WORKSHOPHow do we manage acute care as
safely as a day case.The hospital without walls – delivering
ambulatory emergency care
Dr Ian SturgessClinical Lead, Intensive Support Team
Urgent and Emergency Care
• Ambulatory emergency care (AEC) vs ambulatory care sensitive conditions (ACS)
• AEC is a different way to manage patients who have an acute illness.
• AEC is to emergency care, as day case surgery has been to elective care.
• ACS conditions are where better long term condition management or preventative healthcare avoids the development of the acute condition.
• They are complementary but the impact is at a different point in the care continuum.
Ambulatory Emergency Care - Concept
A whole system perspective
Preventative/Predictive careDisease managementManaged populations
Alternatives to acute admission settings
Alternative access for diagnosis
Alternative settings for therapy
Alternative sites for discharge
Alternative sites for readmission
Health Promotion
General Practice & GP OOH
Community Support
Ambulance Service & GP
OOHA+E MAU/SAU/
Short Stay
Focus on CDM and more effective responses to urgent care needs – ACS condition management
Clear operational performance framework and integrated in to primary careImproved integration with primary care responders
Front load senior decision process incl primary care
Redesign to left shift LOS
Inpatient Wards
Optimise ambulatory emergency care
Information flow converting the unheralded to the heralded
Discharge Process
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 advanced care planning for nursing homes
Ambulatory Emergency Care
How to do it:OpportunitiesImplementation
Structure – physical and organisational People and behavioursProcesses
BundlesReliability
MeasurementOutcome metricsProcess metricsBalancing metrics
NHS South East Coast – 2007/08 Opportunities Assessment – Non-Zero LOS Admissions
0.54%0.38%1,9761,389GM14 & 15 First seizure and seizure in known epileptic
0.58%0.39%2,1371,422GM10 Supraventricular tachycardia0.58%0.34%2,1401,262GM08 LRTI without COPD0.76%0.57%2,7882,094GM29 Deliberate self harm0.78%0.54%2,8871,977GM24 Cellulitis0.91%0.64%3,3392,373GM31 Falls including syncope or collapse1.21%0.83%4,4533,061
TO02 Appendicular fractures not requiring immediate internal fixation
0.69%0.60%2,5532,206GS01 Acute abdominal pain not requiring operativeintervention
0.99%0.88%3,6383,227GM11 Chest Pain368,762368,762Total admissions
% of total admissions
(upper)
% of total admissions
(low)No. of Ad.
Ad. - UpperNo. of Adj. Ad. - LowClinical Scenario
18.1%12.2%46,11132,186Total Non-zero LOS Emergency AdmissionsEtc. etc.
Phase 1 - Project Set Up
Pick Conditions
Identify Team
• Clinical lead(s): clinicians should be willing to take the lead and to think beyond their own specialties
• Nursing lead: the lead doctor and lead nurse should work closely together to develop and implement new processes
• Senior manager support preferably at executive level: dynamic management is invaluable in coordinating supporting processes
• Primary care and/or PCT representation • Assessment Unit - If you have an Assessment Unit, be sure to
have at least one representative from this unit in your group.• Stakeholders - diagnostics, AHPs etc
Establish Measures and Objectives
Planning and Implementation
The Reliable Design Strategy1. Segmentation – volume and engagement
2. High level process map • identify the bottlenecks
3. Prevent initial failure using intent and standardization
4. Identify defects and mitigate• using redundancy and contingency
5. Measure and then communicate learning from defects back into the design process
The Model for Improvement
1. Clear and measurable aims•How much•By when•How measured
2. Real time measurement•Outcome•Process•Balancing
3. Small tests of change•Plan, Do, Study, Act (PDSA)•Start tomorrow!
Model for Improvement
What changes can we make that will result in an improvement?
What are we trying to accomplish?
How will we know that a change is an improvement?
Act Plan
Study Do