1. Acute Medicine - Organisation of Urgent Care Dr Kevin Jones FRCP MD Royal Bolton Hospital

2. Urgent Care “The number one issue facing the NHS in England is reversing the ‘unsustainable’ rise in emergency hospital admissions.... There has been an almost 12 per cent rise in admissions over the last five years” Nuffield Trust, 2010

3. Acute Medical Unit Assessment and Short Stay Beds D1 Ward - female (26 beds) D2 Ward - male (22 beds ) GP Assessment Unit (GPAU) Clinical Decisions Unit (CDU) Emergency Department Bolton Community Unit (BCU) DVT Clinic

5. GP Assessment Unit In Main Outpatients (Blue Bay) Same area as SARC Clinic Purpose Built Ambulatory Area Next to Emergency Department Next to CDU ( Red Area ) Acute Medicine Consultant 0800-1600 Closed weekends and bank-holidays In January 2013 – average 8 patients/day

6. Clinical Decisions Unit (CDU) Purpose built in Red Area of Outpatients Not strictly speaking a CDU Only 14 beds Used as an ultra-short stay unit (12 hrs ideal) Telemetry and monitoring Cardiac chest pains awaiting Troponin-I Acute Medicine Consultant 0800-1600 hrs

7. Clinical Decisions Unit (CDU) February 2013 254 admissions ( 9/day ) 82% discharged home Only 35% with length of stay < 12 hours 33% staying longer than 24 hours

8. Clinical Decisions Unit Ring fencing June 2013 In last 2 weeks – 186 admissions 13 per day 88% discharged home

9. Admissions (January 2013) D1 448 D2 442 CDU 254 GPAU 173 Mean 42 per day 45% discharged directly home from AMU

10. Time of Admission to AMU Do our rotas reflect our demand and support senior review? Approximately 24% total admissions come direct from GPs

11. Discharge Flow does not mirror ‘input’ flow, and lags behind

12. Lengths of Stay for AMU discharges 75% of patients kept on Acute Medical Unit are discharged within 24 hours 45% discharged home 55% admitted to specialist ward

13. How to Reduce Pressure on Beds Maintain 85% bed occupancy Reduce Lengths of Stay Consultant-held Triage Bleep Early senior decision maker review Capacity for Short Stay in AMU Ambulatory Care

15. Consultant held Triage Bleep for GP Direct Results Mean number of calls dealt with per day between 0800 and 1600: 13 (range 8 – 23) On average the consultant is able to divert or deflect 4 – 6 admissions per day. Giving advice to the GP Advising referral to a specialist clinic Giving the patient an appointment in GPAU Asking the hospital Referral and Assessment Team to assess patients with social problems.

16. Triage Bleep - Advice Subarachnoid haemorrhage Temporal arteritis Transient ischaemic attack Bell’s Palsy Pneumonia Atrial Fibrillation Hyperkalaemia Severe Hypertension Iron Deficiency Anaemia

17. GP Assessment Unit Main Referrals Headaches Chest pain Shortness of breath Blackouts and collapses Generally unwell

18. Admissions from ED

19. Emergency Admissions Length of Stay Greater Manchester (12 Trusts) Range 1.8 to 3.8 days Mean 2.6 days Bolton 2.4 days

20. 95% Emergency Dept Target >95% for every month April to Dec 2012 Below 95% for January 2013 Above 95% for February 2013 95.6% for March 2013 95.5% for Quarter 4 96.9% Year to Date

21. Clinical Quality Indicators for Acute Medical Units 1. All patients admitted to the AMU should have an early warning score measured upon arrival on the AMU. 2. All patients should be seen by a competent clinical decision maker within 4 hours* of arrival on the AMU who will perform a full assessment and instigate an appropriate management plan. 3. All patients should be reviewed by the admitting consultant physician or an appropriate speciality consultant physician within 14 hours of arrival on the AMU**.

22. Clinical Quality Indicators for Acute Medical Units All acute medical units should collect the following data Hospital mortality rates for all patients admitted via the AMU Proportion of admitted patients who are discharged directly from the AMU Proportion of patients discharged from the AMU who are readmitted to hospital within 7 days of discharge

23. Consultant held Triage Bleep GP Assessment Unit Clinical Decisions Unit Any Questions ?

25. Ambulatory Emergency Care

27. Acute Admissions from Care Homes Acute Admissions from non-acute NHS beds End of Life Care

28. Percutaneous Endoscopic Gastrostomy Does Not Prolong Survival in Patients With Dementia Lynne M. Murphy, MSN, RN, CNSN; Timothy O. Lipman, MD Arch Intern Med. 2003;163(11):1351-1353.

29. Improving end of life care for nursing home residents: an analysis of hospital mortality and readmission rates.. Ahearn DJ,Jackson TB, McIlmoyle J, Weatherburn AJ. Postgrad Med J. 2010 Mar;86(1013):131-5

30. Ahearn DJ et al, 2010 Analysis of all admissions to the acute medical unit of a busy district general hospital over a 94 day period, comparing nursing home residents with all admitted patients aged over 70 years.

31. Ahearn DJ et al, 2010 Nursing home residents were significantly less likely to survive the admission than elderly people living in the community. 33.9% of nursing home residents did not survive the admission 51.6% died within 6 weeks of admission. Of those discharged alive, 41.5% were readmitted or died within 6 weeks. Patients with a higher level of comorbidity were less likely to survive the admission or live to 6 weeks.

32. Ahearn DJ et al, 2010 Many nursing home residents find acute admission distressing, Many hospital admissions are ‘inappropriate’. Advance care planning can improve patients’ end of life care. Nursing home residents were significantly less likely to survive acute medical admission than elderly people living in the community.

33. Ahearn DJ et al, 2010 Patients with a higher level of comorbidity are less likely to survive the admission or to 6 weeks than those with lower levels. Advance care planning should be considered in all nursing home residents, especially those with the greatest level of comorbidity. Postgrad Med J 2010;86:131-135.

34. Transient Ischaemic Attack

35. Is it a TIA or not? Are the neurological symptoms focal rather than non focal? Are the neurological symptoms negative rather than positive? Was the onset of the focal neurological symptoms sudden? Were the focal symptoms maximal at onset? Syncope does not occur with TIA

36. TIA – ABCD2 Score Age > 60 yrs 1 BP > 140/90 1 Clinical Weakness 2 Speech 1 Duration < 1 hour 1 > 1 hour 2 Diabetes 1

37. TIA – ABCD2 Score Start aspirin 300mg Score 4 or more – clinic within 24 hours Score less than 4 – clinic within 1 week

38. Hypertension

39. Hypertensive Urgency Systolic > 200 mmHg Diastolic > 120 mmHg No symptoms ( headache ) No end-organ damage Usually poorly compliant

40. Headache

41. Subarachnoid haemorrhage Suddeness of onset more important than severity Comes on to maximum intensity within a minute Lasts for at least an hour

42. Haematemesis

43. Stanley et al, Lancet, 373, Jan 3 rd 2009. Glasgow-Blatchford

44. Pneumonia – BTS Guidelines Can be a clinical diagnosis Chest X-ray not essential CRB-65 score of 0-1 may be treated in the community

45. Pneumonia – CURB 65 score Confusion – new onset Urea > 7.0 mmol/l Respiratory rate > 30 / min BP - < 90 syst or < 60 diast Age > 65 yrs

46. Bell’s Palsy Diagnose lower motor neurone palsy Imaging not required unless atypical or not recovering after 8 weeks Give prednisolone 60 mg for 1 week Protect the eye Primary care – not acute medicine

47. Temporal Arteritis Usually aged above 50 years ESR usually above 80 mm/hr Start prednisolone 60 mg daily Temporal artery biopsy within a week

48. Discussion