A survey of acute neurology at a general hospital in the UK

The Association of British Neurologists (ABN) in their publication Acute neurological emergencies in adults (2002) recommend that all patients with acute neurological disease should be seen by a neurologist within 24 hours. We therefore undertook a study to consider the proportion of patients admitted with neurological symptoms to a district general hospital covering a population of 350,000 to determine what level of access they have to a neurologist.

During a two-week period (22 September 2008 and 5 October 2008) all the accepted medical admissions were reviewed. Patients were grouped under a neurological category if the first differential diagnosis at the most senior review was a neurological disorder, or if the differential was yet unclear at the time of clerking but the presentation was predominantly neurological.

A total of 358 patients were admitted in this period, neurology had the highest proportion of admitted patients (93 patients or 26%). This was followed closely by cardiology (23%) and respiratory (22%). The other specialties made up the remainder (104 patients or 29%) (Fig 1).

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Fig 1.

Primary reason for urgent medical admission by specialty.

Of the 93 neurological patients, most (21) were admitted for cognitive disorders, followed by ‘blackouts/seizures’ (19), falls (15), weakness (15), headache (11), dizziness/vertigo (10) and movement disorders (2). The mean age of these neurological patients was 70 (range 21–100); 40% were under 70 years of age; 55 patients were female and 38 were male. Only 10 patients (11%) were referred to the neurology team for specialist advice.

Our findings are similar to previous studies that have reported 19% of inpatients in general hospitals to have neurological symptoms. We were surprised by the low number of patients who were referred to a neurologist. The input of a neurologist has been shown to lead to a change in management of patients in approximately a third of cases.¹ It also improves the diagnosis rate and reduces average length of stay.²

Providing a comprehensive enough service to enable neurological review of all patients with neurological symptoms as recommended by the ABN would require a significant increase in resources. The hospital studied has three neurologists who cover the ward referrals during the week with approximately five hours between them allocated in their job plans for this activity. Carroll and Zajicek described the experience in a 24-hour acute neurology unit in Plymouth.³ They concluded that per 100,000 population, 10.8 hours of specialist registrar time and 11 hours of consultant time per week, 15 neurology beds and 90 outpatient appointments would be required. This study was performed before the European Working Time Directive came into force.

Neurologists in the UK are under increasing amounts of pressure to provide outpatient reviews within timelines set out by the government and this is leading to a greater demand for them in a variety of settings. However, the benefits of their expertise in the management of hospital inpatients, in terms of ensuring appropriate investigation, an accurate diagnosis and reducing average length of stay should not be overlooked when planning services.

• Royal College of Physicians