Ambulatory Emergency Care.What is it, why do we need it and how to do it.

Dr Ian SturgessAssoc Med Dir – Patient SafetyEast Kent Hospitals University NHS TrustClinical Lead – Delivering Quality and Value

Ambulatory Emergency Care

What is it?• Primary Care?• Community Care?• Simplistic shift?• Or a new way of integrated working?• Akin to the development of Day Case Surgery

What is Ambulatory Emergency Care?

RCP (L) Acute medicine taskforce:-

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.

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 care home admissions

Ambulatory Emergency Care

Why do we need it?• Acute care activity• Demographic shift• Changing capacity• Understanding bed swings

Emergency Admissions England 1998 to 2006

0

1000000

2000000

3000000

4000000

5000000

1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

Adm

issi

ons

? Impact of 4 hour target

Actual and Predicted Age Distribution UK, 1981 to 2056

Average daily number of available beds England, 1987-88 to 2006-07

0

50,000

100,000

150,000

200,000

250,000

300,00019

87-8

8

1989

-90

1991

-92

1993

-94

1995

-96

1997

-98

1999

-00

2001

-02

2003

-04

2005

-06

Num

ber o

f bed

s

Day onlyMaternityLearning disabilityMental illnessGeriatricAcute

Short Stay Unit

Home

Social care

D+T -OPA

ICSpecialist units

MAU - Decision to admit

Churn

Handover

Handover

?Handover

Handover

Traditional Model for Acute Medicine

GP referrals

A+E referrals

Handover

In-day variation mismatchadmissions & discharges

In-day Emergency bed swing = 33

-60-40-20

0204060

Emergency admissions and discharges by hour of day for week beginning Monday 01/10/07 EKH

0

5

10

15

20

25

30

35

00.0

0 to

00.

59

12.0

0 to

12.

59

00.0

0 to

00.

59

12.0

0 to

12.

59

00.0

0 to

00.

59

12.0

0 to

12.

59

00.0

0 to

00.

59

12.0

0 to

12.

59

00.0

0 to

00.

59

12.0

0 to

12.

59

00.0

0 to

00.

59

12.0

0 to

12.

59

00.0

0 to

00.

59

12.0

0 to

12.

59

time of day

num

ber o

f em

erge

ncy

adm

issi

ons

and

disc

harg

es

Average daily emergency admissions = 160

No of emergency admissionsEKH 2007

-40

10

60

110

160

210

260

01/0

1/20

07

01/0

2/20

07

01/0

3/20

07

01/0

4/20

07

01/0

5/20

07

01/0

6/20

07

01/0

7/20

07

01/0

8/20

07

01/0

9/20

07

01/1

0/20

07

01/1

1/20

07

01/1

2/20

07

date

nubm

er o

f em

erge

ncy

adm

issi

ons

Average daily emergency admissions = 160

Nubmer of emergency discharges EKH 2007

-40

10

60

110

160

210

260

01/0

1/20

07

01/0

2/20

07

01/0

3/20

07

01/0

4/20

07

01/0

5/20

07

01/0

6/20

07

01/0

7/20

07

01/0

8/20

07

01/0

9/20

07

01/1

0/20

07

01/1

1/20

07

01/1

2/20

07

date

num

ber o

f em

erge

ncy

patie

tns

disc

harg

ed

Average emergency discharges 160

Average daily emergency discharges = 160Day to Day Emergency bed sw ing

-150

-100

-50

0

50

100

150

01/0

1/07

01/0

2/07

01/0

3/07

01/0

4/07

01/0

5/07

01/0

6/07

01/0

7/07

01/0

8/07

01/0

9/07

01/1

0/07

01/1

1/07

01/1

2/07

date (midnight)

Emer

genc

y ad

mis

sion

s le

ss

disc

harg

es= 190 bed swing

Day to day emergency bed swing

Consequences of admissions & discharges variation mismatch

Backlog guaranteed:– Patients stored in ‘Assessment Units’– A&E flow compromised– Patients to the wrong wards

• Outliers

Additional Cost: – Overtime, locum, agency and opening wards

Quality– HSMR and harm events– Patient and staff experience

Total In-patients Pareto: cumulative beds occupied by LOS

Cumulative beds occupied by all in-patients EKH 2007

cum

ulat

ive

beds

occ

upie

d (0

00)

050

100150200250300350400450

1 13 25 37 49 61 73 85 97 109 121 133 145 157 169 181 193

LOS (midnights)

5% of all patients who spent 24 + midnights in hospital occupy 38% of the bednights

80% of patients who spent up to 7 midnights occupy 32% of the bednights

50% of all patients who spend up to 2 nights occupied 11% of the bednights

Ambulatory Emergency Care

How to do it:• Opportunities• Implementation

– Structure – physical and organisational – People and behaviours– Processes – bundles + safety

• Measurement– Process metrics– Outcome metrics– Balancing metrics

• Engaging clinicians• Focus on quality and safety• Whole system planning • Horizontal integration• Joint clinical, managerial and financial

governance framework• Aligning financial incentives

Critical Success Factors

South East Coast Strategic Health Authority Opportunities Assessment

0.8%0.5%2,0411,361GM14 First seizure0.8%0.5%2,0631,375GM15 Seizure in known epileptic1.1%0.6%3,0371,518GM10 Supraventricular tachycardias1.1%0.6%3,0551,527GM08 Lower respiratory tract infections without COPD1.0%0.6%2,5971,731GM29 Deliberate self harm1.0%0.7%2,7981,865GM24 Cellulitis1.3%0.8%3,4112,274GM31 Falls including syncope or collapse1.5%1.0%4,1092,739

TO02 Appendicular fractures not requiring immediate internal fixation

2.2%1.1%5,7872,894GS01 Acute abdominal pain not requiring operative intervention

2.4%1.2%6,2923,146GM11 Chest Pain267,712267,712Total admissions

% of total admissions

(upper)

% of total admissions

(low)

No. of Ad. Ad. - Upper

No. of Adj. Ad. - LowClinical Scenario

22.2%12.9%59,42334,469Total Emergency Care Admissions

Etc etc

South East Coast Strategic Health Authority Opportunities Assessment

0200400600800

1,0001,2001,4001,6001,8002,000

Brighton& Hove

City

EastSussex

Downs &Weald

Eastern& Coastal

Kent

Hastings& Rother

Medway Surrey WestKent

WestSussex

SEC SHAAreaTotal

Cru

de ra

te p

er 1

00,0

00

resi

dent

pop

ulat

ion

Primary Care Trust

RCP Acute Medical Care‘Emergency Floor’

“Minor”

“Life -Threatening”

“Emergency”(for Admit.)

“Emergency”(For assessment)

ENP Home (Always)

Theatre, Critical Care, Tertiary

Emergency N

eeds Assessm

ent Service

Emergency C

are Centre

Level of NeedAssessment

1st Line Treatment and algorithmic assessment

1st Line Treatment and algorithmic assessment

Rapid Diagnostics & Further Treatment

Home +/-Support (Usually)

LEVEL OF CAREStreamed by LOSShort Stay, GIMSpeciality unit

“Emergency”(Specialty)

1st Line Treatment and Algo. Assess.(Always)

ResuscitateStabilise

1stLineTreatmentSpecialist Team

SPEC. UNITCCUStrokeVascular.

FAST - TRACK

FAST - TRACK

Kent and Canterbury Hospital –Emergency Care Centre

Behaviours

Effective clinical decision at point of entry - competency and seniority – being there!:

1o Diagnosis (or differential)Co-morbidity diagnoses + functional/social problemsCase management plan:

• ZLOS - 1o care/IC/SC/OPA/Joint care (Teams ¢ walls)• Non ZLOS:

– Why ‘admission’ required – monitoring/interventions– Investigations/interventions – not just what but when and make it

happen!– Clinical criteria for discharge + Expected LOS – date and time– Stream by LOS– What to expect post-discharge – recovery + follow up

Processes

Remove redundant steps• Point of entry – decision making team at front of house• Handover = delayed decisions = increased LOS

Reduce variation in emergency discharges• Reduce internal batching and carve-out

• Eg Batch ward rounds on-call• Eg Twice weekly Ward rounds• 24/7 + 7/7 demand and 7.5/24 + 5/7 capacity• Standardisation of processes

Segmentation of patient by LOS• Principle of lanes on a motorway

• Different process speed and variation• Standardise case management processes where possible

Managing Length of Stay

0

50

100

150

200

250

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59

Length of stay (days)

Num

ber o

f pat

ient

s

Green bed days vs red bed days –flow management – making it happen!

Maximise ambulatory care

Complex support needs – but how much is hospital based decompensation?

Segmentation by LOS - 1

Short Stay - Locus of control = Internal:• Zero LOS and Short Stay (2 days or less) – up to

65% of all admissions - never hand over – EDD to the minute/hour!

• Left shift to ambulatory care• Big impact on within day and day to day variation in

demand – hourly drum beat• Generalist skills + standardisation (decision making

and case management)• Senior decision making and diagnostics available 8 a.m. to 10 p.m.

Ambulatory Bundles

• Common assessments• Linked diagnostics• ‘Shared’ pathways of care• Provide ‘bite sizes’ of the elephant!

Ambulatory Bundles

• ‘Respiratory/leg bundle’– DVT– Cellulitis– Pulmonary embolism– Pleural effusion– Pneumothorax– Community acquired pneumonia– COPD

Ambulatory Bundles

• Frail Older People Bundle– UTI in older people– Fractures not requiring surgery– Falls– Care Home Admissions– End of life care

Building a Cascading System of Measures

Board & CEO

Service Line

Physician & Patient

Microsystems: Units, Depts

Outcomes – High level - Macro MetricsL 1

L 2

L 3

L 4/ 5

Adapted from Lloyd & Caldwell

Outcomes + Processes - Meso Metrics

Individual Metrics - Processes

Bal

anci

ng M

easu

res

Processes (+ Outcomes) -Micro Metrics

Combined Medicine Admissions (Excl ZLOS)

KCH

QEQM

WHH

0

100

200

300

400

500

600

700

800

900N

ov-0

4

Jan-

05

Mar

-05

May

-05

Jul-0

5

Sep-

05

Nov

-05

Jan-

06

Mar

-06

May

-06

Jul-0

6

Sep-

06

Nov

-06

Jan-

07

Mar

-07

May

-07

Jul-0

7

Sep-

07

Nov

-07

Jan-

08

Mar

-08

May

-08

Num

ber o

f adm

issi

ons

by s

ite

Month

Zero LOS Admissions

0

100

200

300

400

500

600

700

Nov

-04

Jan-

05

Mar

-05

May

-05

Jul-0

5

Sep-

05

Nov

-05

Jan-

06

Mar

-06

May

-06

Jul-0

6

Sep-

06

Nov

-06

Jan-

07

Mar

-07

May

-07

Jul-0

7

Sep-

07

Nov

-07

Jan-

08

Mar

-08

May

-08

KCH

QEQM

WHH

ECC

Acute Physician

Launch Directory

Num

ber o

f adm

issi

ons

by s

ite

Month

Combined Medicine LOS (Excl zero LOS)

KCH

QEQM

WHH

0

2

4

6

8

10

12

14N

ov-0

4

Jan-

05

Mar

-05

May

-05

Jul-0

5

Sep-

05

Nov

-05

Jan-

06

Mar

-06

May

-06

Jul-0

6

Sep-

06

Nov

-06

Jan-

07

Mar

-07

May

-07

Jul-0

7

Sep-

07

Nov

-07

Jan-

08

Mar

-08

May

-08

KCH

QEQM

WHH

Ave

rage

leng

th o

f sta

y (D

ays)

Month

Emergency Re-Admission Rates

6.0%

6.5%

7.0%

7.5%

8.0%

8.5%Ap

r-06

Jun-

06

Aug-

06

Oct-0

6

Dec-

06

Feb-

07

Apr-0

7

Jun-

07

Aug-

07

Oct-0

7

Dec-

07

Month

% 2

8 da

y re

-adm

issi

ons

HSMR - non-elective

50

60

70

80

90

100

110

120

1301/

1/20

04

4/1/

2004

7/1/

2004

10/1

/200

4

1/1/

2005

4/1/

2005

7/1/

2005

10/1

/200

5

1/1/

2006

4/1/

2006

7/1/

2006

10/1

/200

6

1/1/

2007

4/1/

2007

7/1/

2007

10/1

/200

7

1/1/

2008

28 Day Mortality RateIn or out of hospital

5.6%

5.8%

6.0%

6.2%

6.4%

6.6%

6.8%

Apr-0

6Ma

y-06

Jun-

06

Jul-0

6Au

g-06

Sep-

06

Oct-0

6No

v-06

Dec-

06Ja

n-07

Feb-

07Ma

r-07

Apr-0

7Ma

y-07

Jun-

07Ju

l-07

Aug-

07Se

p-07

Oct-0

7No

v-07

Dec-

07Ja

n-08

Month

Indi

vidu

al V

alue

Acute Care Institutionalisation Rate

1.40%

1.60%

1.80%

2.00%

2.20%

2.40%

2.60%

Apr-0

6

May-

06

Jun-

06

Jul-0

6

Aug-

06

Sep-

06

Oct-0

6

Nov-

06

Dec-

06

Jan-

07

Feb-

07

Mar-0

7

Apr-0

7

May-

07

Jun-

07

Jul-0

7

Aug-

07

Sep-

07

Oct-0

7

Nov-

07

Dec-

07

Jan-

08

Month

Indi

vidu

al V

alue

Directory of Ambulatory Emergency Care for AdultsSummary• An enabling document• Focussing on the patient’s outcome, safety and

experience• Evaluate current opportunities• Select a small ‘set’ and build on success• Horizontal integration – true joint working• Joint clinical, managerial and financial governance

• NOT – a demand management tool• NOT – a performance management tool• NOT – a simplistic shift tool

And finally: