Mariam Alansari MD, FRCSI
Consultant Intensivist, Intensive Care Unit
Salmaniya Medical Complex
Ministry of Health, Manama, Bahrain
In most hospitals, medical services are overstretched and senior house officers (SHOs) in particular, have to spread themselves thinly over what is often a significant number of acutely ill patients. The traditional way in which many consultant physicians work, that does not involve significant components of acute care, adds to the complexity of the problem. Unlike the surgical on-call team, the medical team tends to divide itself, so that the consultant physician continues with elective outpatient work and is rarely involved in the acute admission process. Some physicians certainly have a close interest in acute medicine but maintain a distance from acute work.
As a result, doctors in training are both providing and leading the provision of acute care. The problem has recently been exacerbated in certain hospitals by restricting the role of interns on call. This has made them less available for training and, therefore, less experienced and confident than in the past. As a result, in complex cases, there is an inevitable risk that these doctors may provide care, which is less than optimal.
Problems Abound in Staffing for Acute Care
It may appear then that the solution is the provision of comprehensive and adequate critical care facilities to allow rapid admission of all sick and deteriorating medical patients. But here again there are problems with delays in review of patients and subsequent admission to intensive or high dependency care. In many of these cases the delay is related to a lack of critical care beds or staffing shortages, which result in significant numbers of beds actually being closed on a temporary basis. However, provision of an appropriate environment for acute care is only part of the story. Severely ill patients often exhibit clear signs of clinical deterioration on the wards for some time, subjecting them to potentially avoidable in-hospital cardiopulmonary resuscitation if left undetected or ignored. Although nurses may pick up these simple clinical indicators and call for help, the inevitable delay resulting from SHOs working largely on their own may further delay the instigation of appropriate treatment.
Earlier Intervention Would Lower Death
Sub-optimal care before ICU admission is associated with higher ICU and hospital death rates. It is frequently related to poor management of simple aspects of acute care - those involving the patient’s airway, breathing and circulation, oxygen therapy, fluid balance and monitoring. Other contributory factors include organisation failures, lack of knowledge, failure to appreciate the clinical urgency of a situation, a lack of supervision, failure to seek advice and poor communication. It is well documented that adverse events may be reduced by earlier intervention especially those provided by medical emergency teams. However, effective earlier intervention requires that staff is trained in the care of the acutely ill patient.
Undergraduates Should Learn More About Acute
Competence in caring for these patients should be a clearly defined component of undergraduate level curricula, in order to promote a culture of safe care for the acutely ill. Several previous studies have shown that resuscitation training is neglected in the undergraduate curriculum. To add to this problem, in recently developed courses used by some medical schools to educate undergraduates about acute care and resuscitation, consensus or common standard on this important aspect of student education is lacking.
It is therefore extremely urgent to first introduce these types of curricula in all undergraduate medical schools, and more importantly, use consensus techniques to identify those core competencies in the care of acutely ill patients that medical students should possess at the point of graduation. Recently consensus methods were developed, which could form the basis for an international standard for undergraduate training in acute care (Gavin D. et al). Table 1 summarises these proposed competencies for medical students at the point of graduation.