Objective: To assess the value of cusum analysis in hospital bed management. Design: Comparative analysis of medical patient flows, bed occupancy, and emergency department admission rates and access block over 2 years. Setting: Internal Medicine Services and Emergency Department in a teaching hospital. Interventions: Improvements in bed use and changes in the level of available beds. Main outcome measures: Average length of stay; percentage occupancy of available beds; number of patients waiting more than 8 hours for admission (access block); number of medical patients occupying beds in non‐medical wards; and number of elective surgical admissions. Results: Cusum analysis provided a simple means of revealing important trends in patient flows that were not obvious in conventional time‐series data. This prompted improvements in bed use that resulted in a decrease of 9500 occupied bed‐days over a year. Unfortunately and unexpectedly, after some initial improvement, the levels of access block, medical ward congestion and elective surgical admissions all then deteriorated significantly. This was probably caused by excessive bed closures in response to the initial improvement in bed use. Conclusion: Cusum analysis is a useful technique for the early detection of significant changes in patient flows and bed use, and in determining the appropriate number of beds required for a given rate of patient flow.

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SirMr Pollock's Review in this issue (Br J Surg 1993; 80: 964-6) makes

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Teaching trauma management Sir In reference to the article on teaching trauma management in the accident and emergency department (Williams et al., 1991), we are concerned that it may perpetuate the myth that junior staff can and indeed should continue to manage critically injured patients. Many studies have shown that preventable trauma deaths can be reduced from 20-30% to less than 5% with appropriate organizational and staffing changes (Cales et al., 1985; Kreis et al., 1986). The management of major trauma presents a complexity of diagnostic and therapeutic decisions, in addition to requiring skill in multiple invasive procedures that cannot reasonably be expected of junior staff. The ATLS Programme teaches a basic approach to initial trauma care but in no way confers expertise on the participants and is therefore no substitute for management by experienced senior staff. The suggestion that an abbreviated version of ATLS might represent any type of solution to the problem of trauma care by junior doctors is unrealistic. Major trauma is a disease which demands the immediate presence of trained and experienced senior medical staff. Trauma centres, so favoured in the U.S.A., may not be a practical or economic solution in the U.K. environment with its comparatively low rates of trauma. However, redressing the serious imbalance in the ratio of junior to senior medical staff (10:1) in U.K. accident and emergency departments illustrated by Williams would improve the care of all critical and injured patients, not just those with major trauma, and must therefore represent an essential strategy.