• critical care
• acute severe respiratory disease
• non-invasive ventilation
• clinical governance

In the early 1960s the first coronary care units (CCU) were established and are now a “given” in every hospital admitting patients with acute cardiac disease. For patients admitted to hospital with physiological disturbance due to non-acute cardiac medical conditions, the only options are usually either admission to an intensive care unit (ICU) or to a general medical ward. Inevitably, given the differences in staffing and facilities with one nurse looking after one patient with comprehensive physiological monitoring on the ICU compared with perhaps only two or three nurses looking after 30 patients at night with minimal continuous monitoring on a general medical ward, some patients will be admitted to the ICU who could be managed elsewhere. This is economically disadvantageous. Alternatively, patients may be looked after in an area in which proper care is not possible. This is an issue of standards of care and clinical governance. In the UK there are a number of drivers towards improving the acute care for medical patients including two recent reports—one from the Royal College of Physicians of London¹ and the other from the NHS Modernisation Agency.² Patients with respiratory failure constitute a significant proportion of medical admissions and the development of appropriate services for these patients is important from both the clinical governance and the economic perspectives. The provision of appropriate facilities for patients with acute severe respiratory disease is not just an issue in the UK.³