Current changes in the management of minor injuries units are
amounting to a gradual (and quiet) revolution.
The development of the nurse practitioner means that more and more units
are able to run without the regular medical input from local GPs that
has been customary in the past. Trusts responsible for these MIUs have
spotted an opportunity to save money by dispensing with the services of
GPs (for the management of trauma at least), and instead passing full
responsibility for clinical supervision of the unit to local consultants
in A&E.
Since ENPs require less direct supervision than before (and are often
keen to take a more active role which will effectively utilise their
accumulated expertise) telephone support supplemented by regular visits
is a practical option for a supervising consultant, but it is a mistake
to think that this is "free" activity, which can be added indefinitely
to the workload of an already busy, and frequently over-burdened,
individual. This is particularly true where multiple units are involved,
each of which requires management and clinical input. Several minor
injuries units together may easily equal (or even exceed) the patient
turnover of the main department that they are supported from, and this
can be used as a powerful arguement for an expansion in consultant
numbers; a principle which has been successfully applied in at least one
department I am aware of.
The specialty would be wise to resist accepting complete responsibility
for more and more MIUs unless additional staff and funding are
forthcoming; a
reduction in GP input at these units may release the necessary funds,
but there is often a problem in re-allocating the money from one budget
to another. When considering consultant numbers and facilities according
to BAEM guidelines it may be most appropriate to count annual attendance
figures including all the MIUs that the service is responsible for.
Telemedicine provides an alternative way to support MIUs, but should not
been seen as a substitiute for regular visits; rather a way of providing
closer links and more accurate advice to improve the quality of care and
reduce patient transfers. Such equipment can also be budgeted for at the
time that the management of a local MIU is altered, but once in use
tends to occupy a substantial amount of consultant time at the central
A&E department since detailed advice will be regularly required,
particularly when the system is first set-up. This must also be
effectively allowed and budgeted for, ideally through the appointment
of additional staff or sessions.
I am currently preparing to research an MD thesis looking specifically
at
telemedical support of minor injuries units, and have therefore seen
quite a few local arrangements and encoutered very many viewpoints in my
preparatory
travels and visits. I would add that many of the patients who present to
MIUs are likely to fare better with input from a GP than from an ENP
supported by an A&E consultant.
Jonathan Benger.
SpR, Bristol
[log in to unmask] wrote:
>
> I look after 5 and am just being handed my sixth. Politically they are terribly
> difficult to close and I feel that I have to accept them and do as good a job as
> possible. They are certainly my most potent source of litigation and we're
> presently working with Purchasers etc. to tidy things up. I agree with Carlos -
> they need to be heavily Risk Managed with strong protocols and audit - my
> protocols, amongst other things, determine the level of action that any one
> individual unit may proceed to as a satellite of the main A&E unit eg. a
> larger unit with NPs might suture etc. whilst a smaller unit wihout NPs might
> only be allowed to register a patient, dress a wound and refer onwards (extreme
> example!!) - with a whole spectrum in between.
>
> Nick Jenkins
> Abergavenny
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