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Ambulatory Emergency Care
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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
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The evolving bed challenge
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The evolving bed challenge
Admissions per year
A&E attendances per year
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Long stay admissions (RED) and Short stay admissions (YELLOW)
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Pareto Analysis
Glenday Sieve
30%
20
8050% 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
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Acute Care Hub
Future hospital: Acute Emergency Care
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Key principles of AEC• Senior clinician led and delivered
• Systematic - pathways & processes – maximise AEC use
• Patients awareness of AEC concept
• Capacity to meet demand (Environment/staff/diagnostics)
• Set time standards in place
(15 min - first review, 60 min - medical review, completion within 4 hours)
• Communicate & safety netting - primary care/specialty
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Maintaining Quality & Safety
The aim is better quality care
Better pt preparation
Better pt information
Better care
Reduced complications
Reduced waiting
Faster recovery=
Shorter stay
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Capacity is
decision makers & action takers
not
cubicles, beds, trolleys, chairs
(Resources)
MINDSET
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Models of AEC – 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
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4 simple questions to identify AEC patients
1. Is this patient clinically stable?
2. Is the patient functionally capable of being managed in the AEC Unit?
3. Would this patient have been admitted to hospital before AEC existed?
4. Could the patient’s needs be better met by another service?
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VConnolly
Categories of AEC
1.Diagnostic exclusion group-Non-cardiac CP
2.Low risk stratification group-Low risk UGIB / PE
3.Specific procedural group- Paracentesis, Pleural tap
4.Infra-structural group- Care home admissions
5.Facilitated discharges- F/u of bloods, x-rays, clinical review
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Maintaining safety, flow quality & productivity
• Use Measurement to develop an understanding of the service
• AEC activity– Emergency bed days use
– Variation in high volume flow streams
– Adverse event monitoring
– Readmission rate
– Unplanned admissions from AEC
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Helping commissioners understand & invest in the potential of AEC (AEC Croydon University Hospital - Activity Impact)
4/28/2016
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Helping commissioners understand & invest in the potential of AEC (AEC Croydon University Hospital - Activity Impact)
4/28/2016
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4/28/2016
Helping commissioners understand & invest in the potential of AEC (AEC Croydon University Hospital – Changing pathways and processes )
DVT pathway
3.15 appointments per patient (range up to 34!)
1.55 appointments per patient (range up to 6)
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• Set an internal target to review all patients within 1 hour of their time or arrival
• 74% patients are seen within one hour (88% within 2 hours)
Helping commissioners understand & invest in the potential of AEC (AEC Croydon University Hospital –Timely Care)
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In context with AMU
Helping commissioners understand & invest in the potential of AEC (AEC Croydon University Hospital – Impact on admissions)
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Delivering ambulatory emergency care
Patient
Initial contact & assessment
( GP or self present to ED)
Secondary contact assessment Evidence based risk stratification and judgement
/ pathway selection
Access to diagnostics and reporting
Management pathway & locationED ambulatory, ED/CDU ambulatory, Acute Med ambulatory, OPD setting.
Define location and follow up
Define safety netting systems
Leadership
&
Culture
Governance &
safety
Embedded informatics
Robust quality
Improvement systems
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Thank you