Ambulatory Emergency Care an update

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Ambulatory Emergency Care an update

• Dr Vincent Connolly
• Consultant Physician, The James Cook University
  Hospital
• Clinical Lead, ECIST
• Clinical Advisor NHSi AEC Network

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Treatment is department dependent

• 18 year old with type 1 diabetes
• Symptoms of high blood glucose
• RBG 28
• Urine ketones
• ABGs UE normal
• What happened next ?

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Whats in a name?

• Ambulatory Emergency Care
• Clinical Decisions Units
• Same Day Emergency Care

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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

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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
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It builds on existing NHS Institute offers
Data 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
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.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

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Day Case Brain Surgery?
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The Amb Score?
FACTORS 1 if applicable 0 if not applicable
Female sex
Age lt 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)
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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

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Leicester model for older people

• Elderly Frail Unit / Frail Older People Acute
  Liaison
• Based in AE
• Consultant geriatrician
• Single Point of Access
• Comprehensive Geriatric Assessment
• Contact Dr Simon Conroy

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Personalised Ambulatory Emergency Care

• Individual Care plans
• Frequent attenders
• Addisons
• Diabetes
• Unusual clinical conditions
• Acute Intermittent Porphyria
• Inherited metabolic Disorders

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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)

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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

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Same Day Emergency Care Rates 75th Centile and
National Average
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Benchmarking South Tees Performance against NHSi
Directory
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• JCUH Acute heart failure guidelines

Brief history and examination, ECG, CXR, BNP,
FBC, UE, LFT, glucose, ABG If clinical diagnosis
of acute heart failure AND SBPlt90/shock or pulm.
oedema with widespread creps or p02lt8 or
pHlt7.35 then treat urgently as below If none
of the above, use normal heart failure algorithm.
Acute MI/ventricular tachycardia/ongoing
ischaemic chest pain?
Immediate referral to CCU charge nurse,
54801/53624 for angiography/arrhythmia
management. Treat VT as ALS algorithm
Consider alternative diagnosis (although, if
shocked, may be in low output cardiac failure)
Clear chest or BNPlt100?
Bleep cardio SpR (bp 9595) for inotrope
support/advanced cardiac care/ECHO
Systolic BP90?
02 satslt95 (lt90 if COPD) or critically ill?

• 15l/min high flow O21

then
No

• 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.

30 minutes
Improving
Not improving
Continue ACEi and betablockers if commenced
pre-admission. Usual heart failure algorithm.

• Non-invasive ventilation if pHlt7.35 or pO2lt8
  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

Neil Swanson, Nov 2010, v1.23
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Developments In Acute MedicineEnvironment
changesin 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

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Space

• On average the AAU clinic receives 23 patients
  per day
• Procedure room - development

Day AM PM
Monday 1.Nurse Led DVT / PE clinic 2. Gastro clinic 1. TIA clinic 2. Dr Nag Diabetes and GM clinic
Tuesday 1. Nurse Led DVT / PE clinic 2. Dr Hamad Thromboembolic Disease and Heat Failure clinic 1.TIA clinic 2. Dr Guhan Pleural Disease clinic
Wednesday 1. Nurse Led DVT / PE clinic 1.TIA clinic 2. Dr Guhan Chest clinic 3. Dr Whitfield GM clinic
Thursday 1. Nurse Led DVT / PE clinic 2. Dr Hamad Thromboembolic Disease and GM clinic 1. TIA clinic 2. Dr Whitfield Chest and GM clinic
Friday 1. Nurse Led DVT / PE clinic 1. TIA clinic 2. Dr Connolly- Dr Hamad GM clinic
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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
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How to get started

• Location, location, location
• Ideally close to AE 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

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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

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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

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Dont get admitted !
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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
• emergencycare_at_institute.nhs.uk
• vincent.connolly_at_stees.nhs.uk

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Impact of Consultant Streaming
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HRG delivery of Ambulatory Care
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