Ambulatory Emergency Care an update

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

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

11. The Amb Score 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 • 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 Yes Yes Yes Yes No No No 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 Consider alternative diagnosis (although, if shocked, may be in low output cardiac failure) Clear chest or BNP<100? Bleep cardio SpR (bp 9595) for inotrope support/advanced cardiac care/ECHO Systolic BP≤90? 02 sats<95% (<90% if COPD) or critically ill? • 15l/min high flow O21 then No • 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. 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 MedicineEnvironment changesin 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

24. Measures of quality in Acute Medicine No of cases Trust Peer Risk adjusted mortality 24,074 87 93 Ave LoS 38,879 3.6 4.8 Risk adjusted LoS 17,539 86 96 Complication rate 134 0.4% 1.0% Readmissions 3,182 10.1% 10.3% CHKS data

25. 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

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 email us and we would be happy to talk to you: emergencycare@institute.nhs.uk vincent.connolly@stees.nhs.uk

30. Impact of Consultant Streaming

31. HRG delivery of Ambulatory Care