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Improved Acute Medical and Surgical Assessment and Management

Improved Acute Medical and Surgical Assessment and Management. Auckland City Hospital – Admission & Planning Unit. DR JOHN HENLEY Auckland District Health Board. Sydney 2007. RECENT HISTORY Background of increasing medical (and to a lesser extent) surgical acute admissions.

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Improved Acute Medical and Surgical Assessment and Management

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  1. Improved Acute Medical and Surgical Assessmentand Management Auckland City Hospital – Admission & Planning Unit DR JOHN HENLEY Auckland District Health Board Sydney 2007

  2. RECENT HISTORY • Background of increasing medical (and to a lesser extent) surgical acute admissions. • Emergency pressures not significantly diminished during summer months. • Lack of resourced beds / beds in wrong places. • Doctor / Nursing shortages. • Staff / Systems at many hospitals unable to cope with significant flux in admission rates.

  3. REASONS FOR INCREASING ADMISSIONS • Lower threshold for hospital admissions • Ageing population • Raised expectation of GPs and patients • Early or premature discharge • Multiple admissions for chronic conditions • Accident and Emergency Clinics • Social Deprivation [inappropriate admission due to failure of primary care]

  4. COMMON HOSPITAL PROBLEMS • Pressure on medical and surgical beds • Patients distributed in many wards • Inflexible arrangement of diagnostic facilities [inpatient waiting list] • Inadequate discharge arrangements [5/2 week] • Lack of social services facilities and resources • Inflexible junior doctor rosters • A new system of medical and surgical admitting was necessary - co-ordinated and efficient.

  5. “Accident and Emergency and acute medicine should be experienced as a continuum, with patients moving easily and safely from one point in the system to the next, confident that those receiving them are prepared and informed about what has gone before”. The interface of Accident and Emergency and Acute medicine. Report of a working party of the Royal College of Physicians May 2002

  6. Medical Admissions The Past Present Acute Admissions Acute Admission ED ED General Medicine APU General Medicine Specialty Units Specialty Units Strong GM Presence Weak GM Presence

  7. Objectives ADMISSION & PLANNING UNIT • Provide a purpose built facility for inpatient services to admit, assess and manage patients. (Admission and Planning Unit). • Enhance and facilitate the assessment and management of acute medical and surgical patients. • Prevention of double handling of patients, by allowing direct access to an inpatient unit from the primary care sector (bypassing ED).

  8. WHAT MUST APU HAVE FOR SUCCESS ? • Excellent relationship with Emergency Department • Experienced medical staff, preferably at senior level. Senior leadership, inpatient lead • Dedicated area for assessment - close to ED but separated from it • Adequate time without other commitments for doctors on duty • Rapid access to investigations

  9. Rapid review by super-specialist departments • Access to early outpatient clinic appointments [including acute clinic] • Multidisciplinary support [OT, PT, Pharmacy, Social Work] • Multi-skilled nursing workforce • Clerical support • Strong IT support

  10. ADVANTAGES OF APU OVER TRADITIONAL ADMISSION PROCESS • Concentration of medical and nursing expertise in one area - also allied health workers • Availability of high dependency beds, providing high acuity care [including chest pain assessment] • Inpatient departments accountable – no default care • Enhanced ability to sustain ward based teams

  11. Standardised admission documentation • Improving morale • Increase “grunt at the front” • Facilitation of diagnostic pathways • Centralised investigative facilities • Availability of acute ambulatory clinic • Enhance data gathering for clinical research and audit

  12. ADMISSION & PLANNING UNIT – ACH (3 Year Activity Analysis of Acute Admissions)

  13. Data on Distribution

  14. Data on Length Of Stay

  15. Average LOS (days) by calender for patients acutely admitted to Hospital and Discharged from Gen Med, Gen Surg, Orthopaedics or Urology, by Financial Year. APU was introduced in October 03.

  16. Hospitalists / Acute Care Physicians General Physicians wearing different cloaks. Limitations: • Need for shift work with problems of continuity of care. • Extreme high acuity work load – burn out. • Young persons’ game – reduced grunt ‘at the front’. • Advancement to where. • No outpatient / private exposure. • Reduces clinical experience for junior trainees. • Not applicable to peripheral and community hospitals. • Catering to large hospital requirements, rather than community. • Further reducing role of generalist ‘non hospitalists’.

  17. Safe decisions about clinical care depend greatly on the quality and accuracy of the initial assessment…… This is the essential reason for ensuring that acute care physicians , freed from other responsibilities, are readily able to lead, guide and support A & E and on-take medical teams. It represents a key standard of care and is strongly recommended. RACP Working Party 2002

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