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 Update available soon 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

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

…….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

Weidmann & Grundy — J One-day Surg 18: 45, 2008 Day Case Brain Surgery?

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 Pathway driven Pull Process driven 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

Benchmarking South Tees Performance against NHSi Directory

JCUH Acute heart failure guidelines Brief history and examination, ECG, CXR, BNP, FBC, U&E, LFT, glucose, ABG If clinical diagnosis of acute heart failure AND SBP<90/shock or pulm. oedema with widespread creps or p02<8 or pH<7.35 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 Yes No Consider alternative diagnosis (although, if shocked, may be in low output cardiac failure) Clear chest or BNP<100? Yes No Bleep cardio SpR (bp 9595) for inotrope support/advanced cardiac care/ECHO Systolic BP≤90? Yes No 02 sats<95% (<90% if COPD) or critically ill? Yes 15l/min high flow O21 No then 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. 1 As per Trust oxygen prescribing policy 2 As per CCU protocol 3 Guidelines adapted from ESC guidelines 2008 on Acute and chronic heart failure 4 As per Trust NIV protocol http://stm-pathfinder/stpathfinder/minisites/niv/default.asp?page=16 30 minutes Not improving Improving 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 Continue ACEi and betablockers if commenced pre-admission. Usual heart failure algorithm. Neil Swanson, Nov 2010, v1.23

Developments In Acute Medicine Environment 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 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 2. Dr Guhan Chest clinic 3. Dr Whitfield GM clinic Thursday 2. Dr Hamad Thromboembolic Disease and GM clinic 2. Dr Whitfield Chest and GM clinic Friday 2. 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 People 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: emergencycare@institute.nhs.uk vincent.connolly@stees.nhs.uk

Impact of Consultant Streaming

HRG delivery of Ambulatory Care