On this, now well-debated subject: a few opinions. Will not always be 
well-punctuated, so "sorry".

Agree with John Ryan about the various types of unit/ward possible. Have had 
experience of working extensively with first 3 types - short stay ward and 
observation ward, as well as clinical decision set-up.

I don't like the use of the word "ward" at all. In fact, I think (and will 
expect debate on this with thanks) that the only way I like any of these 
possibilities is if they are added on as just another area to the 
department, as are triage, major, minor, resus areas. Having worked in over 
30 ED's of various types and sizes (and contract lengths - I am not 100 
years old), I note that the most efficient ones are those which segregate 
the least. Certain parts of the departments have different facilities, 
surely, but there is an easy overlap, so staff can flow around as needed, 
patients are not forgotten, and responsibility is not abandoned as the 
patient passes through some physical door.

A&E staff train to work as A&E department staff, not as ward-rounders. I 
think our forte is dealing with problems as rapidly and efficiently as 
possible. We do things differently. We are leaders at "1-1-1 teaching" - 1 
senior educates 1 junior on 1 patient at a time. Ward rounds promote another 
(no lesser, but different) type of thinking and education, suited to wards, 
patients who persist in them and staff who hand them over again and again 
and again and thus spend most of the round's time recapping and recalling 
what happened or been discovered during past X days. Not the A&E way.

Putting all these together, each department, as matches its needs, needs to 
be enlarged, rather than have another room/ward built separately outside its 
other areas. The new beds/cubicles and be allocated to patients of various 
groups, as need arises, providing:
1. some short stay options for people about to be taken off our hands by 
relatives, specialised units or transfer vehicles
2. some beds for patients who are still being "worked up". I wholly support 
the notion of NOT treating in-patients, but I think it is misguided to 
believe that ALL patients can be labelled as "admit" or "discharge" within a 
short time of being greeted as has been suggested. This leads to hasty 
decisions, which, with litigation in mind, often translates to unnecessary 
admissions.
3. some observation beds - these really need not be any different from 
normal beds in the department, except that people stay there longer.... BUT:
- only up to a limit set by the senior A&E person on duty according to the 
needs at the time (consider this as a tailor-measured bed number of an 
imaginary observation ward). This is more efficient as needs change, while 
preventing excess bed blockage (as would a finite obs ward size).
- only at the discretion of the senior A&E person!!!
- with a time limit - as is the case with most observation wards
- with strict guidelines as to what to keep - my preference, broadly, is for 
conditions which have been fully evaluated and have had treatment initiated, 
which is expected to bring on a dischargeable state within, say, 24-48hrs. 
e.g. Cellulitis which requires an IV antibiotic to start.

Most important here is not to segregate facilities into another "ward", but 
allow our brains to control resources, rather than walls and doors and 
provide the efficient overlap in usage. So no elderly relatives are 
forgotten, because they stay within A&E. So no-one accidentally accepts a 
patient who should be in some ward, not in A&E, because the patient sticks 
out like a sore thumb, having not been "dumped" in obs ward, but stayed "in 
sight", begging for an admission under someone else. And there are many on 
this list who could certainly work out better than I can how to best use 
this system.

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.


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