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We read with interest the paper by Smith and Poplett.1 We agree that trainee doctors appear to have significant gaps in their knowledge and understanding of acute care. At our hospital, before the introduction of the ALERT course2 for pre-registration house offices (PRHOs) and nurses on the general surgical wards, a questionnaire was completed by a group of medical and nursing staff. The aim of the questionnaire was to identify how confident staff felt in caring for critically ill ward patients, and any particular areas of perceived knowledge or skill deficit. Clinical scenarios were used and respondents were asked to rate on a scale of 1 (low) to 5 (high), their level of confidence. For example, one scenario describes a postoperative patient after total colectomy, who has an epidural in situ. The patient is hypotensive, oliguric, and pyrexial.
The PRHOs felt reasonably confident (mean score 3.5) about assessing the patient’s fluid status clinically, identifying the likely causes of hypotension and oliguria, and assessing the response to fluid challenges and interpretation of central venous pressure readings. They were more confident (mean score 4.0) about assessing arterial blood gases, performing 12-lead electrocardiography, and recognising arrhythmias, and knowing the differences between colloids and crystalloids.
They lacked confidence (mean score 2.6) about practicalities such as using a pressure bag to rapidly infuse fluids, and in their knowledge of the cardiovascular effects of epidurals. Nursing staff however perceived a different pattern of knowledge and skill deficits.
While these are subjective self assessments of knowledge and skill relating to the management of critically ill patients, this model has allowed us to tailor educational strategies to target areas of perceived need.
During the introduction of the ALERT course in our hospital, we were interested to see what impact if any, there would be on the PRHOs management of acutely ill patients. After running a number of ALERT courses we noticed that the documentation by PRHOs in the medical notes appeared to be more structured, following an A, B, C-type approach. A small audit of the medical reviews of sick ward patients by PRHOs, before and after introduction of ALERT, appeared to confirm this. An arbitrary scoring system was devised and points were awarded for the documentation of details such as reviewing doctor’s name, contact details, respiratory rate, capillary refill, etc. From a possible total score of 12, the mean score before ALERT was 4.54 and after ALERT was 7.75, an improvement of 70%.3
Using a combination of generic critical care training such as ALERT and specific targeted educational packages as part of critical care outreach, does appear to improve the management of sick ward patients by PRHOs.
The comments of both Jolobe and Hutchinson and Robson complement the message of our paper—that is, that there is room for improvement in aspects of acute care of patients.1 We believe that, as well as an inadequate level of knowledge by trainees, factors such as poor or late recognition of disordered physiology, suboptimal clinical management, poor communication, poor record keeping, and lack of teamwork lead to deficiencies in care. All of these topics are discussed in the one day, multiprofessional, acute care course, Acute Life-threatening Events—Recognition and Treatment (ALERT),2 now running in over 80 UK hospitals and being praised by the Commission for Health Improvement,3 British Medical Association,4 and others. As with any educational course, it is difficult to prove a positive effect of ALERT training on practice. However, just as Hutchinson and Robson believe that they have identified improved note keeping, we have unpublished evidence that suggests greater team work and cooperation between ward nurses and PRHOs after attendance at an ALERT course. This is now being studied in detail with the help of the Department of Psychology at the University of Portsmouth and we are also currently analysing the effect of attendance at an ALERT course on trainee doctors’ knowledge of acute care topics.
We agree with Jolobe that systems such as the Modified Early Warning Score (MEWS)5 have an extremely important part to play in identifying sick ward patients, as there is already widespread evidence of patients’ abnormal physiology being charted for many hours without intervention. However, such systems can only affect clinical outcome if there is an appropriate response to high scores with associated changes in clinical management. This usually means the early involvement of a critical care outreach service but, as these services are not universally present 24 hours a day, there must also be improved education of ward staff to enable them to deal locally with the identified problems.
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