Dear Editor,

This proposal is the first to suggest the establishment of the new specialty of acute medicine in Sudan. Introducing this specialty will ensure that patients receive the best care in a timely fashion from a well-trained workforce and will aid in delivering optimum care to critically ill medical patients and securing faster, safer, and more effective services. It will provide a comprehensive training program for senior and junior doctors and attract employees by creating more jobs for different specialties (nurses, pharmacists, radiologists, etc.). Further, introducing acute care will help reduce the number of patients who require long-term admission, provide more accessible, holistic, emergency medical care for all socio-economic classes, and empower key stakeholders.

Our proposal involves the unique implementation of two correlated programs. The first focuses on management and leadership, which facilitates the operation of successful acute medical units [AMUs also called acute assessment units (AAUs)] or medical admissions units (MAUs) by doctors and nurses in hospitals.¹ The second involves education and training to develop the knowledge and skills of doctors and to support them in finding a highly motivating career in acute internal medicine. Lastly, we propose the development of twin programmes with the Society of Acute Medicine in the United Kingdom.

Currently, Sudan faces a huge burden of communicable and non-communicable diseases. The non-communicable diseases, such as obesity, type 2 diabetes, renal disease, and cancer, are increasing dramatically and contributing to multimorbidity. However, progress against communicable diseases has been slow, and the burden of chronic and endemic infections remains considerable with parasitic diseases (such as malaria, leishmaniosis, and schistosomiasis) causing substantial morbidity and mortality. Moreover, malnutrition, micronutrient deficiency, poor perinatal outcomes, and antimicrobial resistance are other major threats throughout the healthcare system contributing to chronic diseases.²

Triage systems are insufficient, and patients are allocated poorly within the emergency department. This results in inappropriate initial investigations, drug prescriptions, admissions, and discharges. However, acute medicine physicians, who are experienced and properly trained, can effectively manage this triaging system and allocate patients by directing them to the appropriate medical personnel in the designated area; that is, the acute medical department.

Under this proposal, senior supervisors and other health care professionals who manage acute medical problems would guide junior doctors and improve patient outcomes. Providing 24-hour supervision by medical consultants is difficult to implement. However, a well-established MAU with clear guidelines and appropriately trained mid-grade doctors managing acute medical problems would improve patient safety and medical care with limited out-of-hours senior supervision.^{1, 3} Having a well-trained acute medical consultant present during the day will advance the training of mid-grade doctors and implement evidence-based practice guidelines specific to the Sudanese population. Hence, we consider that the establishment of a UK-based emergency care system (for example, the clear transmission of patient care from the emergency department to a well-established MAU within a four-hour period) serves the above purpose. Acute medicine physicians are trained in the management and can implement a cost-effective approach to tackling medical admission problems; we believe this could be extremely beneficial in Sudan.³

Many acute medicine physicians are trained in performing fast acute medical ultrasound (FAMUS); point of care ultrasound (POCUS); and all have gained one or two specialized skills, such as intensive care, US-guided interventional simple procedures.

Most of the patients in Sudan who require specialist care must wait a long time to be seen by an outpatient clinic with a specific consultant or may need to resort to private medicine for basic care for a condition that a well-trained acute medicine physician could treat the following day in ambulatory care.^{3, 4}

Moreover, there is inadequate auditing of emergency medicine departments’ performance. Acute physicians are well trained (and enthusiastic) to audit the performance of the MAU at any time.⁴

This proposal offers the two following objectives: 1) to support the Ministry of Health of Sudan in taking the initial steps in a long-term program to reform the health system and, 2) to support the Faculty of Medicine and the affiliated university hospital in Sudan under the auspices of the Federal Ministry of Higher Education and Scientific Research and in collaboration with the Ministry of Health.

This project has the following objectives:

1. To introduce a UK-based system of emergency medical care in Sudanese Hospitals by creating acute medical admission units (AMUs, high dependency medical units, and ambulatory care in all secondary care hospitals in Sudan.
2. To introduce acute internal medicine as a specialty to be recognized as a core higher medical specialty in Sudan by the Sudan Medical Specialization Board.
3. To recruit and train registrars to become acute medicine physicians.
4. To recruit general internal medicine consultants to serve as acute medicine physicians to fill the gap in MAUs after a short period of training.
5. To establish a Society of Sudanese Acute Medicine Physicians to set guidelines, targets, and auditing of emergency departments’ performance and to help the Sudan Board of Medical Specialty set a curriculum for training.

Following approval, our proposal encompasses four quarters in which the project will be implemented. In the first quarter, data collection will be undertaken from two or more approved hospitals in different states. The data collected will include the staffing and grade information for each hospital; the number of patients presenting to the emergency department; the number of medical patients who require admission for less than 48 hours; the number of.

In the second quarter, the first Society of Sudanese Acute Physicians conference will be held with the Sudan Ministry of Health members. Subsequently, communication with the Sudanese government regarding the identification of a suitable hospital in which to start the Acute Medical Project together with the need to recruit other healthcare member teams (nursing, physiotherapy, and pharmacy) will commence. The communication will identify the existing resources available and the additional resources required to establish the unit. Further, communication with other societies and institutions, such as nursing schools and pharmaceutical colleges in Sudan.

In the third and fourth quarters, the first Audit of Specific Hospital Performance will occur. The first AMU will be established together with the medical high dependency unit and ambulatory care after receiving approval from the leading Sudanese Society of Acute Physicians (SSAP) committee. Continuous auditing of the first AMU will be conducted. During this phase, planning for another two to three AMUs in other hospitals in Sudan will be formulated.

A potential challenge includes the recruitment of mid- to senior-level medical staff. The medical staff working in the AMU must spend a considerable portion of their time working in the unit per week. The identification of the first AMU location and procuring government approval for the establishment and maintenance of the AMU may be affected by time and resource constraints.

Lastly, a successful AMU would require the collaboration of the accident and emergency department and the critical care team regarding roles in the hospital, systems of referral and communication, and a clear hospital policy established with the management team. It is critical that AMUs must be officially recognised, supported, and adequately funded so that they can become worthwhile units for all hospitals, delivering high-quality care.

Acknowledgement
I would like to thank Editage Services (WKH Author Services), for their support and Dr. Mohammed Ali Homaida, for his kind help and support

References:

1. NICE Guideline [NG 94] Emergency and acute medical care in over 16s: service delivery and organisation March 2018; Available at: https://www.nice.org.uk/guidance/ng94/evidence/24assessment-through-acute-medical-units-pdf-172397464637.
2. Charani E, Cunnington AJ, Yousif AHA, Seed Ahmed M, Ahmed AEM, Babiker S, et al. In transition: current health challenges and priorities in Sudan. BMJ Glob Health 2019 Aug 21; 4(4):e001723-2019-001723. eCollection 2019.
3. Reid LE, Dinesen LC, Jones MC, et al. The effectiveness and variation of acute medical units: a systematic review. Int J Qual Health Care 2016; 28(4):433–446 https://doi.org/10.1093/intqhc/mzw056
4. Scott I, Vaughan L, Bell D. Effectiveness of acute medical units in hospitals: a systematic review. Int J Qual Health Care 2009 Dec; 21(6):397–407 https://doi.org/10.1093/intqhc/mzp045