Yes, thanks for the huge email Doc - and I agree Matt Dunn must be in an
enviable position looking out for more work in Warwickshire!

Firstly, I didn't simply mean I wanted to close the obs ward; I just wish
someone else would take over running it. Actually the geriatricians now use
it very efficiently as a short stay unit with minimal input from A&E staff
so I'm half-way there (the psychiatric liaison team are interested in the
space too).

I agree with many of Matt Dunn's sentiments however; I too want to look
after iller patients but in an A&E setting. I don't want to babysit a
cellulitis for 48 hours, which you have suggested as appropriate use of an
obs ward. The same could be said for the simple overdose and the simple head
injury...why are we seen to take just the simple stuff while other teams
take the complex stuff?  This sort of low dependency work just gives our
specialty a bad name which is why I want to steer clear of it, and gravitate
back to resus. I disagree with Matt Dunn however when he states we should be
looking for this sort of work in a ward based setting. We are doing things
in A&E now which were unthinkable 10 or 20 years ago: ultrasound, CT,
troponins, thrombolysis, RSI, ketamine sedation etc etc. The list will get
longer over the next 10 to 20 years and we don't have the staff to do these
things properly today. We can really become a force to be reckoned with by
developing expertise in the management of the acutely ill. There's no point
trying to develop a ward based service if it's only going to be the low
dependency stuff...and if you wish to get into high dependency ward stuff,
then why not become a physician or intensivist?

John Ryan analyses the usage very neatly (see below). In his analysis,
numbers 1 and 2 are a service many of us have to provide, but let's face it,
it's not very exciting stuff. Number 4 is the other teams' remit so doesn't
thrill me either. Number 3, the clinical decision unit, is more in our ball
park, but we already do that today and I simply keep the patients in the
department pending such decisions.

I can see this debate could run and run...

Adrian Fogarty
A&E Consultant
Royal Free Hospital

----- Original Message -----
From: Doc Holiday <[log in to unmask]>
To: <[log in to unmask]>
Sent: Friday, September 22, 2000 1:26 AM
Subject: "Obs Wards"


> So... before everyone gets bored of my long e-mail...
> Don't close your wards (however you label them), Adrian Fogarty. A bed is
a
> bed is a bed - ask IKEA! See if you can break down the wall (physicall and
> mental) between them and the other areas of the department and use them to
> extend and then flexibly select beds for the various functions.
>
> P.S. For labour force to break above-mentioned walls, suggest you contact
> Matt Dunn in Warwick because, unbelieveably (and I quote)
> ">1. We are underworked at present. Probably doesn't apply to most units."
> So I am sure they will have time to help, even if you supply the pickaxe.


Paste from earlier message from John Ryan:

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.



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