Contrasts in acute medicine: a comparison of the British and Australian systems for managing emergency medical patients

The pressure on hospitals from emergency medical admissions has risen inexorably over recent years, resulting in overcrowded emergency departments (EDs) and associated adverse effects on efficiency, safety and quality of care.1,2 In response, hospitals worldwide have introduced new systems for managing patients who require unscheduled medical admission.3,4 In the United Kingdom, a new medical specialty of acute medicine has been developed and acute medical units (AMUs) have been established. These have been defined by the Royal College of Physicians of London (RCP) as “specialised area[s] of an acute hospital where patients suffering from acute medical illness can be assessed and initially admitted”.5 While these initiatives have undoubtedly met with some success, the evidence base for their overall benefit remains elusive.6-8 Since its advent in the UK in 2004, the “4-hour rule” mandating the maximum length of stay for patients in EDs has also reduced overcrowding in EDs, but without evidence for overall benefit to quality of care.9 A seminal report from the RCP in 2007 made many recommendations for the further development of acute medical services and emphasised the need for collaboration between medical specialties, critical care, acute medicine and emergency medicine.5

An opinion has been voiced that the introduction to Australia of a model similar to that in Britain would be beneficial,10 but there is no substantive evidence to support this. In Australia and New Zealand, some hospitals have established medical assessment units for clinical assessment of medical patients admitted from the ED, before they are either transferred to medical wards or discharged home.11

We describe key aspects of the recent establishment of acute medical services in Britain and discuss the relevance of these experiences to Australia.

In the UK, at the time of the Emergency Services Collaborative (which ran from October 2002 to September 2004), hospitals were brought together to share examples of good practice in acute medical care. The value of this experience was clearly improved by the realisation that adaptation of existing models of care to meet local demands was superior to simply adopting, or cloning, an existing model, and this mantra became a key message from the subsequent UK Department of Health report.12 A system that functions well in one environment may not thrive in a hospital where local demands and resources are different.13,14 Successful UK AMUs developed acute medical services based on local functional needs rather than simply attempting to copy the physicality of another unit.7,15 This argues for caution when making international comparisons between the UK and Australia — especially considering the very different infrastructure of acute care in the two countries.

In Britain in 2004, the RCP recognised the need to develop a specialty of acute medicine with specific training of a group of physicians skilled in managing acutely unwell and physiologically unstable patients.16 This was within the context of a model of care where, as recently as 2000, acute general medical patients on the medical intake were the responsibility of on-call senior clinicians who had conflicting specialty and general medical duties — a conflict that often led to delayed review of these patients by consultants and inconsistent clinical leadership of acute care services.17 Since then, the British acute medicine curriculum for trainees has been developed to ensure a “fit-for-purpose” workforce. Also, the importance of skills in acute care of older people has been clearly recognised, and specialists in geriatric medicine contribute heavily in covering the general medical intake.18,19

In contrast, the specialty of general medicine in Australia appears to be more focused on chronic disease management and the care of older patients.20 The corollary to this is that unstable medical patients are preferentially cared for in EDs and critical care units in Australia, and exposure of Australian general physicians to acute medical problems is probably less as a result.21

Emergency medicine is highly developed in Australia. EDs are the major portal of entry to hospital for acute medical patients and there is a culture of both stabilising sick patients and continuing care for patients with uncertain diagnoses in the ED. In stark contrast, in the UK, up to 75% of such patients are admitted directly to AMUs.7 In recognition of this, the RCP has emphasised the need for close collaboration with critical care services and has recommended that AMUs incorporate an area where unstable patients (requiring single organ support but not mechanical ventilation) can be managed safely.5

In Australia, there appears to be a greater tendency for patients to be admitted to medical specialty units directly from the ED. When this is the case, an AMU will not be in a position to limit flow and manage a single emergency queue for hospital admission.