Don't wish to offend, accept this is a controversial issue etc. Awaiting
flames, but here goes...

I can think of two reasons for taking on extra work:
1. We are underworked at present. Probably doesn't apply to most units.
2. We are the best at dealing with something. I'd like to think this applies
to such areas as acute diagnosis and management of the critically ill
patient; rapid triage a la Tony Redmond; and dealing with certain types of
soft tissue problem (if it doesn't, let's rethink what the point of the
specialty is). These are the sorts of areas where we should expand if we
have more free time.
I don't favour taking on something just because we are as good as
geriatricians, subacute general physicians, neurosurgeons etc. The fact that
these units are good does not mean that we are the best people to look after
them.

On this basis,
1. Short stay for low acuity, low dependency needs no medical input from us
or anyone else. It is a waiting room. If the patients may need admission, it
is a clinical decisions unit (see below). If there may be a social problem
at home, it needs input from someone with community links and experience of
domestic visits in this type of patient (e.g. a geriatrician).
2. Observation ward. OK, but what are we really doing. If the patient needs
no input, why can't they go home? If they may need input from a given
specialty, why not admit them under that specialty in the first place to
stop the patient deteriorates... nurse calls specialty A doctor... wait for
arrival... doctor calls specialty B doctor (at worst, inexperienced SHO who
is trying to find reasons for not accepting patient or delaying)... wait for
arrival. (I admit, I've seen this type of unit work very well, especially
where it is well staffed and there is a maximum length of stay; but does A
and E look after these any better than anyone else). In places where these
have existed, I've seen them used by inpatient teams as a way of avoiding
seeing patients who clearly do require admission. It probably does not have
much of an adverse effect on patient care, and can be avoided to an extent
by good audit, but why bother?
3. Clinical decisions unit. Again, are we better than other specialties at
this? My worry is that it seems to set up the idea that patients are
admitted under A and E as long as there is nothing wrong with them, but if
they turn out to be sick, we need to refer them to someone cleverer.
(Although, being strictly honest, my main worry is that this is protocol
driven stuff without the excitement or kudos of the critically ill patient
and I don't find it that much fun. I'm childish that way). 
4. Assessment unit. Yes, but is this bringing in the A and E consultant as
an extra tier between GP and medical SHO (what used to be the medical house
officer's job). I'm all in favor if the argument is that all critically ill
patients have initial assessment and resuscitation by A and E, in which case
the ward needs to be a HDU or ER; but if it's just assessing the maybe...
maybe not admissions, the subacute general physicians are probably better
(and can change from admission to urgent follow up in their clinics more
easily if needed) (By the way, does anyone else find that the more
experience they  get, the more reluctant they are to discharge patients?)

Remember also, that most of the patients who are discharged from these units
would benefit from follow up (even if they don't receive it at present). It
makes sense to me to admit them  under the specialty who would provide the
best follow up (unless we want to do it ourselves; and train in post
concussion syndrome, elderly care, chest pain clinics etc)

I agree (maybe controversially) with our involvement with acutely ill
patients even after they hit the wards. I think joint management of CDUs and
acute HDUs with joint ward rounds would benefit both us and the inpatient
specialties, but if I expand my role, I want to spend more time with the
more complicated, iller patient where my input directly improves their
outcome; not spend more time as a sive for other specialties.

Matt Dunn
Warwick



> -----Original Message-----
> From: Adrian Fogarty [mailto:[log in to unmask]]
> Sent: Wednesday, September 20, 2000 11:41 PM
> To: [log in to unmask]
> Subject: Re: observation wards
 What do others on the list think?
> 
> ----- Original Message -----
> From: john ryan <[log in to unmask]>
> >
> > 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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