Emergency care in the first 48 hours
Authors: Peter Leman
Journal: BMJ (2007)

The importance of the first 48 hours in producing successful outcomes for acutely ill patients cannot be underestimated. The definition of a successful outcome depends on who is measuring it. Clinicians look for successful diagnosis and treatment, governance directors look for safety and use of pathways and guidelines, educators look for training opportunities, managers want to decrease length of stay, whereas patients (usually) just want to get better and go home. The problem is how to deliver on all of these fronts.1

The traditional model of delivering acute care for medical patients, who make up the bulk of acute admissions to hospital, has been slowly changing. The older model of a hierarchal medical team has begun to disappear.2 There have been many drivers to this change. In the United Kingdom changing patterns in the availability of junior doctors (such as the European Working Time Directive and the Modernising Medical Careers project (www.mmc.nhs.uk/pages/home)) has led to team fragmentation and multiple handovers of acutely ill patients.3 A growing deficit of primary care after normal working hours has meant an increase in hospital admissions at night. The imposition of a maximum stay of four hours in emergency departments in the UK has meant that many acutely ill medical patients have been rapidly moved to medical wards, perhaps before a full assessment.4 Some emergency departments have responded to the challenge by providing some acute inpatient care for up to 24-48 hours, but this is far from widespread.5

Specialty physicians are becoming less keen to participate in the acute medical take roster, which can lead to less input from consultants regarding the initial assessment and care of inpatients.3 This problem is much greater in Australia, where the specialty of internal medicine is facing an increasing shortage of recruits, as increasing numbers of trainees opt for the more remunerative procedural specialties (which provide invasive procedures such as endoscopy, angiography, and bronchoscopy).6 The increasing dearth of general physicians means that some hospitals have no general medical teams. In such hospitals, patients with several chronic diseases can no longer be treated by one team alone and require multiple consultations and longer stays in hospital.7 In the United States the rising role of the hospitalist, who is based entirely in the hospital and provides acute medical care, conflicts with the traditional role of the patient's primary care doctor, who previously visited the hospital to provide inpatient care. The hospitalist model is becoming the benchmark for acute care for many medical patients in hospital in the US, although these clinicians are not recognised as internal medicine physicians in most places.8

The UK has seen the rise of the “acute physician,” who is dedicated to managing the first few days of all acute medical admissions. These individuals come mainly from the specialty of general medicine, but as the acute physician specialty develops its training model and approval for core training, it will soon have its own specialists.4 Individuals with core training in emergency medicine or critical care medicine will also join, so that a specialty dedicated to acute medical care will grow.9

Soon the Joint Committee on Higher Medical Training will implement the model for two years of common stem training in acute care to follow on from the two foundation years that new UK graduates now work. Thus, six months each of intensive care, emergency medicine, anaesthesia, and acute medicine will provide the robust platform for specialty training in acute medicine. 

The question is whether this acute physician model is useful. Has it evolved only out of political change, or can it really make a difference? The expectation of the Royal College of Physicians is that with dedicated acute physicians undertaking ward rounds twice daily, seven days a week, the model should work.10 Acute physicians will initiate investigations and interventions from the moment the patient arrives in the emergency department or acute assessment unit. This will enable rapid assessment and management of patients with potentially complex comorbidities and multisystem disease from the outset. Acute physicians will coordinate allied health interventions and plan discharge from the outset. They will also liaise with specialist inpatient teams and where possible with domiciliary services and “hospital in the home” teams to avoid treating patients in hospital when they could be treated at home. The evidence to date on the effectiveness of the model is piecemeal. Better short term outcomes have been reported with the acute physician model than with traditional team based care in the UK, and the US hospitalist model has shown cost efficiencies without any robust long term outcome data as yet.11

The challenges are obvious if acute physicians are to succeed. The political drivers for change are strong, and hospital executives and commissioners will always favour a service that can deliver safe, effective, efficient, and fast care for inpatients. But what of the specialty of acute medicine itself? Respect from peers is hard to earn, and generalists are not so highly regarded as the superspecialist who may be seen (by colleagues and patients) as the master of a specific craft or skill set. To paraphrase Dame Carol Black (the last president of the Royal College of Physicians and an important figure in the development of this specialty) speaking at a meeting of the Society for Acute Medicine held in September 2006 in London: a specialty can exist only when a robust body of published work provides evidence of what the specialty does and why it should continue to exist. Thus will it earn the respect of its peers. 

This is an exciting time to be in acute medicine; it should be the core specialty in the hospital of the future, around which other inpatient activity will flow.12 Acute physicians should be competent to manage medical emergencies and make complex multisystem medical diagnoses. But they should also be able to smooth the path of the increasingly truncated hospital journey. They should be the link between home treatment and brief but focused hospital based treatment, and they should also coordinate other specialist care whenever it is needed.