Part B - Health Facility Briefing and Planning

330 - MEDICAL ASSESSMENT UNIT (ADDENDUM TO 340

INPATIENT ACCOMMODATION UNIT)
Revision 1.0, 28 June 2012

INDEX

330.0.10 INDEX 1
INTRODUCTION 2
Preamble 2
Introduction 2
Description of Unit 2
PLANNING 5
Operational Models 5
Operational Policies 5
Planning Models 6
Functional Relationships 6
REFERENCES 8
References and Further Reading 8

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330 - Medical Assessment Unit (Addendum to 340 Inpatient Accommodation Unit), Rev 1.0, 28 June 2012
INTRODUCTION
Preamble

330.1.00 PURPOSE OF GUIDELINE

This is a new Health Planning Unit (HPU) addendum to the Inpatient Accommodation
HPU guideline (IPU 340) written for Australasian use in 2011. Its development has
been informed by an extensive consultation process. This Health Planning Unit
(HPU) has been developed for use by project staff (architects, planners, engineers,
project managers and other consultants) and for end users, to facilitate the process of
planning and design.

Introduction

330.2.00 GENERAL
This Addendum outlines the specific requirements for the planning and design of a
Medical Assessment Unit (MAU). Similar requirements would apply for a Surgical
Assessment HPU.

Description of Unit

330.3.00 DESCRIPTION OF HEALTH PLANNING UNIT (HPU)

MAUs are designated units, specifically staffed and equipped to receive medical
patients for assessment, care and treatment for a designated period prior to transfer
to inpatient wards or discharged home (IMSANZ, 2006).
The designated period varies according to the operational policy of the facility but is
generally 24 to 48 hours.

330.3.05 A number of names for this type of unit have been used across jurisdictions in
Australia and New Zealand. These include:
- acute assessment unit (AAU);
- acute medical and planning assessment unit (AMAPU);
- acute medical ward (AMW) or unit(AMU);
- admission planning unit (APU);
- emergency extended care unit (EECU);
- medical assessment and coordination unit (MACU);
- medical assessment planning unit (MAPU); and
- rapid assessment and planning unit (RAPU).
Other names used elsewhere in the world include:
- acute admissions unit;
- clinical decision unit;
- multi-speciality assessment area;
- medical receiving unit; and
- emergency receiving unit.

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330 - Medical Assessment Unit (Addendum to 340 Inpatient Accommodation Unit), Rev 1.0, 28 June 2012
330.3.10 These units differ from emergency department (ED) short stay observation units
(SOU) and emergency medical units (EMU), as they are supervised by ED staff and
involve patients whose length of stay is expected to be less than 24 hours. (IMSANZ,
2006).

330.3.15 OBJECTIVES
The objectives of a MAU are to:
- streamline the process of admission for non-critically ill medical patients with
complex problems, including patients who have medical illnesses but present
with conditions where it is diagnosis is unclear;
- expedite rapid and comprehensive multidisciplinary assessment of acute medical
patients;
- facilitate early consultant and/or senior medical registrar review (including that
performed by subspecialty services);
- improve access to laboratory, radiology and other clinical investigative services;
- improve access to aged care assessment, community health nurse review and
other clinical management resources;
- improve links with general practitioner and community service providers;
- enhance capacity of emergency departments (ED) by the early identification of
non-critically ill undifferentiated medical patients (and the assessment, admission
and supported discharge processes involved in managing these patients) to
MAU;
- maximise optimal bed management by creating alternative care pathways which
obviate need for hospitalisation such as hospital in the home, respite care or
nursing home services etc;
- reduces the need for outlier patients located in wards separate from home wards,
and eliminate inefficiencies from misdistribution of admitted patients;
- standardise care on the basis of agreed care protocols, procedures and
guidelines; and
- facilitate clinical and health services research into care of acutely ill patients.

330.3.20 BENEFITS
If these objectives are achieved, the flow-on benefits include:
- for patients:
- more appropriate and timely care,
- more rapid assessment,
- earlier diagnosis and treatment;
- a reduction in unnecessary admissions and investigations; and
- a reduced length of stay;
- for staff:
- a more organised work environment;
- a significant increase in medical and nursing morale;
- more effective discharge planning;
- improved access to investigation and information technology;
- greater interdisciplinary interaction;
- increased exposure of junior medical staff to training opportunities in
acute medicine; and
- more suitable shift systems for better rostering;

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 - for the hospital:
- significant reduction in admission delay with streamlined admission
processes;
- reduced access block to inpatient beds with flow-on benefits to ED
efficiency;
- improved bed management with buffer bed capacity for acute medical
patients at times of excess caseloads;
- improved risk management as a result of standardised management
protocols and clinical handover involving ED staff and medical staff;
- more effective use of resources with considerable saving in inpatient bed
days; and
- greater retention of staff with enhanced team spirit (IMSANZ 2006).

330.3.25 PATIENT CHARACTERISTICS

The unit deals with admissions only – principally from the emergency department or
ED triage, but also by direct referral from primary care providers, ambulatory care
clinics and specialist rooms. Generally patients should be assessed as triage
category 3 to 5. Other patients may be admitted if it is thought they may be
discharged home within, or close to 48 hours after presentation, or if they would
benefit from comprehensive medical assessment in the first 24 hours of an
anticipated admission to an inpatient unit.
Patients not eligible for admission include those who, as a result of clinical indication
or ED admitting policy may be admitted directly to a critical care or another specific
inpatient unit, or are likely to require an inpatient stay of more than 36 hours.
Patients managed within the MAU need a further period of intensive assessment or
investigation and observation, but not necessarily admission to an inpatient unit or
highly specialised area. The ranges of conditions include those that:
- require repeated diagnostic assessment (laboratory, radiology and other clinical
investigative services);
- treatments not routinely provided in an ED;
- patients with complex or undifferentiated conditions who may require lengthy
evaluation, serial review or investigation, or where the need for intervention is
unclear;
- rapid and comprehensive multidisciplinary assessment (for example, acute
medical patients, chronic disease management, aged care, community health
and other clinical management resources);
- prolonged observation for conditions expected to resolve within 12 to 24 hours;
- those likely to respond to a brief course of therapy, which then can be modified
so that treatment can be continued at home or another community setting; and
- those needing early specialist review by a consultant and/or senior medical
registrar, including that performed by subspecialty services.

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PLANNING
Operational Models

330.4.00 MODELS OF CARE:

MAUs have been developed as part of a strategy to address demand pressures and
improve access to EDs. The model of care for a MAU should also be based on a
clear description of:
- patient criteria;
- admission and discharge processes;
- procedures for the management of clinical conditions;
- skill and resourcing requirements to ensure quality care for patients, including
support required from inpatient specialties and diagnostics, and from social
services and community health services; and
- specific criteria and time limits for referrals, review and departures.
They should avoid:
- the potential to increase ‘intra-hospital transfers’ that can increase length of stay,
duplication, and reduce continuity of care; and
- inappropriate admissions due to bed pressures elsewhere in a health service.

Operational Policies

330.5.00 ADMISSIONS AND DISCHARGE

Admissions policies will be determined by the level of service offered by the facility as
well as the availability of support services. Policies should be developed which detail
the admission and discharge criteria of patients, and aim to manage patient flow and
minimise access and exit block. These should be consistently applied, focussing on
the designated patient conditions and limiting the period for observation and
treatment. There should also be protocols for retrieving patients, and for transferring
patients to other specialised units for more comprehensive patient care when
necessary.
Typically, MAUs aim to discharge patients, either home or to other wards, no later
than 48 hours after admission.

330.5.05 CLINICAL MANAGEMENT

Management responsibility generally lies with general or specialist inpatient units and
focuses on multidisciplinary early assessment and decision making, and on proactive
planning and intervention. These units concentrate on patient assessment and
planning activities that streamline care processes, reduce the risk of prolonged
hospital stay or readmission, and facilitate early discharge.

330.5.10 STAFFING
A MAU is characterised by frequent clinical and/or specialist reviews to deliver care
and ascertain readiness for departure. Staffing levels should reflect the intensive
nature of service delivery. In particular, there should be sufficient numbers of
experienced staff with skills in rapid assessment and decision-making to determine a
patient’s need for admission or discharge. The presence of senior clinicians is
important to support rapid decision making, accountability for unit processes, and
regular review of patients. Regular (at least once daily) consultant or senior medical

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330 - Medical Assessment Unit (Addendum to 340 Inpatient Accommodation Unit), Rev 1.0, 28 June 2012
 staff led ward rounds should be carried out (Department of Human Services 2009).
A MAU should be staffed as follows:
- the unit should be under the overall direction of a designated Medical Director;
- dedicated medical MAU staff forming a medical acute assessment team (MAAT);
- a multi-skilled, highly qualified nursing workforce to support the clinical
management of these patients;
- dedicated allied health staff which may include occupational therapists;
physiotherapists; social workers and access to a pharmacist, speech pathologist,
dietetics services and other allied health staff as required; and
- clerical and support staff.

Planning Models

330.6.00 LOCATION
The MAU should be located within a distinct area to maintain focus on intensive
planning and intervention, and beds quarantined for unit patients only.

330.6.05 CONFIGURATION / LAYOUT

The size and configuration of a MAU is dependent upon local policies, guidelines and
conditions.
Generally, facilities should be aligned with an inpatient unit, rather than an extension
of the ED, as patients may be in MAU for two days. There should be processes to
refer and admit from the ED as required. The level of complexity of the unit requires
high nursing care, and function as a close observation unit. All beds should be
capable of some degree of flexible monitoring capacity. At risk or unstable patients
should be managed in a high dependency (HDU) or intensive care unit (ICU), and not
MAU.

330.6.10 BEDROOM MIX

Determination of the ideal mix of single bed rooms and multi-bed bays is considered
to be outside the scope of this guideline, and may be decided by individual
jurisdictions on a project by project basis.

330.6.15 CLINICAL SUPPORT

The MAU should have access to an appropriately stocked pharmacy; access to
consulting rooms for ambulatory assessment and to support acute follow up clinics;
and a procedures room.

330.6.20 EQUIPMENT REQUIREMENTS

Specialised equipment may be required, including cardiac monitoring, as should
access to stress testing; occupational therapy and physiotherapy equipment.

Functional Relationships

330.7.00 EXTERNAL
A MAU should be closely related to the ED. Local policies will determine which
clinical service will manage the Unit.
The MAU should have same day access to diagnostic services. These may include:
- medical imaging;

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330 - Medical Assessment Unit (Addendum to 340 Inpatient Accommodation Unit), Rev 1.0, 28 June 2012
 - pathology;
- endoscopy;
- stress testing;
- cardiology;
- nuclear medicine; and
- neurophysiology.

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330 - Medical Assessment Unit (Addendum to 340 Inpatient Accommodation Unit), Rev 1.0, 28 June 2012
REFERENCES
References and Further Reading

330.8.00 SERVICE PLANNING

- Booz Allen Hamilton, Key Drivers of Demand in the Emergency Department,
NSW Health 2007;
- Capital and Coast District Health Board (NZ), Medical Redesign – Medical
Assessment and Planning Unit, Capital and Coast District Health Board, 2008;
- Melbourne Health, Models of Care to Optimise Acute Length of Stay: SOU,
MAPU, EMU, Clinical Epidemiology & Health Service Evaluation Unit, 2004;
- Melbourne Health, Short Stay and Observation Units in Victorian Hospitals,
Clinical Epidemiology & Health Service Evaluation Unit, 2001;
- NSW Health, Clinical Services Redesign Program, Surgical Acute Rapid
Assessment Unit (SARA), NSW Health Department, 2008;
- NSW Health, Clinical Services Redesign Program, Models of Emergency Care,
NSW Health Department, 2006;
- SA Department of Human Services, Emergency and Trauma Services
Implementation Plan 2001-2011, Department of Human Services 2000; and
- WA Department of Health, Analysis Of Demand And Utilisation Of Metropolitan
Emergency Departments In Western Australia, WA Department of Health June
2006.

330.8.05 DESIGN AND TECHNICAL GUIDELINES

- American College of Emergency Physicians, Management of observation units,
Annals of Emergency Medicine, June 1995;25:823-830;
- Internal Medicine Society of Australia and New Zealand, Standards for Medical
Assessment and Planning Units in Public and Private Hospitals, ISMANZ, 2006;
- NSW Health, Clinical Services Redesign Program, New Models of Emergency
Care: Reference Guide – Short Stay Units, NSW Health Department, 2006;
- Victorian Government Department of Human Services, Observation Medicine
Guidelines, Department of Human Services, 2009; and
- Victorian Government Department of Human Services, Observation medicine
self-assessment tool, Department of Human Services, 2009.

330.8.10 GENERAL REFERENCE

- NSW Medical Assessment Unit (MAU) Operational Guidelines, NSW Health;
- NSW Key Performance Indicators, Medical Assessment Unit (MAU);
- Health Performance Improvement Branch & Demand & Performance Evaluation
Branch, NSW, May 2009;
- ACT Health, Medical Assessment And Planning Unit (MAPU) Referral Flowchart,
ACT Health, 2008;
- Browne G J, A short stay or 23-hour ward in a general and academic children’s
hospital: Are they effective?, Pediatric Emergency Care 2000, Vol 16 no 4;
- Cooke MW, Higgins J, Kidd P, Use of emergency observation and assessment
wards: a systematic literature review, Emergency Medicine Journal, 2003;20:138-
142; and
- Devine G, MAPU at RMH An integrated model of care for general medical
patients, presentation Royal Melbourne Hospital 2009.
- Goodacre S W, Role of the short stay observation ward in accident and

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 emergency departments in the United Kingdom, Journal of Accident and
Emergency Medicine 1998;15:26-30.
- Henley J, Medical Assessment Units – An Overview, Presentation 2009
- John Hunter Hospital, Medical Assessment and Coordination Unit (MACU) Fact
Sheet, Hunter New England Health, 2008
- The Prince Charles Hospital Queensland, Early Assessment Medical Unit (EMU)
Information for patients and relatives and Information for General Practitioners,
brochures, The Prince Charles Hospital.
- Russell D, Medical Assessment Units: Improving Care & Flow for Medical
Patients, Presentation Royal Melbourne Hospital 2009.
- Scott I, Vaughan L, Bell D, Effectiveness of acute medical units in hospitals: a
systematic review, International Journal for Quality in Health Care 2009; Volume
21, Number 6.

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