Ambulatory Emergency Care · 2016-10-21 · Pareto Analysis Glenday Sieve 30% 20 50% of demand 80 = 7% of types: Green stream: ‘Runners’ \ 15% 5% of demand: Red stream: Rare Strangers

Ambulatory Emergency Care

Background

•Ambulatory Emergency Care is a way of managing a significant

proportion of emergency patients on the same day without

admission to a hospital bed

•It is a transformational change in care delivery – AEC has the

potential to be as significant to emergency care as day case

surgery is to elective care

The evolving bed challenge

The evolving bed challenge

Admissions per year

A&E attendances per year

Long stay admissions (RED) and Short stay admissions (YELLOW)

Pareto Analysis

Glenday Sieve

30%

20

8050% of demand = 7% of types:Green stream: ‘Runners’

\

15%

5% of demand: Red stream: Rare Strangers

Sick Specialty

0

100%

Cumulative Demand

LOS

Sick General

Short Stay

Complex

Acute Care Hub

Future hospital: Acute Emergency Care

Key principles of AEC• Senior clinician led and delivered

• Systematic - pathways & processes – maximise AEC use

• Patients awareness of AEC concept

• Capacity to meet demand (Environment/staff/diagnostics)

• Set time standards in place

(15 min - first review, 60 min - medical review, completion within 4 hours)

• Communicate & safety netting - primary care/specialty

Maintaining Quality & Safety

The aim is better quality care

Better pt preparation

Better pt information

Better care

Reduced complications

Reduced waiting

Faster recovery=

Shorter stay

Capacity is

decision makers & action takers

not

cubicles, beds, trolleys, chairs

(Resources)

MINDSET

Models of AEC – 4Ps

• Passive

– receive referrals

• Pathway driven

– restricted to particular agreed pathways

• Pull

– senior clinician takes calls for emergency referrals

• Process driven

– all patients considered for AEC

4 simple questions to identify AEC patients

1. Is this patient clinically stable?

2. Is the patient functionally capable of being managed in the AEC Unit?

3. Would this patient have been admitted to hospital before AEC existed?

4. Could the patient’s needs be better met by another service?

VConnolly

Categories of AEC

1.Diagnostic exclusion group-Non-cardiac CP

2.Low risk stratification group-Low risk UGIB / PE

3.Specific procedural group- Paracentesis, Pleural tap

4.Infra-structural group- Care home admissions

5.Facilitated discharges- F/u of bloods, x-rays, clinical review

Maintaining safety, flow quality & productivity

• Use Measurement to develop an understanding of the service

• AEC activity– Emergency bed days use

– Variation in high volume flow streams

– Adverse event monitoring

– Readmission rate

– Unplanned admissions from AEC

Helping commissioners understand & invest in the potential of AEC (AEC Croydon University Hospital - Activity Impact)

4/28/2016

Helping commissioners understand & invest in the potential of AEC (AEC Croydon University Hospital - Activity Impact)

4/28/2016

4/28/2016

Helping commissioners understand & invest in the potential of AEC (AEC Croydon University Hospital – Changing pathways and processes )

DVT pathway

3.15 appointments per patient (range up to 34!)

1.55 appointments per patient (range up to 6)

• Set an internal target to review all patients within 1 hour of their time or arrival

• 74% patients are seen within one hour (88% within 2 hours)

Helping commissioners understand & invest in the potential of AEC (AEC Croydon University Hospital –Timely Care)

In context with AMU

Helping commissioners understand & invest in the potential of AEC (AEC Croydon University Hospital – Impact on admissions)

Delivering ambulatory emergency care

Patient

Initial contact & assessment

( GP or self present to ED)

Secondary contact assessment Evidence based risk stratification and judgement

/ pathway selection

Access to diagnostics and reporting

Management pathway & locationED ambulatory, ED/CDU ambulatory, Acute Med ambulatory, OPD setting.

Define location and follow up

Define safety netting systems

Leadership

&

Culture

Governance &

safety

Embedded informatics

Robust quality

Improvement systems

Thank you