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Improving the care of the seriously ill patient: the interface between the accident and emergency department and critical care areas
  1. Peter Nightingale
  1. Intensive Care Unit, Wythenshawe Hospital, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK (pnightingale{at}compuserve.com)

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    If you were suddenly taken ill with an acute medical condition where would you go, and who would you like to have treat you? In the UK, acutely ill patients are usually sent, taken, or self refer themselves to the nearest accident and emergency (A&E) department. There, in the current climate of healthcare provision, they will be attended to in an inconsistent manner.1

    Ignoring here the valuable contribution that nurses make in the A&E department and considering only medical care, ideally a consultant in A&E medicine will see the patient immediately. However, often it may be a trainee from one of the acute specialties, and only some hours later. It is possible that this variability in practice costs lives because of inexperience in appreciating how sick a patient is, despite a plethora of warning signs.

    Here I am dying of a hundred good symptoms.

    Alexander Pope, English poet 1688–1744.

    The initial treatment given by these on call trainees, as well as being delayed, may also be suboptimal, even though evidence is accumulating that early, and appropriate, treatment along physiological lines in the emergency room can have a long term positive effect on outcome.2

    How can this scenario be improved? The two key elements are education and multi-specialty, as well as multi-professional, working patterns by which senior clinicians see and supervise the care of such patients.

    The treatment benefits from a formal, but prompt, assessment of serious conditions such as major trauma and myocardial infarction are now appreciated. The use of protocols is helpful and, working within a defined framework of care or “use of a common language of care” as seen in major trauma, ensures all know what is expected. Progress is now being made in expanding the experience gained in these areas to caring for the seriously ill patient in general.

    It is recognised that there are a number of problems that need to be tackled. The interfaces between the ICU, HDU, A&E, MAU and the medical on take team are often unclear.1 The Royal College of Physician's Working Party on the Interface between Intensive Care and Emergency Medicine, which is to be published later this year, has heard repeatedly of the problems in A&E departments. Specifically, the large number of medical emergencies is causing difficulties because of a shortage of doctors and beds. The introduction of MAUs is recognition of the fact that seriously ill patients are best grouped together where scarce nursing and medical resources can be concentrated. A number of models exist, but MAUs seem to work best when senior medical staff become involved early and where there are close links with the critical care areas, ideally including shared appointments and rotations of trainees between these areas and specialties.

    For the intensivist, a phrase used because there seems to be no better, this is good news. For many years the ICU consultant, usually anaesthetist but now often physician, when called to see a sick patient has often despaired of the care provided by trainees on the ward before referral.3 This has been shown repeatedly to be attributable to a failure to appreciate the seriousness of the situation and refer upwards to senior colleagues. As David Goldhill observed “Intensive care is only one episode in the continuum of care for the patient ..., treatment and decision making in the ER, OR, or on the ward may well be important [in determining the patient's survival]”.4

    Comprehensive Critical Care intends to address these problems.5 Its publication was a seismic event in the world of intensive care medicine; the consequences have yet to be appreciated by many clinicians. Essentially the message is “The right care in the right place at the right time given by the right people”. This should be the message from the Department of Health's current deliberations on access to urgent and unscheduled healthcare.

    To fulfil the aims of Comprehensive Critical Care the National Patients' Access Team is pushing forward an ambitious programme of education and service development. Their goal is to improve access, experience of and outcomes for patients with potential or actual need for critical care. This requires a hospital-wide approach to early identification and assessment of critically ill patients. Historically, when called to the wards, intensivists have generally become involved with patients (usually surgical) late in the course of their acute illness. This will change. Although few ICUs have the manpower at the moment, with the introduction of outreach services, nurse consultants (50% of whose time is for education), and the planned expansion in consultants with an interest in intensive care medicine, the goal is improve care hospital wide; the concept of “the ICU without walls”.

    To drive these changes locally each Trust should now have a Critical Care Delivery Group.6 This committee should be chaired by the chief executive or their nominated representative from the Trust Board and will include a consultant from the A&E department.

    However, it remains vital that doctors acquire the fundamentals of recognition and care of the seriously ill patient early on in their career. Ideally this is done under supervision in the clinical environment. Unfortunately the opportunities for this to occur may be relatively infrequent for individual trainees, who now spend much less time caring directly for patients. There are a number of didactic courses available to aid this process; ideally they should be targeted at undergraduate and PRHO level.

    Eventually, however, one can only hope that the Working Group on Modernising the SHO Grade, chaired by Professor Liam Donaldson, the chief medical officer, will agree that all trainees must rotate through posts where they can be taught these “critical” skills before they need to be put into unsupervised practice.

    Until that time, senior clinicians in A&E departments and critical care areas should continue to work together to improve the early care of the seriously ill medical patient. Such collaborative working has been successful in trauma. A number of such initiatives are now in place, for example, in Edinburgh, Norwich, Whipps Cross and Whiston Hospitals. We should learn from their experiences and continue to press for the necessary increase in the number of senior doctors in emergency medicine and critical care that will be required. I firmly believe all now recognise this need.

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