Same Day Emergency Care - RCP London
Transcript of Same Day Emergency Care - RCP London
Same Day Emergency Care
NotSDEC chairs ( not to be confused with the Titanic )
NotAmbulatory Emergency Care
Dr Vincent ConnollyExecutive Medical DirectorNorth Cumbria IHCS
Patients can be referred to SDEC treatment through a number of different ways, including:
• triage in emergency departments (EDs)• direct referral from GPs• direct transfer from ambulance • direct referral from NHS111
Types of SDEC treatment include:
• acute medical SDEC • surgical SDEC• acute frailty
NHS Long Term Plan
All hospitals with a 24 hour ED (type 1) will provide:
• the provision of SDEC at least 12 hours a day, 7 days a week by September 2019 and by March 2020 for surgical SDEC
• an acute frailty service at least 70 hours a week by December 2019, with the aim to complete a clinical frailty assessment within 30 minutes of arrival in the ED/SDEC unit
• record all patient activity in EDs, urgent treatment centres and SDECs using same day emergency care data sets in April 2020.
https://improvement.nhs.uk/resources/same-day-emergency-care
What is the ambition for SDEC?
The headline for SDEC
This will increasethe proportion of acute admissions discharged on the day of attendance from a fifth to a third
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 & 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
Cohort Seven
• Buckinghamshire• Colchester• Medway• Morriston, Swansea• Neath Port Talbot• North Bristol• North Middlesex• Oxford• Princess of Wales, Bridgend• Singleton, Swansea• Sunderland• West Suffolk
Cohort Eight
• Ashford & St Peters• Barking, Havering & Redbridge• Blackpool• Heart of England• Homerton• Llandough• Maidstone & Tunbridge• Rotherham• Sherwood Forest• University Hospital Wales
Cohort Nine
• Barts Health• Bedford• Brighton & Sussex• Dorset• Frimley Park• Huddersfield & Calderdale SRG• Hull & East Yorkshire• Mid Cheshire• Mid Yorkshire• North Cumbria• Poole• United Lincolnshire• Warrington CCG• Wirral
Cohort Ten
• Airedale• East Lancashire• Hampshire• Lancashire• Pennine• Princess Alexandra Hospital, Harlow• Royal Devon & Exeter• Southampton
Default to Day Surgery
Suitability for day surgery Pathway
Clearly suitable
Unsure
Clearly unsuitable
Day surgeryHome if ok
Inpatient care? Home if ok
Inpatient careHospital stay
20–30%
5–20%
40–65%
Clinical Scenario
• 17y old woman
• Type 1 diabetes
• Symptomatic
• Blood glucose 27mmol/l
• Blood ketones 2.5
• SDEC?
Diagnostic criteria for DKA
Ketonaemia > 3.0mmol/L or significant ketonuria (more than 2+ on standard urine sticks)
Blood Glucose > 11 mmol/l or know diabetes
Bicarbonate < 15 mol/l and/or venous pH < 7.3
Clinical scenario
• 55y old male
• Several weeks of intermittent severe headache, left eye pain
• Holding head
• Bloodshot eye
• SDEC?
Management of cluster headache
Discuss the need for neuroimaging for people with a first
bout of cluster headache
Offer oxygen and/or a subcutaneous or nasal triptan for the
acute treatment of cluster headache. 100% flow at least 12 l
per minute, consider home oxygen
Do not offer paracetamol, NSAIDs, opioids, ergots or oral
triptans for the acute treatment of cluster headache.
Clinical Scenario
• 55 y old man
• Drinking
• After several vomits, small amount of haematemesis
• HR 90 bpm BP 128/76
• SDEC?
Glasgow Blatchford score
Admission risk marker Score component value
Blood Urea (mmol/L)[5]
6.5-8.0 2
8.0-10.0 3
10.0-25 4
>25 6
Haemoglobin (g/dL) for men
12.0-12.9 1
10.0-11.9 3
<10.0 6
Haemoglobin (g/dL) for women
10.0-11.9 1
<10.0 6
Systolic blood pressure (mm Hg)
100–109 1
90–99 2
<90 3
Other markers
Pulse ≥100 (per min) 1
Presentation with melaena 1
Presentation with syncope 2
Hepatic disease 2
Cardiac failure 2
Clinical scenario
• 55y old man
• In ED
• Drinks 1 l of vodka per day
• Distressed
• Unkempt wants emergency detox
• SDEC?
Clinical Scenario
• 55y male in ED
• Faint lightheaded at the toilet
• Brief LoC
• Previous admission with abdominal pain
• Admit to SDEC ?
San Fransisco Syncope Rules
C - History of congestive heart failure
• H - Hematocrit < 30%
• E - Abnormal ECG
• S - Shortness of breath
• S - Triage systolic blood pressure < 90
Clinical Scenario
• 55 y old man
• Breathlessness, PND, ankle oedema
• HR 120bpm BP 110/70
• ECG tachycardia, non-specific t-wave changes
• Cardiomegaly
• SDEC?
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01/10/201101/12/201131/01/201201/04/201201/06/201201/08/201201/10/201201/12/201231/01/201302/04/201302/06/201302/08/2013
Address this with anonymised data, constructive individualised feedback, joint rounds, coaching, developing pathways for high volume scenarios
Huge variation in clinical practice
Going for lunch8.00 8.30 9.00 9.30 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00 15.30 16.00 16.30 17.00
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Measure the backlog
Increased admission rate8.00 8.30 9.00 9.30 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00
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Going for lunch & increased admissions & handover8.00 8.30 9.00 9.30 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00 15.30 16.00 16.30 17.00 17.30 18.00 18.30 19.00 19.30 20.00 20.30 21.00 21.30 22.00 22.30 23.00 23.30
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At 5pm7 patients waiting to be seenMax wait 5.5 hours
SDEC Quality ImprovementCasefile analysis
Managed in AEC Not managed in AEC
Conversion
Appropriate for AEC Group 1: Success(expect about 10% conversion rate)
Group 3: Missed opportunity
Not appropriate for AEC
Group 4a: Waste(patient could be managed in another outpatient service)
Group 2: Success(appropriate inpatient care)
Group 4b: Risk(patient too sick/complex at time of selection)
Programme Sustainability Score
Top 3 areas for action are:
1. Senior Leadership Engagement
2. Infrastructure for Sustainability
3. Clinical Leadership Engagement
Gap between average score and maximum
ranked by decreasing gap
Elements of quality in designPatient Experience
The components of good design
Berkun, 2004 adapted by Bate
Performance
How well it does the
job /is fit for
the purpose
Functionality
Engineering
How safe, well
engineered and
reliable it is
Safety
The aesthetics
of experience
How the whole
interaction with the
product/service
‘feels’/is experienced
Usability