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 Preparation with organisations 2 3 4 Workshop 1 5 6 Workshop 2 7 8 9 10 Workshop 3 11 12 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 Action periods Local teams develop, test and implement changes Input and support from expert Network Reference Group & national team Cohort One Cohort Two • • • • • • • • • • • • • • • • • • • • • Calderdale & Huddersfield Harrogate Hull Leeds Liverpool Nottingham Plymouth Tyne & Wear Weston Super Mare Whittington Bath Bristol Gloucester Imperial Milton Keynes North Cumbria North Lincs Pennine Pilgrim Stockport Warrington Cohort Five Cohort Six • • • • • • • • • • • • • • • • • • • • • • • • • • • • 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 Three • Addenbrookes • Ashford CCG • Chester • Dudley • East Sussex • Heart of England • Kettering • Kings College • Peterborough • Sandwell and West Birmingham • St Helens and & Knowsley • Worcester Aintree Burton Central Manchester Gateshead Leicester Mid Essex North Staffs Royal Cornwall Royal Free – inc. Barnet Shrewsbury & Telford Swindon Walsall West Middlesex Cohort Four • • • • • • • • • • • • • • • Barnsley Basildon Croydon Epsom Heatherwood & Wexham Herts Valleys CCG Ipswich Kingston Mid Staffs Northampton Northwick Park St Heliers St Georges Southport & Ormskirk UCLH 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 as Ambulatory until proven otherwise Non-Condition Specific Row Labels 10/09/2012 20/08/2012 30/07/2012 09/07/2012 18/06/2012 28/05/2012 07/05/2012 16/04/2012 26/03/2012 05/03/2012 13/02/2012 23/01/2012 02/01/2012 12/12/2011 21/11/2011 31/10/2011 10/10/2011 19/09/2011 29/08/2011 08/08/2011 18/07/2011 27/06/2011 06/06/2011 16/05/2011 25/04/2011 04/04/2011 Individual Value BF BFH BEFH BEF F E AEF E AE BF ABF B BF B A Nottingham ‘process model’ What Did We Achieve…. We increased the amount of patients discharged with a LOS of less than 11hrs 0-11 Special Cause Flag 140 120 100 80 60 40 The Amb Score If Score is high, consider re-direct to ambulatory care unit FACTORS 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) 1 if applicable 0 if not applicable 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 - tips Aim 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 Emotional mapping Patient arrives at car park Patient navigates to ED Patient registers with ED reception 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! +ve relieved The triage nurse refers the patient to AEC Patient finds their way t o AEC Informed Frustrated worried -ve Patient waits for treatment The room was cluttered with out of date magazines and notices on the walls and I was already feeling really nervous Pleased pleased relieved Lost nervous upset Patient is seen by clinician I wasn’t sure where to go – the signs were difficult to follow I was anxious I didn’t know what ambulatory meant was this good or bad? anxious AEC staff greet patient and staff explain what to expect anxious The NHS Sustainability Model Programme Sustainability – 57.28 infrastructures Fit with the organisations strategic aims and culture Clinical leadership engagement and support Senior leadership engagement and support Staff behaviours toward sustaining the change Staff involvement and training to sustain the process Effectiveness of the system to monitor progress Adaptability of improved process Credibility of the benefits Benefits beyond helping patients 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) March 2013 “Waiting times at Milton Keynes Hospital’s A&E department are some of the longest in the country.” June 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” 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 Outcome Percentage (%) Home same day 48 Home same day after local procedure/dressings 34 Operation same day 10 Admit as normal 5 Minimum of 82% of patients go home the same day and are saved a hospital stay Other Impacts Wait for an operation for “urgent non-life threatening” problem 3.5 3 Days 2.5 2 1.5 1 2012 0.5 New Service 0 May June July Impact on In-patients August Why do it?... Staff and pts love it 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 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 It feels great to provide great quality care without all that waiting around 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! 35 The bigger picture Best Practice Tariffs for Ambulatory Emergency Care Places 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