1. VConnolly Acute Medicine – an out-patient specialty? Dr Vincent Connolly The James Cook University Hospital Middlesbrough

2. VConnolly

4. What is Ambulatory Emergency Care? RCP (L) Acute medicine taskforce:- 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 out- patient services that can be provided across the primary/secondary care interface.

5. VConnolly Categories of Ambulatory Emergency Care 1.Diagnostic exclusion group Eg chest pain rule outs etc (many already in place) 2.Low risk stratification group Eg low Rockall score GI bleed 3.Specific procedural group Eg effusion drainage 4.Infra-structural group Eg care home admissions

6. VConnolly Selection of clinical diagnoses appropriate for ambulatory care Gastroenterology –Upper gastrointestinal (GI) bleed with Rockall score of 0 –Lower GI bleed with no haemodynamic compromise –Painless obstructive jaundice –Non-acute abdominal pain –Diarrhoea and vomiting Endocrinology –Hyperglycaemia without ketosis –Hypoglycaemia with full recovery –Type 1 diabetes without ketosis –Electrolyte imbalances –Thyroid disease Infectious diseases –Cellulitis –Osteomyelitis

7. VConnolly 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

8. VConnolly How to get started Location, location, location –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

9. VConnolly 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

10. VConnolly Nursing Staff Sister on every shift Nurse practitioners –Clerking patients & developing management plan –Specialty links Training –Clinical skills –ALS - ALERT course (identification and management of the critically ill patient). - ALERT course (identification and management of the critically ill patient). Develop health care assistants & generic workers

11. VConnolly This slide (containing an example of good practice) has been removed to reduce the size of the presentation. To receive an email copy of the complete presentation, please email vincent.connolly@stees.nhs.uk

12. VConnolly What are the advantages of developing emergency care in an ambulatory setting? Patient acceptability More specialist care for patients Structure and predictability to the emergency process Training opportunity Clinical & cost effective Alleviates bed pressures Reduces A&E attendances

13. VConnolly Fast AccesS to Therapist team Activity 1721 patients referred 66% 22% 4% 8% Patients discharged home via FASTeam Unsuitable patients Transfers to non acute beds Patients remaining in acute hospital bed

14. VConnolly Space…Space….Space On average the AAU clinic receives 23 patients per day Procedure room - development DayAMPMMonday 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 1. Nurse Led DVT / PE clinic 1.TIA clinic 2. Dr Guhan Chest clinic 3. Dr Whitfield GM clinic Thursday 1. Nurse Led DVT / PE clinic 2. Dr Hamad Thromboembolic Disease and GM clinic 1. TIA clinic 2. Dr Whitfield Chest and GM clinic Friday 1. Nurse Led DVT / PE clinic 1. TIA clinic 2. Dr Connolly- Dr Hamad GM clinic

15. VConnolly Activity As the activity continues to rise, so too does the number of patients discharged from the directorate.

16. VConnolly Risk adjusted mortality – trust overview

17. VConnolly Risk adjusted length of stay

18. VConnolly Ave Length of Stay – General Medicine

19. VConnolly Primary Care A&E dept Self Referral Community Self Care Intermediate / Community beds Primary care Mental Health Social Care Acute Medical Assessment Unit ITU/HDU Specialist care General care AMBULATORY EMERGENCY CARE FASTeam DVT/PE OHPAT Rapid Access Clinic Chest Pain Clinic Heart Failure Team Diabetes Team COPD Outreach Macmillan Team

20. VConnolly Thank you Any questions?