Volume 192 - Issue 6
Whole-of-hospital response to admission access block: the need for a clinical revolution
Author: James L Mallows
Med J Aust 2010; 192 (6): 354-356. || doi: 10.5694/j.1326-5377.2010.tb03544.x
Published online: 15 March 2010
Published online: 15 March 2010
To the Editor: The Journal took a significant step forward in publishing the three articles on access block in the 6 April 2009 issue.1-4 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.
References
- Fatovich DM, Hughes G, McCarthy SM. Access block: it’s all about available beds. Med J Aust 2009; 190: 362-363. 0_CBBIDAHJ
- Cameron PA, Joseph AP, McCarthy SM. Access block can be managed. Med J Aust 2009; 190: 364-368. 0_pgfId-2017343
- Richardson DB, Mountain D. Myths versus facts in emergency department overcrowding and hospital access block. Med J Aust 2009; 190: 369-374. 0_i1091853
- Walters EH, Dawson DJ. Whole-of-hospital response to admission access block: the need for a clinical revolution. Med J Aust 2009; 191: 561-563. 0_CBBFJBGI