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

2. 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 ?

3. What’s in a name? Ambulatory Emergency Care Clinical Decisions Units
Same Day Emergency Care

4. 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

5. 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

6. 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

7. …….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

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

11. 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)

12. 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

13. 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

14. Personalised Ambulatory Emergency Care
Individual Care plans
Frequent attenders
Addison’s
Diabetes
Unusual clinical conditions
Acute Intermittent Porphyria
Inherited metabolic Disorders

15. 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)

16. 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

17. Same Day Emergency Care Rates 75th Centile and National Average

18. Benchmarking
South Tees Performance against NHSi Directory

19. 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
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

22. 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

23. 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

24. Measures of quality in Acute Medicine
No of cases Trust Peer
Risk adjusted mortality 24,
Ave LoS 38,
Risk adjusted LoS 17,
Complication rate % 1.0%
Readmissions 3, % 10.3%
CHKS data

25. 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

26. 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

27. 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

28. Don’t get admitted !

29. 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 us and we would be happy to talk to you:

30. Impact of Consultant Streaming

31. HRG delivery of Ambulatory Care