1. Ambulatory Emergency Care

2. 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

3. Directory of AEC for adults

4. What’s in a name?
Ambulatory Emergency Care Clinical Decisions Units Same Day Emergency Care

5. 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

6. ….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

8. High Volume Clinical Scenarios (BPT)
Abdominal Pain
DVT
Acute Headache
Epileptic Seizure
Anaemia
Falls inc. Syncope/Collapse
Appendicular Fracture
Low Risk Pubic Rami
Asthma
LRTI without COPD
Bladder Outflow Obstruction
Minor Head Injury
Cellulitis PE
Chest Pain
Renal/Ureteric Stones
Community Acquired Pneumonia
SVT including AF
Deliberate Self Harm

9. Same Day Emergency Care Rates 75th Centile and National Average

10. AEC Delivery Network Proposed Timeline 12 Month Programme
Months 1 2 3 4 5 6 7 8 9 10 11 12
Preparation with organisations
Workshop 1
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
Action periods
Local teams develop, test and implement changes
Input and support from expert Network Reference Group & national team

11. 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
UCLH
Cohort 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

12. Clinical Leads
Dr Vince Connolly
Dr Taj Hassan

13. 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

14. Non-Condition Specific
New Process for GP Assessment and Ambulatory Care
Overarching principle; Treat all patients as
Ambulatory until proven otherwise
Non-Condition Specific
Not condition specific
Monday- Friday (8am-10pm)
Streaming (in blue) Amb care, short stay and long stay
We already have pathways for some of the conditions in the directory (DVT being the biggest one)

15. Nottingham ‘process model’ What Did We Achieve….
We increased the amount of patients discharged with a LOS of less than 11hrs
We discharged the increased workload rather than admitted

16. The Amb Score
If Score is high, consider re-direct to ambulatory care unit FACTORS
1 if applicable
0 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)

18. 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
Mike

19. The ROI tool
Two stages assesses actual impact and future impact

20. 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

21. Chester - Patient Experience

22. Emotional mapping +ve -ve Patient finds their way t o AEC
Patient registers with ED reception
The triage nurse refers the patient to AEC
Patient is seen by clinician
Patient waits for treatment
Patient arrives at car park
Patient navigates to ED
AEC staff greet patient and staff explain what to expect
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!
I wasn’t sure where to go – the signs were difficult to follow
The room was cluttered with out of date magazines and notices on the walls and I was already feeling really nervous
+ve
I was anxious I didn’t know what ambulatory meant was this good or bad?
Informed
Pleased
pleased
relieved
relieved
Lost
anxious
nervous
anxious
upset
Frustrated
worried
-ve

23. The NHS Sustainability Model
The most successful organisations are those that can implement and sustain effective improvement initiatives leading to increased quality and patient experience at lower cost. The Sustainability Model and Guide has been developed to support health care leaders to do just that.
Health services around the world need to consistently deliver high quality care at lower cost and against rising expectations and demand. To achieve this we need to continually improve our existing health systems and processes. Any change requires a significant investment of time, financial resource and leadership effort. There is evidence that up to 70% of all organisational change fails to survive and that is just not acceptable when undertaking health care improvement.
The Sustainability Model is a diagnostic tool that will identify strengths and weaknesses in your implementation plan and predict the likelihood of sustainability for your improvement initiative.
The Sustainability Guide provides practical advice on how you might increase the likelihood of sustainability for your improvement initiative.

24. Programme Sustainability – 57.28

25. Areas to focus on Infrastructures Senior leadership
Effectiveness of the system to monitor progress

26. 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”

27. 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)

28. March 2013
“Waiting times at Milton Keynes Hospital’s A&E department are some of the longest in the country.”

29. 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”

32. 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

33. 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

34. Other Impacts
Wait for an operation for “urgent non-life threatening” problem

35. Why do it?... Staff and pts love it
Everyone was really helpful, friendly and relaxed, which made it very supportive for me
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 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

36. The bigger picture Influencing beyond immediate system:
Ian Smith, British association of day surgery (BADS) clear parralell
Vincent connelley, secondee, consultant in acute medicine at james cooke
Lightbulb moment – form national group for AEC
BPT for AEC
Working with the colleges, identify stakeholders

37. For the 1st Annual National Ambulatory Emergency Care Conference on
14th October 2014
Central Hall Westminster, London
Places cost £99 plus £6.59 booking fee, to book your place to go:

38. Contact details
If you have a query or want to access work shared by other organisations please use: