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

Cohort One

• Calderdale &

Huddersfield

• Harrogate

• Hull

• Leeds

• Liverpool

• Nottingham

• Plymouth

• Tyne & Wear

• Weston

• 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

• Guys & St Thomas

• Heart of England

• Ipswich

• Kettering

• Peterborough

• Sandwell and West

Birmingham

• St Helens and &

Knowsley

• Worcester

Cohort Four

• Barnsley

• Basildon

• Croydon

• Epsom

• Heatherwood &

Wexham

• Herts Valleys CCG

• Kingston

• Northampton

• Northwick Park

• St Heliers

• St Georges

• Southport &

Ormskirk

• UCLH

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

Emergency Care is a wicked problem A social or cultural problem that is difficult or impossible to solve because • Of incomplete or contradictory

knowledge • Of the number of people/opinions

involved • Of the large economic burden • Of the interconnected nature of this

and other problems • Solutions, depend on the framing

of the problem, may be only partially correct, lack evidence and are not definitive, they require an iterative approach.

What’s to blame?

• Patients • GPs • Staffing levels in emergency departments • Acuity • Admissions • Discharges • Finances

Bed occupancy is increasing

Acute admissions per bed per year

Solutions often: • Miss the point – e.g. focus on ‘minors’ • Are vigorously opposed • Lack clarity – ‘care closer to home’, ‘integration’ • Are misguided – opening more hospital beds

So what to do?

*See Purdy, S et al. Interventions to reduce unplanned hospital admissions, 2012

The evidence base for what does works is strong

Most studies suggest that admissions can be avoided in 20-30% of >75 year old frail persons

“Avoiding admissions in this group of older people depended on high quality decision making around the time of admission, either by GPs or hospital doctors. Crucially it also depended on sufficient appropriate capacity in alternative community services (notably intermediate care) so that a person’s needs can be met outside hospital, so avoiding ‘defaulting’ into acute beds as the only solution to problems in the community”. Mytton et al. British Journal of Healthcare Management 2012 Vol. 18 No 11

As well as tackling avoidable admissions, we must: Optimise hospital care:

• Systematic, early, multidisciplinary assessment of frail older people (CGA – comprehensive geriatric assessment)

• Improve patient flow through hospitals • Prioritise discharge planning • Discharge to normal residence– avoid bedded

destinations • Assertive short stay and ambulatory care

Non-elective admissions >65 years per weighted head of population. FT Network Survey .

Failure to assertively manage elderly people leads to rapid, in-hospital decompensation, extended inpatient stays and poor outcomes. See Silver Book.

Trusts with early comprehensive geriatric assessment have 33% fewer admissions than those that don’t

Nine principles of great patient flow

• Early senior review

• Daily senior review

• A focus on discharge and case management

• Continuity of care

• Appropriate standardisation and matching capacity to demand

• Key services must run seven days a week and late evenings

Principles of great patient flow (continued)

• Standardise and manage response times

• Ambulatory emergency care as the ‘default’ position

• Cohort admissions into short stay, frailty and organ specialty streams, with minimal handovers, to optimise outcomes and resources (manage low volume, critically conditions, separately)

As well as tackling avoidable admissions, we must: Optimise hospital care:

• Systematic, early, multidisciplinary assessment of frail older people (CGA – comprehensive geriatric assessment)

• Improve patient flow through hospitals • Prioritise discharge planning • Discharge to normal residence– avoid bedded

destinations • Assertive short stay and ambulatory care

Home

Care Home

Home Care

home

Care Home

Home

Hospital

12.3 days

14 days

31.7 days

Initial residence

Discharge location

Hospital average length of stay

Avoid ‘bedded’ discharge destinations – we should ‘discharge to assess’.

FTN Benchmark March 2012

So, does emergency care need radical change? Likely trends • Centralising some services (stroke, heart attack, vascular) • Reduction in number of urban emergency departments • More investment in community health services • Confederation of primary care to work at greater scale • Confederation of hospitals • Vertical integration of hospitals, community services,

primary care confederations and social care But most change will be in a drive towards systematic implementation of good practice, particularly in hospitals

Managing byFlow Streams Identify the stream

Short stay Sick specialty Sick general Complex

Allocate early to teams skilled in that stream

Vincent Connolly

0

50

100

150

200

250

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59

Length of stay (days)

Nu

mb

er o

f p

atie

nts

Clarity of specialty criteria Specialty case management plan at

Handover – no delays Green bed days vs. red bed days

Short stay – manage to the hour Maximise ambulatory care

Complex needs – how much is decompensation? Detect early and design

simple rules for discharge

Minimise handover Decompensation risk

Early assertive management Green bed days vs. red bed days

Pareto Analysis

Glenday Sieve

30%

20

80 50% of demand = 7% of types: Green stream: ‘Runners’ \

15%

5% of demand: Red stream: Rare Strangers

Sick Specialty

0

100%

Cumulative Demand

LOS

Sick General

Short Stay

Complex

0%

20%

40%

60%

80%

100%

120%

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 74 77 80 83 87 90 97 100103106110113130141147199233

Length of Stay (Days)

A Hospital: LOS Cumulative Profile –understanding LoS by Flow Stream

Excluding Obstetrics, Midwifery and Paediatrics Excluding zero LOS

50% 4 midnights 80% 10 midnights 95% 23 midnights

0%

20%

40%

60%

80%

100%

120%

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 74 77 80 83 87 90 97 100103106110113130141147199233

% O

BD

Length of Stay (Days)

A Hospital: Cumulative Occupied Bed Midnights (OBD) by LOS - Understanding bed use

Excluding Obstetrics, Midwifery and Paediatrics Excluding zero LOS

4 midnights = 15.7% OBD 10 midnights = 41.1% OBD 23 midnights = 73.6% OBD

Capacity is decision makers & action takers

not

cubicles, beds, trolleys, chairs

etc – hold that thought.

Little progress

DSU vs Day Ward

Self-contained unit

Day surgery ethos

Functionally separate

Ringfenced

Efficient

Finite capacity

Duplication of skills

Duplication of resource

Ward-based day unit

Day surgery ethos

Relatively ringfenced

Easily expandable

Retains specialist (theatre) expertise

Flexible

Potential for mixed lists

Both models can be highly successful

Specialist Units

Model of care

Orthopaedics, 2005

Dedicated DSU

Inpatient “day beds”

Number of cases

634

642

Unplanned admission rate

13 (2.1%)

108 (16.8%)*

Fehrmann, et al. — J One-day Surg 19: 39, 2009

* p <0.01 from dedicated DSU

All day surgery, 2008

Dedicated DSU

Satellite DSU

6,419

1,015

64 (1%)

27 (2.7%)*

Written Information

What to expect

Wound care

Analgesia

Follow-up

Return to work

Warning signs

Emergency contact

Default to Day Surgery

Suitability for day surgery Pathway

Clearly suitable

Unsure

Clearly unsuitable

Day surgery Home if ok

Inpatient care ? Home if ok

Inpatient care Hospital stay

20–30%

5–20%

40–65%

Maintaining Quality & Safety

The aim is NOT shorter LOS

Better preparation

Better information

Better care

Less trauma

Less ill

Better recovery =

Shorter stay

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

Updated version

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

Model Of Acute Care

Ambulatory

and Short

Stay Unit

Home

Social

care

D+T -

OPA

IC

Discharge plan and case management

‘Making it Happen!’ – Publicise Performance

Specialist units

VS GIM >2 days

– don’t confuse!

Complex

discharges –

detect early

Decision

to admit

Handover = Handoff = Increased LOS

Em

erg

en

cy N

ee

ds

As

se

ss

me

nt

Serv

ice

RA

T/S

TA

R +

/- S

IFT

Row Labels

Total current

ambulatory: 0 day

spells

Total ALL

ambulatory

spells

Minimum shift

Potential:0 Day

Spells

Maximum shift

Potential:0 Day

Spells

Ambulatory

Potential for all

non-0 Day Spells

Sum of

Opportunity

- Low (£)

Sum of

Opportunity

- High(£)

Ealing Hospital NHS Trust 792 1530 82 262.0 17.12% £47,112 £173,152

Northumbria Healthcare NHS Foundation Trust 1959 4502 313 1027.3 22.82% £213,940 £723,752

Newham University Hospital NHS Trust 804 1892 140 449.1 23.74% £73,386 £247,368

Southampton University Hospitals NHS Trust 1401 3290 254 831.8 25.28% £99,746 £459,594

Chelsea and Westminster Hospital NHS Foundation Trust 580 1413 100 366.1 25.91% £41,769 £155,899

Airedale NHS Foundation TrustAcute headache 14 9 * * 30 0.0 0% 4.0 13% £0 £0

Airedale NHS Foundation TrustAcute painful bladder outflow obstruction* 9 8 * 23 10.8 47% 17.7 77% £3,005 £7,217

Airedale NHS Foundation TrustAcutely hot painful joint * * 0 * 8 0.0 0% 1.6 20% £0 £0

Airedale NHS Foundation TrustAnaemia 0 * * 6 10 6.0 60% 9.0 90% £6,470 £10,356

Airedale NHS Foundation TrustAppendicular fractures not requiring immediate internal fixation* 7 * 11 25 12.0 48% 19.5 78% £6,336 £15,840

Airedale NHS Foundation TrustAsthma 6 8 * 16 * 0.1 0% 4.5 13% £0 £288

Airedale NHS Foundation TrustCellulitis * * 9 34 51 25.6 50% 40.9 80% £22,553 £37,762

Airedale NHS Foundation TrustChest pain 105 105 17 25 252 0.6 0% 46.2 18% £1,428 £2,856

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

Which type of doctor?

Acute Physician General Physician

• Specific training

• Focus on acute med

• Assessment & 1st 48

hours

• Will develop acute med

• Out of hours

Generic training

Holistic approach

Long ward rounds

Office hours

Redesign

• Focus on decisions, tasks & workflows to optimise care

• Sort out the high variation

• Reconfigure the supporting infrastructure to match the redesigned clinical processes

• Design structures and processes to help learning from daily work

• Fixing Healthcare from Inside and Out, Harvard Business Review

Vincent Connolly

Vincent Connolly

Emergency Care is a complex problem!

@ECIST