Ambulatory Care UnitRoyal Free Hospital

Dr Tara Sood

Dr Andres Martin

Background• Hampstead North London Suburb

• Merged with Barnet and Chase Farm Hospital in July 2014, 3 site trust.

• Seeing increasing numbers of patients – last 3 months 17% increase

• The current department was designed to see 60,000 attendances a year, however the ED is currently seeing over 100 ,000 attendances.

• The ED is undergoing a major redevelopment over the next two years and by September 2016 there will be a newly opened ambulatory emergency care unit within the department alongside a CDU/23 hour unit.

• We also have a 9 bedded CDU as part of the ED which runs on conjunction with the AECU.

Getting Started

• Existing pathways

• Membership of AEC Network cohort Vi

• Directory of ambulatory emergency care

• Visits to established units

• Existing patient surveys

• Developed business case for pilot unit

Pathway Driven Approach Initially

• Local expertise

• Key stakeholders involved

• Two way process

• Support from Trust Exec

• Moving to process driven with further experience

Ambulatory Work at the Royal Free

• Ambulatory Emergency Care Unit run by ED

• CDU

• TREAT ( over age 80)

• PITU ( procedures)

Benefits of ED Led Ambulatory Care

• Patients considered for ambulatorymanagement at first stage of patient journey

• Can flex service to meet demands• Easy for other speciality teams to feed into

service.• Promotes cross speciality learning and

development of new skills

Patient presenting to ED with Ambulatory Care Sensitive Condition

Discharge home via

ED

Short stay on CDU

AECUTREAT

(over 80) Admit under

speciality team

AEC pathways

• DVT / Leg swelling• Cellulitis / Bursitis• Pyelonephritis• Ureteric Colic• PE• Pneumonia• MRI• Diabetes related • Low risk GI bleed

Pathways run via ED

• First fit

• TIA

• SVT /Dysrhythmia

• Urinary retention and catheter change

• Asthma

• Anaemia ( via PITU )

• Pneumothorax

Pathways run via CDU

• Pubic rami #• # not requiring orthopaedic intervention• Non traumatic vertebral fractures• Hip pain secondary to fall and NWB• Head injury• Community acquired pneumonia• Hypoglycaemia• Overdose and poisoning• Seizure in known epileptic• TREAT patients

Practical solutions

Current facilities

Current facilities

Current facilities

Future facilities

Future facilities

Future facilities

Future facilities

Late Summer 2016

AEC Data• 10 months data

Total Weekdays Total

weekend

Total N◦

Patients

F 607 104 711

N 1175 145 1320

1782 249 2031

Referral Complaint %

DVT 35.3%

Cellulitis 25.7%

Renal Colic 16.8%

PE 12.0%

Pyelonephritis 5.9%

Other 2.7%

DVT/Cellulitis 1.4%

Pneumonia 0.2%

AEC Data• 10 months data

Discharge diagnosis %

Cellulitis 25.7%

DVT 25.6%

Renal colic 13.3%

Other 7.9%

PE 6.5%

Non-specific leg pain (e.

musculoskeletal) 5.4%

Pyelonephritis 5.2%

Non-specific chest pain (e.g.

Musculoskeletal)3.8%

Non-specific abdominal pain

/flank pain 1.6%

Mechanical Back Pain 1.0%

Non-specific Swollen leg 0.9%

Baker cyst 0.8%

Pneumonia/chest infection 0.6%

Abscess 0.6%

Thrombophlebitis 0.5%

UTI 0.4%

Cellulitis/Lymphoedema 0.2%

AEC Data• 10 months data

Overall AEC admission rate

Admission 6.0%

Discharge 94.0%

Admission rate 5-main pathways –

by referral complaint

Referral Complaint Admission rate

DVT 2.4%

Cellulitis 7.6%

Renal Colic 8.6%

PE 1.4%

Pyelonephritis 14.5%

Admission rate 5-main pathways –

by final diagnosis

Referral Complaint Admission rate

Cellulitis 8.6%

DVT 2.3%

Renal Colic 9.0%

PE 2.6%

Pyelonephritis 18%

Total Bed days saved 5-main

pathways (10 months)

Annualised bed Days saved Actual Beds saved

2190 2627 7

Before you arrive

How did you feel?

When you arrived

How did you feel?

When you saw the doctor or nurse

How did you feel?

During your treatment

How did you feel?

Next steps/ follow up

How did you feel?

Please circle the words that best describe your feelings at each stage, or write your own words.

What made you feel like this? Was it friendly staff or a long wait- whatever it was, we’d like to know.

We would also appreciate your feedback on specific parts of our service to help us improve.

How was the signage to the unit?

Please rate on a scale of 1-5.

How were the facilities and the environment of

the unit? Please rate on a scale of

1-5.

Did you have to wait a reasonable amount of

time to be seen? Please rate on a scale of 1-

5.

Did you feel informed about your treatment?

Please rate on a scale of1-5.

Did you understand what was going to happen

next? Please rate on a scale of

1-5.

Please review the above on a scale of 1-5. 5- very good 4- good 3- satisfactory 2- poor 1- very poor

Ambulatory Emergency Care- patient experience questionnaire

Patient experience data

Challenges

• Space

• Building work slow, loss of momentum on project.

• Staffing constraints impacting on opening hours.

• Tariff not yet agreed

• Data collection

Next steps

• Implementation of pathways in development

• Development of surgical pathways

• Expand scope of nursing practice

• Introduction of HOT clinics with surgical and medical teams

• Expand scope to more process driven approach

• Development of ambulatory dashboard across both sites.

• Move into new unit and increase hours of operation

• Integration with community based teams

What have we learnt ?

• Champions required

• Patient feedback excellent

• Staff satisfaction

• Working relationships key

• Data collection critical

• Patients over 80 can be ambulated !

• Keep enthusiasm alive