Impact of specialist care on clinical outcomes for medical emergencies

Abstract

-General hospitals have commonly involved a wide range of medical specialists in the care of unselected medical emergency admissions. In 1999, the Royal Liverpool University Hospital, a 915-bed hospital with a busy emergency service, changed its system of care for medical emergencies to allow early placement of admitted patients under the care of the most appropriate specialist team, with interim care provided by specialist acute physicians on an acute medicine unit -a system we have termed 'specialty triage'. Here we describe a retrospective study in which all 133,509 emergency medical admissions from February 1995 to January 2003 were analysed by time-series analysis with correction for the underlying downward trend from 1995 to 2003. This showed that the implementation of specialty triage in May 1999 was associated with a subsequent additional reduction in the mortality of the under-65 age group by 0.64% (95% CI 0.11 to 1.17%; P=0.021) from the 2.4% mortality rate prior to specialty triage, equivalent to approximately 51 fewer deaths per year. No significant effect was seen for those over 65 or all age groups together when corrected for the underlying trend. Length of stay and readmission rates showed a consistent downward trend that was not significantly affected by specialty triage. The data suggest that appropriate specialist management improves outcomes for medical emergencies, particularly amongst younger patients. KEY WORDS: acute medicine, mortality, outcome, specialism IntroductionThere is good evidence that patients with acute medical conditions may fare better in respect of a range of clinical outcomes if they are cared for by a medical team whose specialty interest is relevant to their complaint. This has been shown for myocardial infarction, 1 unstable angina, 2 asthma, 3-8 pneumothorax, 9 pleural effusion, 10-11 acute upper gastrointestinal haemorrhage, 12-14 diabetes 15 and stroke. 16 Indeed, it would be a strong indictment of the emphasis on specialty training over the past 20 years if there were no benefit in being looked after by a specialist. Nevertheless, it is common practice in the United Kingdom for patients who are ill enough to warrant emergency admission to be looked after by a specialty team that has been randomly selected according to the day of the week or week of the year, a system that might be termed 'calendar triage' , even though less ill patients, referred to the same hospital for an outpatient opinion, are likely to be seen by the relevant specialists. This widely accepted anomaly has arisen partly as a result of perceived necessity driven by staffing constraints and partly by the need to provide training in general internal medicine. An alternative model, 'specialty triage' , can be developed for the larger general hospital to allow patients admitted as medical emergencies to be placed under the care of the relevant specialty team with initial care directed by specialists in acute medicine. 17 We introduced this system at the Royal Liverpool University Hospital in ...

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