Academic journal article Australian Health Review

The Effect of Context on Performance of an Acute Medical Unit: Experience from an Australian Tertiary Hospital

Academic journal article Australian Health Review

The Effect of Context on Performance of an Acute Medical Unit: Experience from an Australian Tertiary Hospital

Article excerpt

Introduction

Australia has an aging population with an increasing burden of chronicdiseases.1Financial constraints,highrates ofhospitalbed occupancy, and medical manpower constraints have increased pressure within the public system, particularly with respect to emergency admissions.2

Experience and evidence from the UK3-8 suggests reorgani- sation of resources to target selected patients to acute medical units (AMU) may improve patient care and reduce length of stay, both in the emergency department (ED LOS) and in the hospital (LOS). In the UK, AMUs have been established with strong senior medical staff presence, prioritised investigations and early input from allied health staff.3-6 However, few data have been published on the outcomes of these units. Previous studies have reported reduced LOS,4 mortality,5 ED LOS,4,6 and cost4 without compromising readmission rates.3 These analyses, however, compared data from the years before and after the establishment of an AMU and are potentially biased, as they do not remove the confounding effects of independent improvements in LOS and mortality that may occur from other improved practices and advances in technology.

In Australia, NSW Health has implemented the opening of AMUs state-wide, based partly on a position statement by the Internal Medicine Society of Australia and New Zealand (IMSANZ),9 and on data from the UK and NZ.10 The aim of this study is to analyse and compare the function of a tertiary hospital general medicine department before and after the im- plementation of an AMU to determine primarily if LOS or ED LOS had reduced. Although this study is observational, not all general medicine patients are admitted to the AMU, enabling a concurrent comparison group to evaluate the performance of the unit.

AMU description

In March 2008, an AMU, termed the 'Medical Assessment and Coordination Unit' (MACU), was opened at John Hunter Hos- pital, a tertiaryteaching hospital in Newcastle, NSW. It is a15 bed unit located near the ED and next to the Emergency Short Stay Unit. It is staffed with medical registrars and a resident medical officer, nursing staff, physiotherapist, occupational therapist, pharmacist, dietician, social worker and a case manager, with priority access to imaging and Community Acute/Post-Acute Care Services (CAPAC). Junior medical staff are rostered to be present on the ward from 8 a.m. to 6 p.m. 7 days a week. Consultants on the general medicine roster accept patients under their care during their 'on take' time and start at the AMU during the post-take rounds. It has admission criteria for acute general medicine patients who are haemodynamically stable and who may benefit from rapid intervention from medical and allied health professionals. Patients are referred to the AMU registrars by the ED medical staff or the ED Aged Care Coordinator (EDACC) nurse. Any vacant beds after 5 p.m. are filled by patients of any speciality at the discretion of the after hours nurse manager. The aim is for a 48 h discharge from the unit. Patients who requirealonger admission are transferred to other units in the hospital.

Methods

Data were collected for all general medicine patients admitted from June through November 2008. Age, sex, postcode of residence, discharge destination, the need for community support after discharge (community nurses or other community services), ED LOS, hospital LOS and Charlson co-morbidity index were collected for all patients via review of electronic discharge summaries. If further clarification was required, patients' previ- ous discharge summaries, pathology, imaging results and outpa- tient correspondence were accessed.

ED LOS and LOS were also collected for all general medicine and medicine sub-speciality patients for the periods June through November 2007, 2006 and 2005 for comparison. A test of trend for improvement in LOS over time, independent of the opening of the AMU could then be performed. …

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