I’m really looking forward to the panel discussion in September at the National Health Executive NHS Emergency and Urgent Care conference.
The focus of the panel will be on preventing admissions. We’ve seen, and now have fairly good evidence, that preventing attendance to ED/UEC isn’t an effective strategy to improving ED performance. One of the key areas we’ve been working on for the last couple of years has been admission avoidance – particularly for patient groups who have a short length of stay, between one and three days.
Consider the following story – Dave is a 48 year-old chap who goes to see his GP around 1pm with an episode of upper abdominal pain and vomiting. The GP wonders if this may be biliary colic or cholecystitis and wants to refer the patient to his local hospital for blood tests, ultrasound and review by a surgeon. What are the options open to the GP – she could send Dave directly to the ED with a letter requesting a surgical consultation, she could phone the hospitals admission line and see if Dave could be seen in the surgical assessment unit (if there is space). If Dave is still in excruciating pain or has a high National Early Warning Score (NEWS) these are certainly potential possibilities. If we follow this route it’s likely Dave will attend either SAU or the ED and get seen and clerked, but it’s likely too late in the day for any further investigation beyond blood tests till tomorrow, so Dave will sit in a cubicle and bed space for the next 12-24 hours awaiting these tests (depending on how soon they get requested and approved). If we rewind to the previous day however, and Dave’s observations are normal and his pain has settled for now, he still may need to attend the hospital but now this could be to an appointment on the surgical same day emergency care (SDEC) to be seen directly by a Consultant and have an ultrasound done in specific time slot that is already assigned to that clinic and having a plan to be managed as an outpatient to the point of cholecystectomy if confirmed.
For better or worse, acute admissions come with risks and delays at all points in the patient’s journey. Ambulatory care services have usually been designed with specific focus on optimised workflows for patients to be seen and managed in a timely and effective manner. They can be capacity constrained and there is potentially risk involved in allowing patients to go home or to delay their attendance to site, but provided there is good safety netting and that the access is provided within a 24 hour period, in many cases this can help avoid patients sitting in chairs or trolleys in cubicle spaces with very little happening through the evening and overnight period when they could be far more comfortable at home with a planned attendance the next day.
There are a host of conditions that can be managed in this way – so much so there is an AEC directory of these conditions and an RCEM Toolkit (https://rcem.ac.uk/wp-content/uploads/2021/10/RCEM_Ambulatory_Emergency_Care_Toolkit_Feb2019.pdf) to support service development for these conditions. The following is not exhaustive but provides examples of conditions that can be managed on an ambulatory basis through an emergency care area and where admissions can potentially be avoided. Certainly short stay admissions waiting for investigations the next day when not with the patient may well be able to go home and return to the department tomorrow ina planned manner.
- Low risk chest pain
- Cellulitis
- Suspected DVT
- Suspected Pyelonephritis
- Suspected PE, Headache
- TIA
- Low risk Upper GI bleed
- Low CURB pneumoniaRenal Colic
- Catheter problems
- Low risk abdominal pain
- Low risk AKI
- Electrolyte disturbance
- Early pregnancy.
As you can see from the list, there are a mix of medical and surgical conditions that can be managed in this way. These are the groups of patients who predominantly make up the short length of stay group (one to three days) that will be trying to target with admission avoidance. We have seen that within our acute medical team in Leeds, they have avoided 300 short admissions a month by providing ambulatory care services through an SDEC. For many of these patients there isn’t a great deal that happens in the journey and the overnight period from being admitted one evening to the following day when the investigations can take place, sot it makes complete sense to manage these patients in a planned manner, maintaining beds and capacity for patient flow for those who truly need to be admitted overnight.
There are systems available within an ICS to again try and prevent admission to hospital. Urgent Community Care Response have a two hour window to respond to patients in the community with a list of nine different conditions where care in their own home can often prevent tendons at the ED that usually leads in this patient group to subsequent admission. The urgent care response for these conditions can also help remove stress and strain on the ambulance service where these calls often start as category three or four calls but will get upgraded to category two due to the time taken to get to the patient. Across the development of these strategies to manage patients in their own home, preventing hospital attendance and combined with the short length of stay admission avoidance work to provide that care in a more planned manner through an SDEC within the first 24 hours of that patient presenting to UEC services are always in which the limited capacity that we have got can be optimised for those patients who truly need an admission and to try and maximise flow through the emergency department.
But what about risk? Admission to hospital is not without risk of pressure sores, infection, falls, clinical error in the same way what we want to avoid is a patient deteriorating at home and then not being able to access services where their condition may have been very clearly treatable. Patient selection for these pathways is therefore a key component of the service design. Ideally any high risk factors mean that patients are not managed through an ambulatory pathway. There is always some degree of risk involved (that is what is required otherwise all patients will be admitted 100%of the time, and there will be even less flow out of the emergency department). As such, it is a balance of the conditions that have been listed as suitable for ambulatory emergency care, and where short admission avoidance works, where we know there is actually relatively small chance of rapid deterioration. Cases who are usually stable and with low probability of serious pathology rather than the high probability that are suitable for these pathways. The aim is also that the care is delivered within the first 24 hour period and so it is not adding unnecessary delay to the diagnosis. Certainly a service where the next available appointment wasn’t for three or four days would not be meeting the safety requirements of an SDEC service. Close monitoring outcomes for patients managed in this way should be done to maintain safety and ensure the right patients have been selected, with the right number of patients progressing through these pathways to make it worthwhile and to make it safe.
Virtual wards are another option to help avoid admission, particularly for patients who need repeat or follow-up blood tests or monitoring following initial treatment. There are community matrons for patients in the community and they will usually have access to consultant lead care at the end of the phone for further discussion regarding admission if required. The safety netting through daily visits by experienced community team helps provide assurance and reduce the risk for patients being discharged at home rather than being admitted with low or chronic conditions that can be managed in the community.
Stuart.