Coping with pressures in acute medicine. The Royal College of Physicians Consultant Questionnaire Survey

To assess the impact of reduced junior doctors' hours and increasing emergency admissions on patterns of acute medical care, and to evaluate recent innovations.

Questionnaire survey of all 2,980 consultant physicians in England, Wales and Northern Ireland potentially involved in acute medicine. The response rate was 63% with 1,3632 respondents undertaking unselected takes.

WORKLOAD: The median average number of admissions per 24 h was 20-24, but 25% of consultants admitted > or = 30. The median frequency of take duties was 1 day in 5. COMPOSITION OF RESIDENT MEDICAL TEAMS: The most common permutation was one specialist registrar (SpR), senior house officer (SHO) and house physician (HP), coping with 20 admissions on average. However, the teams of 25% of respondents did not include a SpR, and 9% consisted solely of one SHO and one HP, with an average 17 admissions. PARTIAL SHIFT ROTAS: Forty-two per cent of consultants had introduced these. Most were critical of them because of their adverse impact on continuity of care and junior staff training, and their unpopularity with trainees. PATTERNS OF CARE: Only 10% of consultants indicated that myocardial infarction patients were managed exclusively by a cardiological team. Forty per cent operated an age-limit (varying between 65 and 85) for admission under care of the elderly physicians. Seventy per cent had introduced an admissions ward. NEW INITIATIVES TO COPE WITH ADMISSIONS: These included twice-daily consultant take rounds, use of nurse practitioners and staff-grade doctors, 12-hour takes and ward-based admission schemes. Measures to expedite discharges included 'discharge lounges', nurse facilitators, low-dependency wards and 'hospital at home' schemes.