¬By Abeera Khan
Acute Medicine is a specialty concerned with the assessment, diagnosis and treatment of adult patients with urgent medical needs. Acute Medicine is distinct from Emergency Medicine (A&E), although specialist acute physicians often work in close collaboration with specialists in Emergency Medicine. In the NHS hospitals, both departments work side by side.
There can be different names of Acute Medical Unit in different hospitals like CDU (Clinical Decision Unit) or AAU (Acute Assessment Unit). AMU is a short stay unit where patients stay for a maximum of 72 hours. They are then transferred to respective wards (Gastro/Respiratory/Care of Elderly or else) depending upon their line of management, transferred out of Trust if needed or discharged home direct from AMU.
If you have worked in the NHS, you must be familiar with the breech time in A&E. The NHS Constitution sets out that a minimum of 95% of patients attending an A&E department should be admitted, transferred or discharged within 4 hours of their arrival. However, on the floor, it’s not practically possible many a times due to number of reasons (huge influx of patients, understaffing in A&E at various shift times, blood tests and other results, shortage of beds in the hospital especially during winters/weekends and many more). However, trusts do their best to reach this target.
When the patient comes to the A&E, he/she is stabilised and then transferred over to the Acute Medical unit (if the patient is undergoing medics). The AMU is a team led by Consultants, on call Registrar, on-call SHOs (CMTs, GPSTs, Trust grade, FY1/FY2), Advanced Nurse Practitioners and the base team of AMU. In my previous Trust, we had 3 SHOs who were AMU based. The Consultant can be an Acute Physician or from a sub-specialty.
AMU also receives urgent admissions from GPs, patients from chemotherapy unit for suspected neutropenic sepsis, from Ambulatory care and Outpatient department.
Aim/Purpose of AMU:
The basic aim of AMU is to assess the clinical condition of the patient, follow up pending blood and Radiology results, start appropriate line of treatment, request further tests if required, refer to sub-specialties for review, make a diagnosis and then transfer to ward/discharge home.
I have worked as AMU based doctor for 06 months. Around 80-90% of admissions are from A&E (roughly my statistics). The AMU team (SHOs/Reg) will review the patient, clerk, follow the pending investigations, do further tests (depending what the patient is coming in with), make a management plan and discuss with the Registrar and patient is then reviewed by the Consultant.
AMU ward rounds start at 08:00. This is called post-take ward round (PTWR) when the consultant reviews the patients admitted overnight. As there is constant influx of patients, so Consultants try to move patients to the ward if they need to stay in the hospital for few more days or discharge them home from AMU.
If the patient is admitted overnight with a mild/moderate acute attack of Asthma, had baseline investigations, CXR, ABGs, Nebulisers, steroids, antibiotics (if needed) and is now clinically stable, maintaining saturations on air and not needing Nebs, peak flow within normal range, he can be discharged home from AMU with a prescription.
After the ward round there is a handover in which the team goes through the patients and you write up on the board what further investigations need to be requested for each patient, any referrals to be made to specific teams or subspecialties within the hospital, TTOs( discharge letters) to be done, any investigations to chase up or expedite, mostly with Radiology like CT scans/MR/Ultrasound. If any discussion need to be done with Consultant Microbiologist on call or any out of hospital referrals.
It is best to work as a team in AMU. After the ward round, we used to divide work like half of SHOs used to do the jobs mentioned above and 1-2 SHOs keep clerking new patients coming in. If at times there was a bed blockage and no movement is happening from AMU to the wards, we used to finish the jobs at AMU and 2 of us (SHOs) used to go to A&E with the on-call registrar and start clerking patients there in ED who are definite admission. This helps your night team if you are working on days as staffing at night is less as compared to full day team. The same we used to do at night shifts too.
Common cases encountered in AMU:
There is a broad spectrum of clinical work in AMU. The range of clinical problems encountered is very wide, which gives the work a great deal of variability and that’s what I like best, mixture of medicine and blended work. AMU routine is tough on everyday basis, but I like continuity of work, so I thoroughly enjoyed my rotation. You would commonly see,
Headache (Rule out Subarachnoid haemorrhage). Would have had their CT Brain from ED and would get LP in AMU.
Acute exacerbation of COPD
Chest infection/ Pneumonia
Acute Kidney injury
Overdose (most common- Paracetamol)
Acute flare up of Inflammatory Bowel disease (Crohns/Ulcerative Colitis)
UTI in elderly causing delirium
Suspected Pulmonary embolism
Suspected cauda equina (in my previous trust, it used to come under medics)
Anaemia requiring blood transfusion
Sometimes patients come in for pain management, social admissions
What I learnt:
- Best place to work as a team, constant support from fellow colleagues and Consultants
- Clerk patients every day, make your own plan of management, discuss it with your Reg/Consultant and then mark it off as a CBD (case base discussion) and mini-CEX (Clinical evaluation exercise)
- Do ACATs (Acute Care Assessment Tools)
- Opportunity to do various procedures (Lumbar puncture, ascitic drain, pleural taps)
- Good mix of cases keep you up to date
Overall, it’s a good learning opportunity and make the most of it when you are working in AMU (Well, that holds true for every rotation). Hope it helps.