Acute Care Hospitals

Introduction. Acute care can be defined as the short-term care and treat­ment of patients suffering an episode of serious illness or who have sustained an injury. Across the world, the preferred location for the delivery of this form of care is the hospital.

Hospitals are a ubiquitous human institution, common to all modern societies. However, the form and organization of hospitals varies greatly from country to country, reflecting different cultural, medical, and economic traditions.

Origins and History of Acute Hospitals. A number of European hospitals can trace their roots back to the twelfth century. These were typically founded by religious orders, and usually formed part of an almshouse for the poor and infirm. By the late eighteenth century, similar institutions were becoming more common in larger towns and cities as the process of urbanization and industri­alization began to gather pace in Europe and North America.

However, these hospitals were still seen as places of death, disease, and destitution from which few emerged alive, and were shunned by the wealthy (who were treated at home by their physicians and surgeons). This bleak picture was trans­formed during the nineteenth century as the concepts of hygiene and antisepsis and the beginnings of modern anes­thesia delivered startling improvements in patient survival, so that hospitals began to be seen as a place of safety and healing, rather than a place for the indigent to die.

This transformation was complete by the middle of the twentieth century, as effective antimicrobials greatly reduced the risks of infection, and advances in therapeutic technology steadily improved the clinical outcomes that patients could expect to receive from hospital treatment. Indeed, by the end of the twentieth century, calls for a reduced reliance on hospital care and a concern that acute hospitals may over- medicalize the natural processes of birth, aging, and dying, had become commonplace in many countries.

Roles and Functions of Acute Care Hospitals. Common Functions. An acute hospital is instantly recognizable as such any­where in the world. Yet the precise nature ofthe conditions they treat, the staff who work in them, and their place within the wider health-care system vary substantially.

At their most generic level, the common functions of all acute hospitals can be described as follows:

1. To provide the fixed physical and technological infra­structure required to support care for acutely ill patients, much of which could not be provided (for technical or economic reasons) at a smaller scale of institution or in the patient’s home.

2. To concentrate personnel with specialized and scarce skills onto the same location, allowing them to provide 24-hour care for many patients simultaneously, and to give acutely ill patients rapid access to a wide set of diagnostic and therapeutic skills should their condition change.

Both of these functions fundamentally reflect the exis­tence of some degree of economies of scale and of scope (Posnett, 2002) in the care of acutely sick patients.

However, these economies are not fixed; over time and across continents technologies, processes, and costs will vary substantially. Certainly the mix of patients likely to present at an ‘acute’ hospital of notionally similar size (and the care that can be provided for them) might differ wildly between Canada and Cameroon, for example.

While resource availability will dictate exactly what activities are carried out, any acute hospital will provide the following basic services:
- Initial assessment and stabilization of the acutely ill patient;
- Provision of more definitive diagnosis;
- Immediate/urgent treatment.

What happens next for a patient with a given condition may, however, vary more substantially between different health systems. In some, patients may be hospitalized for longer, receiving treatment and rehabilitation as inpati­ents in the acute hospital; in others, they may be dis­charged to home or nonacute facilities to receive treatment and rehabilitation outside the acute setting.

In some systems, a single acute hospital may provide both urgent and planned care (e.g., elective surgery), while in others planned follow-up care may be provided by different organizations.

Specific Functions. Beyond the most basic function of providing a clinically and economically viable platform for round-the-clock care for acutely ill patients, acute hospitals may often perform a range of other very important roles within the health-care system.

In most countries, acute hospitals form part of a refer­ral system, which allows patients to be referred to increas­ingly specialized levels of care - allowing escalation and de-escalation of care from initial contact with generalist first-contact providers up to highly specialized centers of expertise. In many developing country health systems, an acute hospital may well be the first level of care at which any qualified physicians might be encountered.

Many acute hospitals also play an important role in the educa­tion and training of health professionals, providing practi­cal training opportunities for many different staff groups. However, this role can vary substantially from country to country, reflecting traditions and customs as much as deliberate design.

For example, practically every acute hospital in the United Kingdom’s National Health Ser­vice (NHS) is a training hospital - because almost all NHS hospitals rely heavily on junior doctors who are still in training posts for two years after initial qualifica­tion to provide much of their basic nonspecialist medical cover, and upon specialist registrars (i.e., more experi­enced doctors who are training for accreditation as spe­cialists) to provide much of their specialist care. In many other countries, these doctors would be concentrated in a much smaller proportion of hospitals, which are explicitly designated as university or teaching hospitals.