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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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