The importance of the first 48 hours in producing successful outcomes for acutely ill patients cannot be underestimated. The definition of a successful outcome depends on who is measuring it. Clinicians look for successful diagnosis and treatment, governance directors look for safety and use of pathways and guidelines, educators look for training opportunities, managers want to decrease length of stay, whereas patients (usually) just want to get better and go home. The problem is how to deliver on all of these fronts.1

The traditional model of delivering acute care for medical patients, who make up the bulk of acute admissions to hospital, has been slowly changing. The older model of a hierarchal medical team has begun to disappear.2 There have been many drivers to this change. In the United Kingdom changing patterns in the availability of junior doctors (such as the European Working Time Directive and the Modernising Medical Careers project (www.mmc.nhs.uk/pages/home)) has led to team fragmentation and multiple handovers of acutely ill patients.3 A growing deficit of primary care after normal working hours has meant an increase in hospital admissions at night. The imposition of a maximum stay of four hours in emergency …