants to deliver this standard. The RCP has since suggested a minimum of 10-12 per hospital. The Federation of Medical Royal Colleges has recommended that a consultant should carry out a ward round with the on-call team at least every 24 hours to review all newly admitted patients.

Despite a shortage of physicians, Withybush General Hospital in Haverfordwest has developed a method of on-call review to help relieve the pressure on medical beds and support its junior staff.

Direct admission to the medical admissions unit rather than accident and emergency is encouraged to ensure rapid medical consultant review. Trolley waits are unusual, as regular review on the MAU makes beds available for transfers.

Withybush, a 320-bed district general hospital, has no full-time A&E consultant. Six consultant GPs carry out an unselected medical emergency take (where all patients are admitted under a single consultant) on a 1:6 rota. There are two specialist registrars, two experienced senior house officers and six staff-grade physicians providing second on-call cover. Cancelling normal sessions when on call has not been possible, and a 'physician of the week' scheme (a weekly rota for providing dedicated emergency care) was not workable.However, the physician on call is immediately available onsite in the day and easily contactable for advice at night.

The consultant carries out formal post-take ward rounds at 8am and 5pm every day (including weekends) but may also see patients on the MAU soon after arrival. The consultant cardiologist additionally carries out two ward rounds per day on the coronary care unit, adjacent to the MAU, and is usually available for advice on cardiological patients admitted elsewhere.

In 2003, there were 6,378 acute medical admissions.We looked at a random sample of 80 admissions to the MAU over six weeks.Half were admitted via A&E and half directly from primary care. From the hospital notes and computer tracking system, the time between hospital admission and assessment by the on-call consultant physician (the door-to-consultant time) was determined.

The average time for patients to be seen by a consultant physician was 8.2 hours (standard deviation of 5.6 hours). Longer delays occurred after the evening ward round, which unfortunately is when 62 per cent of acute admissions arrive.However, over half the patients had a consultant review within 12 hours, and two-thirds within 13 hours.Using this system, each patient receives a prompt specialist opinion, enabling earlier investigation and therapy, as well as early discharge planning.

Could door-to-consultant time could become an index of hospitals' ability to provide quality emergency care?

Nigel Jowett is clinical director and Hywel Evans staff-grade physician, Department of Integrated Medicine, Pembrokeshire and Derwen trust.