Medicine at the sharp end
Editor – We read with interest the article by McNeill and colleagues (Clin Med June 2009 pp 214–8) suggesting that benefits from a consultant presence on an acute medical unit (AMU) included greater numbers of same-day discharges and a shorter length of stay. There remains little evidence as to why consultant presence results in these positive outcomes.
We retrospectively audited 145 randomly selected patients admitted via the AMU at the Countess of Chester Hospital NHS Foundation Trust. Patients clerked by a foundation or core medical training grade doctor were then reviewed on the post-take ward round (PTWR) by a consultant or middle grade (specialist registrar (SpR) or staff grade). We studied the number of same-day discharges following the PTWR and accuracy of diagnosis at the PTWR compared with final diagnosis on the hospital discharge summary.
Consultants reviewed 72 patients (mean age 68 years; 33 men) and middle grades reviewed 73 patients (mean age 66 years; 39 men) on the PTWR. Consultants made an accurate PTWR diagnosis in 69 patients (95.8%) which was significantly higher (χ2, p<0.0001) than the middle grades who made an accurate diagnosis in 60 patients (82.2%). The main reason for this difference appeared to be that there was only a documented PTWR diagnosis in 89% of the patients reviewed by middle grades, whereas there was a written PTWR diagnosis in all (100%) of the patients reviewed by consultants. Consultants also discharged higher numbers of patients at the PTWR (17 patients v 6 patients; χ2, p<0.01).
Our data confirm that consultant review at PTWR results in a greater number of same-day discharges and suggests that the benefits of a consultant presence on the AMU may be due to the higher rate of accurate initial diagnosis. This seems to be because of an increased willingness of consultants to commit to a written diagnosis. The Joint Royal Colleges of Physicians Training Board curriculum for general (internal) medicine identifies ‘developing a problem list and action plan’ as a key competency, and we would suggest that trainees should be encouraged to commit to and
‘formulate admission diagnoses’ as this may improve management of patients and facilitate earlier discharge.
Medicine at the sharp end
The issues raised by Joseph and colleagues in response to our article are thought provoking. It appears likely that consultants are often more able than trainees in committing to a clear problem list and action plan. Reports by the National Confidential Enquiry into Patient Outcome and Death and the Royal College of Physicians highlight the dangers of trainee-led clinical decision making and also emphasise the importance of consultant review early in the acute admission.1,2 Our study showed that for the acute medical unit (AMU) to be effective, the consultant decision-making process should not be restricted to the post-take ward round.
Our prospective study of 2,928 patients over an eight-month period demonstrated that early consultant-led review of patients admitted to the AMU significantly reduces length of stay when compared to the consultant-led post-take ward round model. It would therefore appear intuitive that improvement in patient care will only be achieved if there is continual consultant presence on the AMU throughout the working day and early evening. It is therefore imperative that trusts continue to expand acute medicine consultant numbers. In addition AMU consultant job planning must reflect the importance of a strong consultant presence at the AMU front door.
The additional issue raised by Joseph and colleagues of how to develop acute medicine trainees in to consultant decision makers is pertinent. Our study adds weight to the evidence that acute medical services should be consultant led.1,2 Within this setting, the need to allow registrars to develop decision-making skills must be balanced against the need to provide effective service provision and good clinical governance. Further study to elucidate the most effective educational strategies to deliver the acute medicine syllabus is required.
Footnotes
Please submit letters for the Editor's consideration within three weeks of receipt of the Journal. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk
- © 2009 Royal College of Physicians
References
- ↵National Confidential Enquiry into Patient Outcome and Death. Emergency admissions: a journey in the right direction? A report of the National Confidential Enquiry into Patient Outcome and Death. London: NCEPOD, 2007.
- ↵Royal College of Physicians of London. Acute medical care: the right person in the right setting – first time. Report of the Acute Medicine Task Force. London: RCP, 2007.
Footnotes
Please submit letters for the Editor's consideration within three weeks of receipt of the Journal. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk
- © 2009 Royal College of Physicians
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