Online Publications : Working Party Reports

Isolated acute medical services:
Current organisation and proposals for the future

Summary & Recommendations

Summary

A questionnaire survey was undertaken of all hospitals in England, Wales and Northern Ireland which take acute medical admissions but which do not have, on-site and on a 24-hour basis, one or more of the following services: acute general surgery, an accident and emergency department taking unselected admissions, resident anaesthetic cover, an intensive care unit (ICU) or a cardiac care unit (CCU). These services were designated as being 'isolated'. Services not included in the survey were: hospitals providing only specialist tertiary services, large inner city hospitals lacking only an on-site accident and emergency department which was based in a neighbouring hospital, non-NHS hospitals, hospices and palliative care services, community hospitals and intermediate care services.

Sixty-one isolated services were identified and completed questionnaires were obtained from 59 (97%), of which 22 (37%) took unselected acute medical admissions. The other 24-hour services present in these hospitals were: acute general surgery (27%), A&E (26%), resident anaesthetist (26%), ICU (12%), CCU (47%), chest radiology (53%), laboratory services (36%) and blood cross-match (34%). Elderly care medicine was present in 95% of the services; it was the only acute medical specialty in 36% and these hospitals were less likely than the others to have acute general surgery, A&E, anaesthetic cover, ICU, CCU, radiology or laboratory services. When on call for the isolated medical service, 42% of consultants were also responsible for acutely ill patients in another hospital, and this caused difficulties in supervising both patients and trainees. Thirty per cent of hospitals without acute general surgery and 33% of those without blood transfusion facilities admitted patients with acute gastrointestinal haemorrhage.

Fifty-four per cent of services described clinical risk issues due to lack of critical care facilities or anaesthetic cover; 49% had experienced problems due to lack of surgical cover resulting in delays and inconvenience to patients, but only one respondent regarded this as a clinical risk issue. Whether physicians working in these hospitals regarded their services as successful or unsuccessful was strongly correlated with the presence or absence of facilities for critical care and with problems relating to anaesthetic cover (p=0.002), and to a lesser extent with problems relating to surgical cover (p=0.041).

Recommendations

  1. Acutely ill medical patients should not be admitted to hospitals which do not have critical care and appropriate diagnostic services. No further such services should be created.

  2. Hospitals which do not have critical care and diagnostic services should be reconfigured to provide intermediate or step-down care. Patients should be transferred to these hospitals only when a definite diagnosis has been confirmed, the patient's condition has been stabilised and a plan for further management has been formulated.

  3. It is not appropriate for a consultant physician to have responsibility for emergency admissions or acutely ill patients on two separate sites. Job plans for new or replacement posts should not require the postholder to take on this dual responsibility and hospital trusts should work towards phasing out this requirement for existing postholders.

  4. Interim arrangements should be put in place while existing isolated services are still taking acute admissions. These arrangements should include:

    1. Outreach critical care services to identify patients whose condition is deteriorating

    2. Agreed protocols for the transfer of sick patients to a hospital with appropriate services. In the case of patients needing critical care this may need to include provision of a flying squad which can resuscitate and stabilise the patient before transfer.

    3. A 24-hour on-site resuscitation team led by a clinician with advanced life support (ALS) training.

    4. In hospitals which take only selected admission, there should be written protocols which explicitly define those patients who are suitable for admission and those who are not. Staff who are responsible for accepting admissions should have appropriate training on the implementation of the protocols as part of their induction course.

    5. Hospitals which do not have an on-site surgical service should:

      • not admit patients who might require urgent surgical intervention.

      • ensure that there are agreed arrangements to provide surgical opinions in a timely and appropriate manner. Patients should not normally have to be transferred to another hospital solely for a surgical opinion, unless this is warranted by their clinical condition or if radiological or other investigations are needed as part of the surgical consultation.

    6. These interim arrangements should be audited regularly.

  5. Further research is needed to establish the potential role of telemedicine in the provision of acute medical services.

  6. Proposed solutions for reconfiguring acute hospital services should be tested in trials before they are introduced.

  7. The Royal College of Physicians should continue systematically to identify and monitor all isolated acute medical services, using information obtained from Regional Advisers, District Tutors and General Professional Training Visits. Consultants with responsibilities for acutely ill patients on more than one site should be identified through the annual manpower census and from job descriptions for new or replacement posts

 

This page last updated on June 26, 2002