METHOD

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.

RESULTS

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.

Specialist clinics

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.

DISCUSSION

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 ).

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.