Ambulatory Emergency Care
Background
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
Directory of AEC for adults
What’s in a name?
Ambulatory Emergency Care
Clinical Decisions Units
Same Day Emergency Care
What is AEC?
“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”.
The Royal College of Physicians – Acute Medicine Task Force & endorsed by the College of Emergency Medicine, 2012
….What is it about?
• Improving patient experience
• Reducing waits for tests
• Early and frequent senior review
• Improving patient flow
And so better outcomes for patients
High Volume Clinical Scenarios (BPT)• Abdominal Pain• Acute Headache• Anaemia• Appendicular Fracture• Asthma• Bladder Outflow Obstruction• Cellulitis• Chest Pain• Community Acquired
Pneumonia• Deliberate Self Harm
• DVT• Epileptic Seizure• Falls inc. Syncope/Collapse • Low Risk Pubic Rami• LRTI without COPD• Minor Head Injury• PE• Renal/Ureteric Stones• SVT including AF
Same Day Emergency Care Rates 75th Centile and National Average
AEC Delivery Network Proposed Timeline 12 Month Programme
Months 1 2 3 4 5 6 7 8 9 10 11 12
Workshop 1
Action periodsLocal teams develop, test and implement changes
Input and support from expert Network Reference Group & national team
Workshop 2 Workshop 3 Workshop 4
Topic specific Webinars, virtual visit series (1- 2 x monthly)
1:1 team support (Initial site visit with each organisation plus ongoing support to support implementation
Topic specific events eg measurement , clinical skills
Preparation
with organisations
Cohort One
• Calderdale & Huddersfield• Harrogate• Hull• Leeds• Liverpool• Nottingham• Plymouth• Tyne & Wear• Weston Super Mare• Whittington
Cohort Two
• Bath• Bristol• Gloucester• Imperial• Milton Keynes• North Cumbria• North Lincs• Pennine• Pilgrim• Stockport• Warrington
Cohort Three• Addenbrookes• Ashford CCG• Chester• Dudley• East Sussex• Heart of England• Kettering• Kings College• Peterborough• Sandwell and West Birmingham• St Helens and & Knowsley• Worcester
Cohort Four
• Barnsley• Basildon• Croydon• Epsom• Heatherwood & Wexham• Herts Valleys CCG• Ipswich • Kingston• Mid Staffs• Northampton• Northwick Park• St Heliers• St Georges• Southport & Ormskirk• UCLHCohort Five
• Bournemouth • Bradford • Coventry and Warwickshire • East Cheshire • Guys & St Thomas• Lewisham• Lister – East & North Herts• Portsmouth • PRU Kings College • Southend • South Manchester • Tameside • West Sussex• Wye Valley• Yeovil
Cohort Six
• Aintree• Burton• Central Manchester• Gateshead• Leicester• Mid Essex• North Staffs• Royal Cornwall• Royal Free – inc. Barnet• Shrewsbury & Telford• Swindon• Walsall• West Middlesex
Clinical Leads
Dr Vince Connolly Dr Taj Hassan
Models of AEC - the 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
New Process for GP Assessment and Ambulatory Care
Overarching principle; Treat all patients asAmbulatory until proven otherwise
Non-Condition Specific
0-11
40
60
80
100
120
140
04/04
/2011
25/04
/2011
16/05
/2011
06/06
/2011
27/06
/2011
18/07
/2011
08/08
/2011
29/08
/2011
19/09
/2011
10/10
/2011
31/10
/2011
21/11
/2011
12/12
/2011
02/01
/2012
23/01
/2012
13/02
/2012
05/03
/2012
26/03
/2012
16/04
/2012
07/05
/2012
28/05
/2012
18/06
/2012
09/07
/2012
30/07
/2012
20/08
/2012
10/09
/2012
Row Labels
Indi
vidu
al V
alue
A B BF B ABF
BF AE E AEF
E F BEF
BEFH
BFH
BF
Special Cause Flag
Nottingham ‘process model’ What Did We Achieve….
We increased the amount of patients discharged with a LOS of less than 11hrs
The Amb Score
If Score is high, consider re-direct to ambulatory care unit FACTORS
1 if applicable0 if not applicable
Female sex
Age < 80 years
Has access to personal / public transport
IV treatment not anticipated by referring doctor
Not acutely confused
MEWS score = 0
Not discharged from hospital within previous 30 days
TOTAL Amb Score (Maximum 7)
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)
Programme measures - tipsAim for standard cohort wide data collection
Suggested measures are in the guide including:• Patient experience / staff experience• Number of non elective bed days used per month• Number of 0 LOS patients • Number of medical outliers • AEC activity (New and follow up) • Emergency readmissions (7 day)• Emergency patient flow (4 hour performance)
Use the 7 step model - baseline, frequent measurement, review, use the 7 points rules
The ROI tool
Two stages assesses actual impact and future impact
The EBD Tool Kit
• Introducing the AEC Service - Patient Leaflet• The Ambulatory Emergency Care Journey • AEC Short Animated Film• Using SMS Mobile Text Messaging Feedback• Patient Experience Questionnaire • Volunteer’s Log Book• A day in the life of... To capture staff experience• Staff Perspective on patient journeys
Chester - Patient Experience
Patient waits for
treatment Patient finds their
way t o AEC
AEC staff greet patient
and staff explain what
to expect
Patient arrives at car park
Patient navigates
to ED
The triage nurse
refers the patient to
AEC
Patient registers with ED
reception
Patient is seen by clinician
+ve
-ve
Frustrated
relieved
anxious
anxiousnervous
worried
Pleasedpleased
upset
It took ages to find a car parking space and then I found it was a 15 minute walk
to the AEC clinic. How frustrating!
The room was cluttered with out of date magazines and notices on the walls
and I was already feeling really nervous
I wasn’t sure where to go – the signs were
difficult to follow
Emotional mapping
I was anxious I
didn’t know what
ambulatory meant was this good or
bad?
Lost
relieved
Informed
The NHS Sustainability Model
Programme Sustainability – 57.28
Benefits beyond helping patients
Credibility of the benefits
Adaptability of improved process
Effectiveness of the system to monitor progress
Staff involvement and training to sustain the process
Staff behaviours toward sustaining the change
Senior leadership engagement and support
Clinical leadership engagement and support
Fit with the organisations strategic aims and culture
infrastructures
0 2 4 6 8 10 12 14 16
Areas to focus on
• Infrastructures • Senior leadership • Effectiveness of the system to
monitor progress
The Benefits
Value for money
‘ Definitely good value for money’ for what we have paid we will definitely get ROI, by admissions saved”
‘Would happily pay join the network again’ knowing what we know now.’
Improved service design
"I love the web seminars - they're a great way of learning without travelling miles and I can get the messages to the rest of the team.“
“The network has ‘definitely and undoubtedly’ helped us move forward.”
Speed of service development
”It has been very useful seeing what other organisations have done . The networking has given us examples to take back to our Trusts and get funding and sign off faster than usual”
“Ambulatory Care unit evolved even faster because of our involvement in Ambulatory Emergency Care Delivery Network”
Reported benefits of being in the Network
• Investment for a 2.9m bespoke AEC unit (Whittington)• AEC has really helped patient flow and achieving the target
(Kettering)• 50% of our GP referrals are now managed in AEC (Notts)• 83% of surgical patients processed via AEC are saved at least
1 night in hospital (Bath)• 134 patients were seen during our pilot and all admissions
avoided (Glos)
“Waiting times at Milton Keynes Hospital’s A&E department are some of the longest in the country.”
March 2013
“Shadow Health Secretary Andy Burnham visited the hospital to see how a new ambulatory care unit, giving patients a "short, sharp treatment", had helped turn around the department”
June 2013
DUDLEY PILOT OUTCOMES
• 1810 patients seen in AEC during the 3 month pilot• AEC admission rates through the 3 months ranged from 24% - 31%• ‘0’ Days LoS increased by 6%• EAU discharge rate increased by 1%• Average LoS in EAU down by 1.7hrs• Full year effect on closing beds is 4.13 beds (+4 trolley spaces closed for space
to run AEC)• Full year effect cost saving realised £234,219 • Friends & Family Score of 73
What has happened? – Surgical AEC
Approximately 140 patients seen per month
Minimum of 82% of patients go home the same day and are saved a hospital stay
Outcome Percentage (%)
Home same day 48
Home same day after local procedure/dressings
34
Operation same day 10
Admit as normal 5
Other ImpactsWait for an operation for “urgent non-life threatening” problem
May June July August0
0.5
1
1.5
2
2.5
3
3.5
2012
New Service
Impact on In-patients
Day
s
35
Why do it?... Staff and pts love it Everyone was really helpful,
friendly and relaxed, which made it very supportive for me
Everyone was so helpful; and very kind. I was less stressed after my
care
Everyone was wonderful. Thank you so much for allaying my fears
All aspects of care were very good. The staff was efficient and
courteous, the nurses were professional and caring; the doctors were professional,
personable and knowledgeable. A lot of good old common sense
evidenced throughout
Got treated fairly quickly because was in pain/bleeding. Didn't have
to stay in hospital to have IV antibiotics - excellent. Excellent
and sensitive nurses. Got better!
It feels great to provide great quality care without all that waiting around
The bigger picture
Best Practice Tariffs for Ambulatory Emergency Care
For the 1st Annual National Ambulatory Emergency Care Conference
on 14th October 2014
Central Hall Westminster, LondonPlaces cost £99 plus £6.59 booking fee, to book your place to go:
https://ambulatoryemergencycare.eventbrite.co.uk
Contact details
If you have a query or want to access work shared by other organisations please use:
www.ambulatoryemergencycare.org.uk