-A cornerstone of the development of acute medicine has been the principle of consultant presence within the acute medical unit (AMU). There is the hypothesis that consultant supervision improves patient care. This view is not currently supported by firm scientific evidence. When Ipswich AMU opened in 2004, there was a consultant presence on some weekdays only. Admission data were collected and assessed with respect to the presence or absence of the consultant. Overall length of stay was significantly lower, by a mean of 1.3 days, when there was a consultant present, and 9% more patients were discharged on the same day of their assessment (95% confidence interval 5.7% to 12.6%, pϽ0.001) without affecting readmission or mortality. These results suggest the absence of a consultant leads to fewer same-day discharges and causes the inappropriate admission of patients not needing inpatient management. Further study is required to determine whether these findings are shared by other AMUs.

In acutely ill NH residents, MEWS is an important predictor of early hospital mortality and can be used in both the community and the hospital settings to identify patients whose death maybe predictable or unavoidable, thus allowing a more holistic approach to management with discussion with patient and relatives for planning of immediate care. In addition, CRP and eGFR levels on admission have also been shown to predict early hospital mortality in these patients and can be used in conjunction with MEWS in the same way to allow decision making on the appropriate level of care at the point of hospital admission.

Simple and readily available hospital admission parameters predict not only the in-patient mortality but also longer term outcome for NH residents who require acute hospital admission. Further studies are required to examine whether opportunities exist to intervene and improve outcome in this patient population.

Whilst the admission characteristics are similar between younger and older patients from NHs, there is evidence to suggest worse long-term survival prospects for oldest old patients.

Poisoning is a common presentation to hospital acute medical units, and can produce a variety of clinical scenarios. This review discusses the epidemiology of poisoning, a framework for managing patients with drug toxicity and considerations in the diagnosis of toxicity with unknown substances. The commonest substances seen in toxicity in the UK – paracetamol, antidepressants, sedatives and opioids are discussed in more detail.