> If there is a (an) unit in the hospital, of say 20 beds,
> where the medical SHO/Reg sees patients sent over from A/E to
> arrange their subsequent management then unless the same
> entity that controls A/E also controls that unit then there
> will be conflict and the patients will suffer delay and
> inconvenience or even danger. I think A/E should run both and
> therefore should "direct" physicians.
I'm not sure of the reasoning here. Am I right in thinking you mean clinical
care by the medical SHO/ Reg but administrative input from A and E? Or are
you saying that there are problems in initiating treatment in A and E and
then handing over to inpatient teams? (If so, I agree with you, but feel
that this is more of a problem with the more seriously ill patients- the
argument for A and E looking after all admissions until stable)
> I too would be very interested in seeing / developing definitions to
> prevent manipulation and misuse of A&E. As usual, the devil will be in
> the detail.
> Can I suggest as general starting points the following ideal elements
> for any XXU protocol:
> A time limit on occupancy.
> Regular Senior clinical input.
> Efficient use of senior nurse extended roles.
> 24/7 "backup" services (social services, physio, OT).
> Contingency plans for what happens when full.
> Entry and exit pathways (especially commitment to provide
> sufficient in-
> patient beds when required)
> Clear managerial and clinical lines of responsibility.
Care pathways? Define conditions that will be admitted; investigations to be
done for each condition; estimated time ready for discharge; audit of
deviations from pathway.
>
> As an aside, most of these units are "medical". Does the list
> feel they
> should be a physician's clinical responsibility or A&E?
Depends what 'medical' problems you put in them. If it is patients still
requiring resuscitation (emergencies) then an emergency physician. If the
patient is a bit unwell, under observation but without a firm diagnosis and
further investigation is ongoing with possible follow up required (i.e. it
is a medical problem but not obviously under any subspecialty- a 'general
medical' problem) then whoever follows this sort of patient up in
outpatients (usually a general physician) . If it is patients requiring
significant discharge planning/ social services involvement then it needs
someone with community sessions (usually a geriatrician).
If it is just for patients requiring a defined period of observation mainly
because there is a risk of decline in conscious level (head injury, post
sedation, certain overdoses etc.) then it's difficult to make a strong case
for any speciality over another.
Matt Dunn
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