Journal of the Royal Society of Medicine
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A large and continuing increase in medical emergency admissions has coincided with a reduction in hospital beds, putting the acute medical services under great pressure. Increasing specialization among physicians creates a conflict between the need to cover acute unselected medical emergencies and the pressure to offer specialist care. The shortage of trained nursing staff and changes in the training of junior doctors and the fall in their working hours contribute to the changing role of the consultant physician. ⋯ Excellent bed management is essential. There must be guidelines for all the common medical emergencies and all units must undertake specific audits of the acute medical service. Continuing professional development (CPD) and continuing medical education (CME) should reflect the workload of the physician; that is, it must include time specifically focused on acute medicine and general (internal) medicine, as well as the specialty interest.
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We do not have good information on the incidence and prevalence of emergency conditions nor is there good research evidence on the best ways of meeting these. There are, however, some indicators for evaluating emergency services activities and we have a good framework from Donabedian for evaluation, and the important dimensions of quality specified by Maxwell. The range of emergency services covers primary care, community crisis care, ambulance services, hospital services (accident and emergency [A&E] department, inpatient, critical care), laboratory (blood supplies, tests), social services, and public health. ⋯ We need to specify a comprehensive, valid and easily collectable data set for assessing the quality of emergency services. This would include better ways of forecasting for early warning purposes. This could be done by monitoring the incidence of absenteeism, the sale of over-the-counter drugs, and the number of deaths in nursing homes.
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Anaesthetists provide services throughout acute hospitals in areas such as the delivery floor and the intensive therapy unit as well as working in their traditional role in the operating theatre. Consensus standards of the number of staff needed to provide a satisfactory level of acute anaesthetic services, their qualifications and experience and the resources they require have been produced by a number of organizations. It is probable that many small and medium-sized district general hospitals will be unable to meet these standards without changes to traditional UK staffing structures.
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There are numerous standards currently available that relate to accident and emergency medicine. Some of these relate to organizational structure; others are clinical and relate either to the process of care or to outcomes. Few, if any, deal explicitly with the dimensions of quality mentioned in recent white papers about the NHS. It is suggested, to maximize the effect standards have on care, that they should be developed for existing technologies not just for novel ones, rigorously developed and effectively disseminated and implemented, formally evaluated after their introduction and mutually compatible.
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This paper examines some of the misapprehensions that have often underpinned the planning of accident and emergency services in the UK. Accident and emergency (A&E) is not a homogenous group of activities and the different components that make up the service should be planned separately. This planning needs to be accompanied by some significant redesign to meet growing patient expectations. In particular, there is a major challenge for services to offer local access in an environment in which acute care is increasingly centralized.