Role of the accident and emergency review clinic in UK service provision
- S Dasan,K Hashemi, Accident and Emergency Department, Mayday University Hospital, Croydon, Surrey, UK
- Correspondence to: Dr S Dasan, Accident and Emergency Department, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 7XX;
- Accepted 1 May 2002
Objectives: Selected patients attending accident and emergency (A&E) are seen again in the A&E review clinic for planned follow up. Despite the large number of patients being seen in these clinics, this area of A&E service provision has rarely been studied. The aim of this study was to determine the current provision of review clinic services in UK A&E departments, their organisation, and their perceived role in current practice.
Methods: Postal survey of all major UK adult and paediatric A&E units.
Results: Almost all major UK A&E departments have a review clinic service and almost three quarters see less than 10% as reviews in line with current guidance. Many departments feel their clinics are well run and fulfil their objectives. Others are under pressure from external sources to see more patients. Over a third of departments have no written policies or protocols guiding referral to these clinics.
Conclusion: Review clinics are an important part of the A&E service in the UK and minimum standards need to be set in the provision of these services. Further audit and research needs to be carried out on the review clinic service to guide its future development.
Patients who attend accident and emergency (A&E) departments with acute illnesses or injuries and who are not admitted to a ward may have some form of outpatient follow up arranged. This may be with their general practitioner or with a specialist in the hospital outpatient department. In some circumstances they may continue to be seen in the A&E department in a more structured, clinic type setting. This form of planned patient review usually occurs in what is variously known as the review or A&E clinic.
The numbers of patients returning to A&E departments for review have fallen in the UK over the past 20 years. In 1980, 42% of patients as a proportion of new patient attendances were being seen in a review clinic but by 1990–91 this was down to 22%.1
Despite the large proportion of patients being seen in these clinics, this area of A&E service provision has rarely been studied. Guidance has been produced on two occasions, firstly by the National Audit Office in 19921 and the British Association of Accident an Emergency Medicine in 19982 suggesting that review patients should account for no more than 10%–15% of new patient attendances, but there has been no further detailed guidance on the clinics' role or function.
The aim of this study was to determine the current provision of review clinic services in UK A&E departments, their organisation, and their perceived role in current practice.
A postal survey of all major UK adult and paediatric units as listed in the 1998/99 BAEM directory was carried out. A double sided A4 questionnaire was sent with a covering letter and prepaid envelope to a consultant in each department in July 1999 with a second mailing to non-respondents after eight weeks (see the journal web site for a copy of the questionnaire). A senior member of staff who regularly saw patients in the review clinic was asked to complete the questionnaire.
Of the 263 departments surveyed, 210 returned their questionnaires giving a response rate of 80%. As not all questions were answered on each questionnaire, the results are presented as a percentage of those who responded to each question (n=total number responding to each question).
Ninety six per cent of UK A&E departments run review clinics (fig 1 ). The number of review clinic patients seen as a proportion of new patient attendances varies widely from 0%–65% with a median of 7%. Seventy four per cent of departments see no more than 10% as reviews in line with BAEM guidance and many departments commented in their free text responses that they had made a conscious effort to try and reduce the number of their reviews.
Review clinic organisation
The median number of clinic sessions per week is five (fig 2 ). Most departments (69%) have one doctor staffing each clinic though 28% have two and 3% have three (n=200). Middle grades or consultants regularly staff the vast majority of clinics, but in a minority senior house officers see patients (2%).
Eighty per cent of departments hold their review clinics in the main department with the remainder holding them outside the A&E (fig 3 ). Sixty six per cent of departments send letters to GPs and 46% take direct referrals from them though in the free text responses some did specify that these were both occasional occurrences. Sixty three per cent of departments have written policies or protocols for referral to the review clinic.
Referrals to the review clinic
Conditions seen regularly in the review clinic are shown in figure 4 . In the free text responses head injuries (14 departments) and pre-tibial lacerations (11 departments) were also mentioned.
Thirty four per cent of departments have a special interest that could affect the casemix seen in the review clinic (n=183). Some departments have separate specialist clinics including hand (28%), soft tissue (57%), burns (55%), and wound care/dressing clinics (65%). Unfortunately there was a high non-response rate to these questions (31%–35%).
Views relating to the review clinic
Ninety per cent of A&E departments feel the review clinics play an essential part in their departments (fig 5 ). Ninety five per cent also feel their clinics act as a safety net for junior staff. Ninety four per cent feel that their clinics are well run and fulfil their objectives. This is despite the fact that 49% have insufficient resources mainly relating to floor space and nursing support, 35% have experienced an increase in attendance figures over recent years, and 12% have had pressure from external sources to see more patients. This pressure had come mainly from primary care or the hospital's surgical specialties. Fifty three per cent responded positively to the possibility of further guidance regarding the role of review clinics in the future.
This survey provides the most detailed information to date on review clinic services in major A&E departments in the United Kingdom. It shows that A&E review clinics are almost uniformly present with three quarters of major A&E departments (74%) seeing less than 10% of patients as reviews in keeping with the latest guidance from BAEM. This is despite the pressures that many departments are under from rising new patient attendances, insufficient resources, and pressure from external sources, including hospital inpatient specialties and primary care, to see more patients. It is also encouraging that despite this, 94% of departments feel that their clinics are well run and fulfil their objectives.
There is little research relating to the A&E review clinic service in the published literature. In the only study looking specifically at A&E review clinics, the appropriateness of review clinic referral was studied using existing departmental guidelines as the standard.3 This study quoted an inappropriate referral rate of 15%–20% but in a large proportion of these (61.5%), the reason for referral was not given. This study may have therefore overestimated the rate of inappropriate referral.
Our study gives a clear picture of current review clinic service provision and provides a basis for further work in his area. We feel that the role of the review clinic in UK A&E departments needs to be debated further and more audit of current practice and research into new methods of practice needs to be carried out to guide its future development. To further this debate, we would like to suggest a set of guidelines that could act as a minimum standard for review clinic services in the UK (box 1 ).
Box 1 Proposed guidelines for A&E review clinics in the United Kingdom
Review clinics should be present in all departments that employ doctors in training
Review clinics should be run on a daily basis to permit next day assessment (if necessary) of clinical problems by an experienced member of staff
Written protocols or policies should be in place to guide referral to the review clinic
These protocols should be widely disseminated to primary and secondary care services and agreed upon to ensure that patients can then be discharged via the appropriate channels for continuing care
Review clinics should decide locally which conditions they see but in deciding this they should consider the following:
Full and appropriate use should be made of services in primary and secondary care. Patients should be discharged from the review clinic with the necessary documentation as soon as referral to these services is appropriate
If local expertise exists within an A&E department, patients may then return to the clinic for specialist follow up as necessary
Examples of cases that should be seen in the general, non-specialist review clinic include cases where diagnostic uncertainty exists and cases where specific complications are anticipated in the short-term
With most patients still being seen by comparatively inexperienced members of staff and the absence of 24 hour middle grade cover in many departments, the review clinic provides patients with access to an assessment by an experienced member of staff soon after the initial attendance. We feel this has many advantages, not only for patients, but also for staff in terms of training, education, and feedback.
We feel that clinics should be organised to provide a next day review of clinical problems as this will prevent avoidable delays in providing appropriate management. Having clinics on a daily basis should therefore be the aim though this may be more difficult in departments with fewer members of experienced staff
Whatever the organisation of these clinic services, we feel it is essential that policies are in place to ensure appropriate use of the review clinic. These policies must be widely distributed among staff in the A&E department. Agreement also needs to be sought from primary and secondary care services with which the clinic may have contact so that appropriate patients are reviewed whose care can then be transferred smoothly to other services as necessary.
We feel that detailed guidance is essential to achieve a minimum standard for this part of the A&E service and that in the future, guidelines based on regular audit and well designed research will help to develop a network of efficient and appropriate A&E review clinics throughout the UK.
In conclusion, review clinics are an important part of the A&E service in the UK. Detailed guidance is needed to achieve a minimum standard for the provision of these services that at present vary widely in the proportions of patients they see and the existence of local referral policies. If the service is to develop in the future, further audit and research is essential to guide its progress.
We would like to thank Professor John Henry and all those associated with the Thames Academic Emergency Medicine forum for their help, advice, and encouragement.
Contributors Sunil Dasan initiated and designed the study, collected and analysed the data, and wrote the paper. Kambiz Hashemi discussed core ideas and edited the paper. Sunil Dasan acts as the guarantor of the paper.
Funding: Research Grant from South Thames (West) Regional Accident and Emergency Committee.
Conflicts of interest: none.