Ambulatory Emergency Care A Generalist’s View Dr Simon Chapple simon.chapple@shropdoc.nhs.uk

It’s The Little Things That Count

The Elephant in the Rome Room

Objectives By the end of this session you should be able to: define Ambulatory Emergency Care (AEC) describe what’s going on with AEC locally understand your role in AEC better describe the latest guidance for some conditions

Overview AEC Defined Situation Awareness in Medicine Local initiatives Situation Awareness in Medicine The Healthcare Continuum ‘Phone a Friend’ or Informing Uncertainty Overview of some guidance: CAP PE

AEC Defined1 ‘Ambulatory care is clinical care which may include diagnosis, observation, treatment and rehabilitation, not provided within the traditional hospital bed base or within the traditional outpatient services, and that can be provided across the primary/secondary care interface.’ 1Royal College of Physicians (RCP) Acute Medicine Task Force, and endorsed by The College of Emergency Medicine, 2012.

A Specialist’s View of AEC2 http://tinyurl.com/o6kkpq5 2 RCP Acute care toolkit 10; Oct 2014

AEC Locally Breaking The Cycle Week AEC Steering Group Site-specific AEC Project Groups T&W Pathways Committee Website Pan-health economy group

Situation Awareness Situational awareness (SA) is defined3 as a person’s perception of the elements in the environment within a volume of space and time, the comprehension of their meaning, and the projection of their status in the near future (PCP), or When perception matches reality4 3 Dr Mica Endsley (1995) 4 Dr Simon Chapple (Just Now)

70% of error in medicine is due to a level 1 SA failure

The Healthcare Continuum Respite Care Hospiceat Home Outpatients GP Surgery Home WMAS CMHT Hospital ED DNs Community Hospital OOH Social Services Int’ Care

A Word From Our ‘Sponsors’

Informing Uncertainty – Sharing The Plan Referral Letters SBAR Fitness to Sit AMB score and EWS

Referral Letters

SBAR Situation Background Assessment Recommendation

AMB Score Sex: Age Access to transport Will likely need IV Rx Female 0 Male -0.5 Age <80 years 0 >80 years -0.5 Access to transport Yes 2 No 0 Will likely need IV Rx Yes 0 No 2 Acutely confused Yes 0 No 2 NEWS NEWS=0 1 NEWS >1 0 Discharged last 30 days No 1 If score is ≥5 consider ambulatory care

(N)EWS Heart/pulse rate Breathing rate Blood pressure Temperature Conscious level Oxygen saturation (SpO2) Inspired gas (air or oxygen?)

Community Acquired Pneumonia6,7 NICE released guidance on CAP in 2014 BTS reviewed their guidance in light of the above Thorax article7 summarises the recommendations Both guidelines recommend the use of: clinical judgement in conjunction with the CURB-65 score (CRB65 score for primary care) to assess illness severity, a single antibiotic as initial empirical therapy in patients with low severity CAP, dual combination antibiotics comprising amoxicillin and a macrolide for patients with moderate severity CAP, and dual combination antibiotics comprising a β-lactamase stable β-lactam (such as co-amoxiclav) and a macrolide for patients with high severity CAP. In addition, both guidelines recommend that processes are be put in place to allow the radiological diagnosis and treatment of patients with CAP within 4 h of presentation to hospital. 6https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/community-acquired-pneumonia-in-adults-guideline/ 7http://thorax.bmj.com/content/early/2015/05/13/thoraxjnl-2015-206881.full

CRB-65 CRB65 score is calculated by giving 1 point for each of the following prognostic features: confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time) raised respiratory rate (30 breaths per minute or more) low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg) age 65 years or more. Use clinical judgement in conjunction with the CRB65 score to inform decisions about whether patients need hospital assessment as follows: consider home‑based care for patients with a CRB65 score of 0 consider hospital assessment for all other patients, particularly those with a CRB65 score of 2 or more.

CURB-65 The above plus: Consider home based care if score is 0 or 1 raised blood urea nitrogen (over 7 mmol/litre) Consider home based care if score is 0 or 1

Community Acquired Pneumonia6,7 If a diagnosis of pneumonia has not been made after clinical assessment and it is unclear whether antibiotics should be prescribed, GPs should consider a CRP test NICE recommends: if the CRP > 100 mg/litre antibiotics should be prescribed if the CRP is between 20 mg/litre and 100 mg/litre a delayed prescription should be considered if the CRP concentration is less than 20 mg/litre antibiotics should not be offered routinely 6https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/community-acquired-pneumonia-in-adults-guideline/ 7http://thorax.bmj.com/content/early/2015/05/13/thoraxjnl-2015-206881.full

VTE8 Dichotomised Well’s Score For PE Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3 An alternative diagnosis is less likely than PE 3 Heart rate > 100 beats per minute 1.5 Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5 Previous DVT/PE 1.5 Haemoptysis 1 Malignancy (on treatment, treated in the last 6 months, or palliative) 1 Clinical probability simplified scores: PE likely - more than 4 points PE unlikely - 4 points or less 8 ttp://www.nice.org.uk/guidance/cg144/chapter/1-recommendations

Summary AEC Defined Situation Awareness in Medicine Local initiatives Situation Awareness in Medicine The Healthcare Continuum ‘Phone a Friend’ or Informing Uncertainty Overview of some guidance: CAP PE

For The Appraisal Folder What 3 things would you like to change?

Anticipatory Care Plan Options For Change Wells’ Criteria SBAR Working Diagnosis EWS Phone a Friend CURB-65 Anticipatory Care Plan Web Resources