Ambulatory Emergency Care an update Dr Vincent Connolly Consultant Physician, The James Cook University Hospital Clinical Lead, ECIST Clinical Advisor.

Ambulatory Emergency Care an update

Dr Vincent Connolly

Consultant Physician, The James Cook University Hospital

Clinical Lead, ECIST

Clinical Advisor NHSi AEC Network

Treatment is department dependent………………

• 18 year old with type 1 diabetes

• Symptoms of high blood glucose

• RBG 28

• Urine ketones ++

• ABGs & U&E normal

• What happened next ?

What’s in a name?

• Ambulatory Emergency Care

• Clinical Decisions Units

• Same Day Emergency Care

Admit To Decide: Decide To Admit?

• c50% of emergency in-patient admissions are a result of GP referrals

• Each GP has to refer one extra patient per quarter to produce a 5% rise in Emergency Admissions

• 80% of GP appointments relate to Long term conditions

• 70% of admissions are medical

• 70% of admissions are elderly

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

Update available soon

Row Labels

Total current ambulatory: 0 day

spells

Total ALL ambulatory

spells

Minimum shift Potential:0 Day

Spells

Maximum shift Potential:0 Day

Spells

Ambulatory Potential for all non-0 Day Spells

Sum of Opportunity

- Low (£)

Sum of Opportunity

- High(£)Ealing Hospital NHS Trust 792 1530 82 262.0 17.12% £47,112 £173,152Northumbria Healthcare NHS Foundation Trust 1959 4502 313 1027.3 22.82% £213,940 £723,752Newham University Hospital NHS Trust 804 1892 140 449.1 23.74% £73,386 £247,368Southampton University Hospitals NHS Trust 1401 3290 254 831.8 25.28% £99,746 £459,594Chelsea and Westminster Hospital NHS Foundation Trust 580 1413 100 366.1 25.91% £41,769 £155,899

Airedale NHS Foundation TrustAcute headache 14 9 * * 30 0.0 0% 4.0 13% £0 £0Airedale NHS Foundation TrustAcute painful bladder outflow obstruction* 9 8 * 23 10.8 47% 17.7 77% £3,005 £7,217Airedale NHS Foundation TrustAcutely hot painful joint * * 0 * 8 0.0 0% 1.6 20% £0 £0Airedale NHS Foundation TrustAnaemia 0 * * 6 10 6.0 60% 9.0 90% £6,470 £10,356Airedale NHS Foundation TrustAppendicular fractures not requiring immediate internal fixation* 7 * 11 25 12.0 48% 19.5 78% £6,336 £15,840Airedale NHS Foundation TrustAsthma 6 8 * 16 * 0.1 0% 4.5 13% £0 £288Airedale NHS Foundation TrustCellulitis * * 9 34 51 25.6 50% 40.9 80% £22,553 £37,762Airedale NHS Foundation TrustChest pain 105 105 17 25 252 0.6 0% 46.2 18% £1,428 £2,856

It builds on existing NHS Institute offersData that is available on the NHS Institute website shows the potential tariff savings related to the conditions in the directory for each NHS organisation

We also have the data down to condition level for each organisation

These data suggest that the potential tariff savings related to ambulatory

emergency care is in the region of £373 million per year

…….but its not all about money

• Its about– Improving patient experience– Reducing waits for tests– Early and frequent senior review– Improving patient flow

• And so better outcomes for patient

Day Case Brain

Surgery?

Weidmann & Grundy —J One-day Surg 18: 45, 2008

The Amb Score

FACTORS

1 if applicable

0 if not applicable

Female sex

Age < 80 years

Has access to personal / public transport

IV treatment not anticipated by referring doctor

Not acutely confused

MEWS score = 0

Not discharged from hospital within previous 30 days

TOTAL Amb Score (Maximum 7)

If Score is high, consider re-direct to ambulatory care unit

Ala L, Mack J, Shaw R, Gasson A. The Amb Score: A pilot study to develop a scoring system to identify which emergency medical referrals would be suitable for Ambulatory care management. Acute Medicine 2010; 9: 139 (Abstract)

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

Leicester model for older people

• Elderly Frail Unit / Frail Older People Acute Liaison

• Based in A&E

• Consultant geriatrician

• Single Point of Access

• Comprehensive Geriatric Assessment

• Contact Dr Simon Conroy

Personalised Ambulatory Emergency Care

• Individual Care plans

• Frequent attenders– Addison’s– Diabetes

• Unusual clinical conditions– Acute Intermittent Porphyria– Inherited metabolic Disorders

Retained Clinical Scenarios for Best Practice Tariff

• cellulitis

• pulmonary embolism

• asthma

• acute headache

• chest pain

• lower respiratory tract infections without chronic obstructive

• pulmonary disease

• appendicular fractures not requiring immediate fixation

• renal/ureteric stones

• falls including syncope and collapse

• epileptic seizure (first & known)

• deliberate self harm

• deep vein thrombosis (DVT)

Expanding the list of clinical scenarios covered by the Same Day Emergency Care

best practice tariff to include

• Transient ischaemic attack (TIA)• Community acquired pneumonia• COPD• Supraventricular tachycardias• Minor head injury• Low risk pubic rami• Bladder outflow obstruction• Anaemia• Abdominal pain

Same Day Emergency Care Rates 75th Centile and National Average

BenchmarkingSouth Tees Performance against NHSi Directory

JCUH Acute heart failure guidelines

Acute MI/ventricular tachycardia/ongoing ischaemic chest

pain?

02 sats<95% (<90% if COPD) or critically ill?

Systolic BP≤90?Bleep cardio SpR (bp 9595) for inotrope support/advanced

cardiac care/ECHO

•15l/min high flow O21

Immediate referral to CCU charge nurse, 54801/53624 for angiography/arrhythmia management. Treat VT as ALS

algorithm

Continue ACEi and betablockers if commenced pre-admission.

Usual heart failure algorithm.

Clear chest or BNP<100?

Consider alternative diagnosis(although, if shocked, may be in low output cardiac

failure)

•iv GTN infusion 10µg/min, increase up to 100µg/min till SBP ≈100mmHg 2•iv furosemide 50mg. •Consider morphine if acutely distressed or in pain 3.•Reassess frequently. Close monitoring, including urine output.

•Non-invasive ventilation if pH<7.35 or pO2<8 despite high flow O2 4 •Further 50mg iv furosemide.•Senior medical review (reg/consultant/staff grade).•Refer cardiology registrar & ECHO urgently•If hypoxic/acidotic despite NIV/aggressive medical therapy, refer to ITU for possible ventilation

Yes

Improving

No

No

No

No

Not improving

Neil Swanson, Nov 2010, v1.23

Brief history and examination, ECG, CXR, BNP, FBC, U&E, LFT, glucose, ABGIf clinical diagnosis of acute heart failure AND

SBP<90/shock or pulm. oedema with widespread creps or p02<8 or pH<7.35then treat urgently as below:

If none of the above, use normal heart failure algorithm.

then

Yes

Yes

Yes

30 minutes

Developments In Acute MedicineEnvironment changes

in collaboration with the PCT

Funded clinic facility– 4 trolleys– 4 consulting rooms– Staff room– Storage area– Waiting area– Discharge lounge

Out of Hours Primecare centre

Space

• On average the AAU clinic receives 23 patients per day

• Procedure room - development

36004223 4642

5266 55266300

01000200030004000500060007000

2003 2004 2005 2006 2007 Sep-08

AAU clinic activity

DayDay AMAM PMPM

MondayMonday 1.Nurse Led DVT / PE clinic 1.Nurse Led DVT / PE clinic

2. Gastro clinic2. Gastro clinic

1. TIA clinic 1. TIA clinic

2. Dr Nag Diabetes and GM clinic2. Dr Nag Diabetes and GM clinic

TuesdayTuesday 1. Nurse Led DVT / PE clinic 1. Nurse Led DVT / PE clinic

2. Dr Hamad Thromboembolic Disease and Heat 2. Dr Hamad Thromboembolic Disease and Heat Failure clinicFailure clinic

1.TIA clinic 1.TIA clinic

2. Dr Guhan Pleural Disease clinic2. Dr Guhan Pleural Disease clinic

WednesdayWednesday 1. Nurse Led DVT / PE clinic1. Nurse Led DVT / PE clinic 1.TIA clinic1.TIA clinic

2. Dr Guhan Chest clinic 2. Dr Guhan Chest clinic

3. Dr Whitfield GM clinic3. Dr Whitfield GM clinic

Thursday Thursday 1. Nurse Led DVT / PE clinic 1. Nurse Led DVT / PE clinic

2. Dr Hamad Thromboembolic Disease and GM 2. Dr Hamad Thromboembolic Disease and GM clinicclinic

1. TIA clinic 1. TIA clinic

2. Dr Whitfield Chest and GM clinic2. Dr Whitfield Chest and GM clinic

Friday Friday 1. Nurse Led DVT / PE clinic1. Nurse Led DVT / PE clinic 1. TIA clinic 1. TIA clinic

2. Dr Connolly- Dr Hamad GM clinic2. Dr Connolly- Dr Hamad GM clinic

Measures of quality in Acute Medicine

No of cases Trust Peer

Risk adjusted mortality 24,074 87 93

Ave LoS 38,879 3.6 4.8

Risk adjusted LoS 17,539 86 96

Complication rate 134 0.4% 1.0%

Readmissions 3,182 10.1% 10.3%

CHKS data

How to get started• Location, location, location

– Ideally close to A&E & AAU– Waiting facilities– Consulting rooms– Trolleys

• People– Enthusiastic capable clinicians, nurse practitioners– HCAs/generic workers– Senior management

• Diagnostic support– Pathology– Radiology

• Clinical guidleines/algorithims/patient flow– Agreed

• Clinical Outcomes & Process Measures– Activity

Services which can be linked to Ambulatory Care

• Chronic obstructive pulmonary disease outreach• Pleural diseases clinics• Rapid access chest pain clinics• Transient ischaemic attack/stroke clinics• Epilepsy clinic• Pain management service• Functional assessment and support teams• Diabetes nurse specialist• Falls clinic• Macmillan nurses• Outpatient parenteral antibiotics team• Endoscopy services• Heart failure team

Ambulatory emergency care in the future

• Default point of “admission” based on pre-specified clinical presentations and/or low EWS

• Greater involvement of non-acute medicine specialties

• Improved links with primary care for follow up and prevention strategies eg multiple attenders

• Extended hours• Telemedicine support• Acute Oncology Service• Readmission avoidance

Don’t get admitted !

If you would like to find out more….

If you would like to find out more or join the next Ambulatory emergency care delivery network, starting in Autumn 2012, please email us and we would be happy to talk to you:

[email protected]

[email protected]

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HRG delivery of Ambulatory Care

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