Fellows of the UCEM embrace WHORe model
I’d like to draw attention to a recently published article in the Medical Journal of Australia “Whole-Of-Hospital Response to admission access block: the need for a clinical revolution”.
The Whole Of Hospital Response to Emergency (WHORe model) is unique, insightful and thoroughly modern in it’s approach to the management of acutely ill patients and overcoming the problem of access block – but does it go all the way?
Original WHORe Abstract
- The major problem of access block to acute hospital admissions in Australia needs a more radical response than a focus on increasing inpatient beds, as suggested recently.
- Australia needs to take on board recent changes in United Kingdom hospital systems, which have revolutionised patient flow during acute admissions and dramatically improved efficiency, clinical quality and outcomes.
- Accident and emergency departments in the UK became recognised as part of acute hospital dysfunction. Now, increasingly, patients needing admission are directed as soon as possible to an acute medical assessment and admission unit (AMAAU), thus freeing accident and emergency staff for re-defined core priorities.
- AMAAUs require supervision by a new style of acute general physician, who drives timely management of acute medical patients, defines patient needs, estimates the likely date of discharge, and selects the most appropriate inpatient clinical stream.
- These reforms are staff-intensive and expensive, but cost-effective and patient-focused. They highlight the need for an adequate scale for acute clinical services and defined streams of care within individual hospitals, as well as explicit networking at a regional level to guarantee specialist acute services when needed.
This landmark article describes a novel and alternative approach to overcoming the problem of access block. The authors outline the serious deficiencies inherent within our Emergency Departments (ED) and astutely identify that this problem is actually located outwith the ED, i.e. the rest of the hospital.
The Bored of Censors at the Utopian College of Emergency for Medicine (UCEM) have long been aware of this problem, and have pre-emptively developed the discipline of peri-departmental medicine to educate MUPPETS in the art of Waiting Room Medicine; Unmonitored Cardiology; Bus Stop Surgery and to prepare the Whole Hospital Organisation for the ultimate time-management system – the ‘Four Minute Rule’.
With such an extensive track record in the acute management of medical emergencies, the Fellows of the UCEM feel well placed to comment and pass judgment on the several minor glaring deficiencies within the WHORe model.
A/E physicians had to take on too much of the acute medical load and investigate and manage too many acutely ill medical patients for too long.
Agreed. Emergency physicians have for too long been investigating and managing acutely ill patients. It must stop! We should really invest time, money and resources in re-naming, re-educating and re-packaging the tasks and functions of current emergency physicians.
development of the acute medical assessment and admissions unit (AMAAU)
Why stop there? We should develop more specialised units such as the ‘acute medical assessment and monitoring of acutely unwell patients despite lack of initial resuscitation admissions unit’ (AMAAMAUPDLIRAU).
Within the first few hours of admission (to AMAAU), each patient requires rapid nursing assessment, medical clerking, and initiation of investigations by junior doctors. When all the early data are available, timely senior review of the patient’s condition is essential to formulate a provisional diagnosis and management plan.
This is brilliant! I can’t fathom out why we have not been doing this for years. If only our current Emergency Departments functioned in such a streamlined manner.
Two complementary acute roles for general physicians have emerged: the acute physician (AP), which is a new concept, and the more conventional role of inpatient general physician. The AP will need to acquire some acute procedural skills that are more commonly associated with ED specialists.
This won’t work. The UCEM believes the ‘new concept physician‘ should be known as an Uber Physician (UP). The UP should be a physician who is “trained specifically in the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioral disorders.” [Reference]
The UCEM has consequently drafted a response to the WHORe model. We believe that the WHORe model is attractive, but as you can see, WHORe’s don’t go all the way. Here are our suggestions,
UCEM Proposed Solution
- The major problem of access block to acute hospital admissions in Australia needs a more radical response than a focus on increasing inpatient beds, what is really required is more chairs in the waiting room, specifically the provision of monitored chairs and designated resuscitation chairs.
- Australia needs to take on board recent changes in United Kingdom hospital systems, which have revolutionized patient shuffling during acute admissions and dramatically improved efficiency, clinical quality and outcome in the day to day activities of hospital orderlies and catering staff.
- Accident and Emergency departments in the UK became recognised as part of the problem. Therefore, let us not base potential solutions to the problem on a system, which was inherently different to ours in the first place (UKaic model). Now patients needing admission are directed as soon as possible from the waiting room to the AMAAMAUPDLIRAU, thus freeing emergency staff for re-defined core priorities such as FOXtel and table tennis.
- AMAAMAUPDLIRAU‘s require no on-site supervision by medical staff, as timely management of medical patients will occur when a cute general physician arrives some time in the first 24 hours to define the patient needs; estimate the likely date of discharge; select the most appropriate sandwiches to be served and efficiently re-direct the already admitted patient to a third-tier inpatient unit.
- These reforms are staff-intensive and expensive, but cost-effective and patient-focused. They highlight the need for an adequate scale for acute clinical services; increased behind-the-scenes medical administration staff and defined streams of care within individual hospitals, as well as explicit networking at a regional, national and intergalactic level to guarantee specialist acute services when needed.
It may be idealistic, but the UCEM firmly believes that in the future the management of emergency patients should be outsourced and entirely orchestrated from offshore. Hands-off-medicine, teleconferencing, the iPhone and video assisted robotic technology (VART) will assist in the management of critically ill patients within the waiting room. The nursing, administration, clerical staff, hospital orderlies and parking attendants will maintain a continuous patient flow from the Waiting Room Stream to the Effluent River of Admission. Once the patient is admitted to AMAAMAUPDLIRAU, senior medical staff and the cute physicians will then be available within 24 hours to provide untimely management decisions and inappropriate medical care.
