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									■ MEDICINE AT THE SHARP END                                                              Clinical Medicine 2009, Vol 9, No 3: 214–18

What is the effect of a consultant presence in an acute
medical unit?

Gregor BS McNeill, Darshan H Brahmbhatt, A Toby Prevost and Nicola JB Trepte

ABSTRACT – A cornerstone of the development of acute                    order to expedite the clinical decision-making process.3 It has
medicine has been the principle of consultant presence                  been postulated that this will bring a range of benefits including
within the acute medical unit (AMU). There is the hypoth-               reduction in admission and readmission rates, reduced length of
esis that consultant supervision improves patient care.                 stay and improved patient care (including reduced mortality).1,3
This view is not currently supported by firm scientific evi-            However, there is at present little supportive evidence for these
dence. When Ipswich AMU opened in 2004, there was a                     intuitive benefits.
consultant presence on some weekdays only. Admission                       In many AMUs, a consultant-led service has been introduced
data were collected and assessed with respect to the pres-              as the units themselves have developed. This has presented a
ence or absence of the consultant. Overall length of stay               challenge in studying the effect of the consultant presence
was significantly lower, by a mean of 1.3 days, when there              alone. A group in Bournemouth found that following the
was a consultant present, and 9% more patients were dis-                introduction of an acute physician there was a reduction in
charged on the same day of their assessment (95% confi-                 medical outliers.4 There was also a fall in the admission rate
dence interval 5.7% to 12.6%, p 0.001) without                          year on year. However this fall coincided with a progressive
affecting readmission or mortality. These results suggest               expansion of the AMU bed numbers. It is therefore unclear
the absence of a consultant leads to fewer same-day dis-                whether the consultant presence or the expansion of the
charges and causes the inappropriate admission of                       admission unit facilities improved the discharge rate.
patients not needing inpatient management. Further                      Internationally, Moloney and colleagues showed that introduc-
study is required to determine whether these findings are               tion of an admissions unit in Dublin without a consultant
shared by other AMUs.                                                   presence led to a reduction in length of hospital stay with
                                                                        resulting cost benefits.5 A study in a rural district hospital in
KEY WORDS: acute, admission, consultant, cost, discharge,               Australia showed that the presence of an emergency physician
mortality, readmission                                                  resulted in reduced admission rates, reduced ordering of
                                                                        pathology tests and also a reduction in specialty referral.6 The
Introduction                                                            majority of published data to date focuses on the effect of the
                                                                        existence of the admissions unit rather than the putative ben-
The specialty of acute medicine has developed rapidly over the          efit of the grade of clinical staff supporting it.7
past few years. Acute medical units (AMUs) are now found in                At the Ipswich Hospital, a purpose-built AMU was opened
virtually every secondary and tertiary referral hospital in the         in late 2004. Part of the initial design of this unit incorporated
UK.1 The specialty is an integral part of the Acute Care                a single consultant presence on four days out of five during the
Common Stem training programme and training numbers in                  working week. The consultant would be present on the unit
acute medicine continue to expand rapidly.2                             from 09.00 until 17.00. The main aims of the consultant pres-
  Prior to the development of acute medicine, the traditional           ence within the AMU were to expedite the clinical decision-
model would involve a team of junior doctors admitting                  making process and improve patient care by targeting early
patients during the day. The on-call consultant would arrive to         review of each patient as they arrived in the unit. This early
conduct an admissions ward round in the evening or the fol-             consultant review would lead to earlier ordering of diagnostic
lowing morning at which time definitive patient management              investi
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