To the Editor: We read with interest Walters and Dawson’s call for a clinical revolution to tackle access block1 and are heartened by the interest shown by general physicians in a problem that primarily affects the emergency department (ED). The efficient management of admitted medical patients is paramount to patient flow within the hospital, and “buy-in” from general physicians is essential.

When considering any new model of care, it is important to note that longer patient assessments in ED by emergency doctors has a relatively small effect on access block; the claim that the length of assessments is a significant factor in access block has been established as a “myth” by investigators who have mapped process times.2 Therefore, it is unlikely that substituting one workforce of acute physicians for another would make any difference to overall patient flow through the ED. On the contrary, it is likely to be associated with increased costs3 and adverse effects on the emergency medicine labour supply.4

In addition, the ability and willingness of the general physician workforce to implement and sustain the newer role of “acute physician” is unknown. The root cause of access block lies in ward-bed shortages, ward processes and community capacity, which should be solved by improved flow processes across the continuum of care.

Access block will not be solved by a second tier of acute physicians duplicating the role of emergency physicians. However, there are many aspects of Walters and Dawson’s model of change that would improve patient flow, in particular: improved rostering of medical staff; improved access to pathology and radiology services; and, perhaps, specific retraining of medical staff in the efficient discharge of inpatients. These aspects should be rigorously explored as we strive together to tackle access block.

To the Editor: Walters and Dawson1 correctly highlight access block (hospital overcrowding) as a whole-of-system problem. Acute medical assessment and admission units (AMAAUs), or other similar incarnations in Australia and New Zealand, are part of the solution, although the evidence presented is low-level non-Australasian data. The reduced length of stay achieved by these units and reported in papers cited by Walters and Dawson would, if replicated in Australasia, produce additional capacity, improving bed availability and patient flow. As has been repeatedly stated: it’s all about available beds!2

However, Walters and Dawson’s article stretches well beyond the evidence in its approach to emergency department (ED) roles and the interactions between AMAAUs and EDs. None of the cited studies suggested that AMAAUs provide better environments than EDs for sick undifferentiated patients. None studied effects that AMAAUs have on ED treatment and none proposed interventions specifically designed to alter ED management. They essentially examined improved patient journeys for front-loaded AMAAU versus standard (slower) general medical inpatient care. In addition, Walters and Dawson imply that these changes related to introduction of the United Kingdom’s 4-hour rule. However, many references were either non-UK or not specific to the 4-hour rule. Rigorous research in an Australasian context would be required before adopting models from a different system.

The authors promote a view that undifferentiated acutely sick patients bypass the ED to be managed by “new” acute-care specialists. No evidence is presented to support this change, and it is difficult to see how this would be a sensible policy for Australia and NZ, which have mature ED systems. Emergency physicians are specialists specifically trained and skilled in early diagnosis, management and disposition of the undifferentiated, unwell patient. What is required is a system that builds on the excellent start made by the ED, removes the blocks to patient care caused by waiting for beds in the ED and then continues to emphasise rapid diagnosis, early management, disposition and flow. This is what AMAAUs can deliver and why they should be effective. Australasian EDs already provide an exemplary service in a difficult, access-blocked environment. What patients need is sufficient hospital capacity — hospitals that provide enough appropriate beds. We look forward to seeing AMAAU staff meet this need in partnership with their emergency physician colleagues.

In summary, it’s all about available beds, about having enough overall capacity and optimising patient flow to maximise bed availability.2 The only revolution required is for governments to recognise this fundamental precept.

To the Editor: Although written from a United Kingdom perspective, the recent article by Walters and Dawson1 suggests a change in the clinical culture within hospitals, so that patient care and throughput can be improved. A critical factor in achieving change is the creation of an acute medical assessment and admission unit (AMAAU) within each district hospital. Characteristics of the AMAAU will “depend on local circumstances”: there is no one size that fits all.1

Because of Australia’s unique demography, and the number of communities beyond the reach of tertiary centres, many primary-care physicians (general practitioners and “rural generalists”) provide the continuum of care required by patients, both within the community and within their local hospitals (the acute admission, ongoing inpatient care and discharge planning).

Twenty-first-century GPs deal daily with patients needing management of multiple comorbidities and the consequences of polypharmacy (the “sick general” and “complex elderly” clinical streams1). GP training prepares doctors for these responsibilities and could easily be expanded to include an AMAAU role for interested GPs, especially those in outer urban and major rural areas.

The advent of AMAAUs is an opportunity to change the mindset in medicine: after 8 to 9 years of primarily hospital-based training, some GPs suddenly have no hospital access! This would seem to be a callous waste of talent and resources.

To the Editor: Walters and Dawson1 highlight growing interest in new models of care aimed at ameliorating hospital-bed pressures and access block. They advocate acute medical assessment and admission units (AMAAUs) as a potential solution, and claim, principally based on the United Kingdom’s experience, that these units can significantly improve clinical care and patient outcomes. A recent systematic review confirms that these units (which have attracted several different synonyms) have promise, although controlled trials have yet to be performed, and publication bias remains a potential confounder.2

Experience with such units in Australia and New Zealand is growing, with more than 30 units in operation, and up to another 15 due to open over the next few years. Several national workshops conducted during the past 12 months have allowed staff of the units to share lessons and insights, and to debate how to balance service needs with resource availability. Operating standards for AMAAUs have been developed by the Internal Medicine Society of Australia and New Zealand (IMSANZ),3 which represents consultant general physicians. A recent survey shows the operations of Australasian units concord, in the most part, with these standards.4

We caution against Walters and Dawson’s suggested separation of AMAAU physicians into two streams — acute physicians working shifts, and ward-based general physicians responsible for patients requiring transfer from the AMAAU. Given that at least half of AMAAU patients will require transfer to inpatient wards, and many may warrant ongoing outpatient care even if discharged from the AMAAU, the need for continuity of care is paramount at the interface between the AMAAU and ward or clinic. To minimise the number of handovers and their attendant hazards and inefficiency, the medical team assessing and managing the patient in the AMAAU should ideally be the same team that provides ongoing inpatient (and indeed subsequent outpatient) care. This practice also eliminates any confusion around who is ultimately responsible for decisions about individual patient care, particularly for patients who remain in the AMAAU for any length of time. General physicians can acquire and maintain skills in acute medicine by making use of professional development programs sponsored by the IMSANZ. Clinical directors are needed in AMAAUs to oversee unit operations, develop policies and procedures, and provide capacity for rapid consultant response if on-call consultants are temporarily unavailable. The real challenge, to which Walters and Dawson refer, is the need for health care professionals to recognise that whole-of-hospital redesign solutions — which include AMAAUs — are needed, if access block in emergency departments is to be successfully overcome.

To the Editor: The Journal took a significant step forward in publishing the three articles on access block in the 6 April 2009 issue.1-3 Walters and Dawson’s viewpoint article,4 in a later issue, touches on some ideas that will be useful in finding solutions to access block — ideas that some hospitals are implementing. However, I am not sure a microsolution aimed purely at acute medical patients can be called a whole-of-hospital revolution.

The acute medical assessment and admission unit (AMAAU) is potentially a good idea. Fortunately, many hospitals all over Australia already have units that are highly efficient at the role that is proposed for it — they are called emergency departments (EDs). Most acute medical patients can be identified as needing admission after a few seconds in the ED by experienced emergency physicians. The remaining patients need some basic pathology or imaging service before a decision can be made, which should take an hour at the most. Having secondary inpatient units providing this role to the community via direct general practitioner referrals, as well as having some patients bypassing the ED by being cherry-picked by inpatient teams, may generate inefficient duplications of service.

The AMAAU has merit, streaming patients to the right specialty and the right inpatient bed early in their presentation. Emergency physicians have largely known this for over a decade and these kinds of units have already been introduced in hospitals all over the country. Nepean Hospital, in western Sydney, has the PECC (Psychiatric Emergency Care Centre), AGS (Acute Gynaecological Service), MAU (Medical Assessment Unit), EDMAU (ED Medical Assessment Unit), EMU (Emergency Medical Unit) and ASU (Acute Surgical Unit), to name just a few acronyms. Unfortunately, this does not deal with the 20 patients in the ED, already admitted and sorted, waiting for an inpatient bed at 8 am on a Monday. Increased inpatient bed numbers to cope with the predicted acute ED admissions and the planned elective surgical workload must be the number-one priority. Once we have bed numbers to cope with demand, then we can plan how to use them.

I propose my own revolution. We need to provide a true 7-day-a-week service to our hospital inpatients. Ward rounds should be conducted 7 days a week. All inpatient consults, including those of allied health practitioners, should be completed on the same day, including weekends. All complex imaging should be completed on the day it is ordered, not the next working day, with formal reports available the same day. Once we acknowledge that acute hospital medicine does not fit in with the 38-hour working week, then we can truly start acting as patient advocates.