Unlike Adrian, I would strongly support Observation wards or what ever you
wish to call them. I believe they can have different functions and can have
different names:

1)  A Short Stay Ward:  For elderly people being collected later by
relatives or being discharged to a nursing home. Or somewhere a patient can
wait for a relative to bring new clothes etc etc.  In other words a pre
discharge area where patients have low acuity and relatively low dependancy.

2)  An Observation Ward:  Where patients can be observed for instance as
they recover through a post ictal state, patients following concious
sedation, following an assault or where the toxic effects of an overdose
could be monitored.

3)  A Clinical Decision Unit:  Some patients require time before an
admission or discharge can be confirmed.  For example this might be pending
the results of cardiac markers in low risk patients or pending a review
following initial therapy say an asthmatic with nebulisers.

4)  An Assessment Unit:  Where patients referred by general practitioners
could by-pass the emergency triage system and be assessed by appointment
with a senior emergency doctor for an acute problem.

Like it or not the extended role of the emergency physician is coming your
way.  It no longer makes financial sense to work in a simplistic world of
every patient being admitted ot discharged.  That type of practice is
historical.  I think we should look at expanding our resources to fill the
demand not send the patients away because we can't  manage them.  The future
points towards the management of acute care in an ambulatory setting.  The
governement  don't want us to admit more patients (despite the National
Plan), the patients dont want to be admitted (but more numbers are attending
every year).  We have to look at imaginative and innovative ways of
prioviding acute care.  The properly resourced 'Acute care Area' /
'Observation ward' / 'Clinical Decision Unit' / 'Short stay ward' is one
such initiative.

Such units have been around a long time.  I have seen them work successfully
in 4 different healthcare systems.   Their usefulness is well described in
the literature (including, wayback, Pete Driscoll's description from the
Royal Free, Adrian ?).  Useful books include the American College of
Emergency Physicians  book on Observation Units.

I am sure that no 'one single model fits all'  and I believe that local
needs will dictate the fine tuning of the make up of such units.  However I
think blanket disnissal of these units is not the way forward for emergency
medicine even if resources dictate otherwise at present.


Dr John Ryan



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