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:

aec@nhselect.org.uk

deborahataec@nhselect.org.uk

www.ambulatoryemergencycare.org.uk