WORKSHOPHow do we manage acute care as

safely as a day case.The hospital without walls – delivering

ambulatory emergency care

Dr Ian SturgessClinical Lead, Intensive Support Team

Urgent and Emergency Care

• Ambulatory emergency care (AEC) vs ambulatory care sensitive conditions (ACS)

• AEC is a different way to manage patients who have an acute illness.

• AEC is to emergency care, as day case surgery has been to elective care.

• ACS conditions are where better long term condition management or preventative healthcare avoids the development of the acute condition.

• They are complementary but the impact is at a different point in the care continuum.

Ambulatory Emergency Care - Concept

A whole system perspective

Preventative/Predictive careDisease managementManaged populations

Alternatives to acute admission settings

Alternative access for diagnosis

Alternative settings for therapy

Alternative sites for discharge

Alternative sites for readmission

Health Promotion

General Practice & GP OOH

Community Support

Ambulance Service & GP

OOHA+E MAU/SAU/

Short Stay

Focus on CDM and more effective responses to urgent care needs – ACS condition management

Clear operational performance framework and integrated in to primary careImproved integration with primary care responders

Front load senior decision process incl primary care

Redesign to left shift LOS

Inpatient Wards

Optimise ambulatory emergency care

Information flow converting the unheralded to the heralded

Discharge Process

Categories of Ambulatory Emergency Care

1. Diagnostic exclusion group• Eg chest pain rule outs etc (many already in place)

2. Low risk stratification group• Eg low Rockall score GI bleed

3. Specific procedural group• Eg effusion drainage

4. Infra-structural group• Eg advanced care planning for nursing homes

Ambulatory Emergency Care

How to do it:OpportunitiesImplementation

Structure – physical and organisational People and behavioursProcesses

BundlesReliability

MeasurementOutcome metricsProcess metricsBalancing metrics

NHS South East Coast – 2007/08 Opportunities Assessment – Non-Zero LOS Admissions

0.54%0.38%1,9761,389GM14 & 15 First seizure and seizure in known epileptic

0.58%0.39%2,1371,422GM10 Supraventricular tachycardia0.58%0.34%2,1401,262GM08 LRTI without COPD0.76%0.57%2,7882,094GM29 Deliberate self harm0.78%0.54%2,8871,977GM24 Cellulitis0.91%0.64%3,3392,373GM31 Falls including syncope or collapse1.21%0.83%4,4533,061

TO02 Appendicular fractures not requiring immediate internal fixation

0.69%0.60%2,5532,206GS01 Acute abdominal pain not requiring operativeintervention

0.99%0.88%3,6383,227GM11 Chest Pain368,762368,762Total admissions

% of total admissions

(upper)

% of total admissions

(low)No. of Ad.

Ad. - UpperNo. of Adj. Ad. - LowClinical Scenario

18.1%12.2%46,11132,186Total Non-zero LOS Emergency AdmissionsEtc. etc.

Phase 1 - Project Set Up

Pick Conditions

Identify Team

• Clinical lead(s): clinicians should be willing to take the lead and to think beyond their own specialties

• Nursing lead: the lead doctor and lead nurse should work closely together to develop and implement new processes

• Senior manager support preferably at executive level: dynamic management is invaluable in coordinating supporting processes

• Primary care and/or PCT representation • Assessment Unit - If you have an Assessment Unit, be sure to

have at least one representative from this unit in your group.• Stakeholders - diagnostics, AHPs etc

Establish Measures and Objectives

Planning and Implementation

The Reliable Design Strategy1. Segmentation – volume and engagement

2. High level process map • identify the bottlenecks

3. Prevent initial failure using intent and standardization

4. Identify defects and mitigate• using redundancy and contingency

5. Measure and then communicate learning from defects back into the design process

The Model for Improvement

1. Clear and measurable aims•How much•By when•How measured

2. Real time measurement•Outcome•Process•Balancing

3. Small tests of change•Plan, Do, Study, Act (PDSA)•Start tomorrow!

Model for Improvement

What changes can we make that will result in an improvement?

What are we trying to accomplish?

How will we know that a change is an improvement?

Act Plan

Study Do