1. Ambulatory Emergency Care A Generalist’s View
Dr Simon Chapple

2. It’s The Little Things That Count

3. The Elephant in the Rome Room

5. 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

6. 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

7. 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.

8. A Specialist’s View of AEC2
2 RCP Acute care toolkit 10; Oct 2014

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

10. 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)

11. 70% of error in medicine is due to a level 1 SA failure

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

13. A Word From Our ‘Sponsors’

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

15. Referral Letters

16. SBAR
Situation
Background
Assessment
Recommendation

17. 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

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

19. 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://
7http://thorax.bmj.com/content/early/2015/05/13/thoraxjnl full

20. 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.

21. 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

22. 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://
7http://thorax.bmj.com/content/early/2015/05/13/thoraxjnl full

23. 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://

24. 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

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

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