The Amb Score. A pilot study to develop a scoring system to identify which emergency medical referrals would be suitable for Ambulatory Care.

Transcription

1 The Amb Score A pilot study to develop a scoring system to identify which emergency medical referrals would be suitable for Ambulatory Care. Les Ala 1, Jennifer Mack 2, Rachel Shaw 2, Andrea Gasson 1 1. Department of Acute Medicine, Royal Glamorgan Hospital, South Wales 2. 3 rd Year Medical Student, Cardiff University 4 th International Conference, Society for Acute Medicine, Edinburgh 7-8 October 2010

2 Format Background Aim Methods Results Conclusions Questions

3 Background In our DGH patients seen by on call Medical team in 24 hours % discharged same day Acute Medical Unit (Admissions hours Many medical emergencies can be managed in ambulatory care 1,2 1. Strang G (2008) 2. Connolly v, Hamad M (2008)

4 Which patients do not require admission? MEWS 1 identifies acutely ill patients at risk of immediate deterioration Other Scores (HOTEL 2, SCS 3 ) predict mortality SEWS 4 correlates with in-hospital mortality and length of stay Current scores rely on clinical parameters and tests (eg ECG) measured after arrival in hospital Limited data on identifying ambulatory patients 1.Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified Early Warning Score in medical admissions. Q J Med 2001; 94: Kellet J, Deane B, Gleeson M. Derivation and validation of a score based on Hypotension, Oxygen saturation, low Temperature, ECG changes and Loss of independence (HOTEL) that predicts early mortality between 15 min and 24 h after admission to an acute medical unit. Resuscitation 2008; 78: Kellet J, Deane B. The Simple Clinical Score predicts mortality for 30 days after admission to an acute medical unit. Q J Med 2006; 99: Paterson R, MacLeod DC, Thetford et al. Prediction of in-hospital mortality and length of stay using an early warning scoring system: clinical audit. Clin Med 2006; 6:

5 Why the need to know beforehand if admission or ambulatory? Appropriate arrangements for Home Work Social services Care agencies Appropriate amount of personal belongings Admission paperwork Bed Management

6 Aim Identify factors for a scoring system Predict who could be discharged same day (within 12 hours) A surrogate marker for ambulatory care Clinical, demographic, social Simple to use Easily calculated in community

7 Methods Cross-sectional study (RGH) All emergency referrals to Medicine from GPs Over a 4 week period (May / June 2010) Study population divided into 2 groups Discharged 12 hours (Ambulatory cases) Admitted for 48 hours (Admission cases) Routine data extracted from GP letter, Ambulance notes, Bed Management notes, Medical & Nursing notes Data on Social, demographic and clinical aspects collected using questionnaire Analysis using Epi Info 2000 Version (CDC Atlanta 2008)

8 282 patients Results 64 % females, 36% males Age Males (Mean age 67, SD 16) Females (Mean age 63, SD 19) Number in each group Ambulatory Cases: 143 (50.7%) Admission Cases: 139 (49.3%)

9 Which factors were NOT significant?

10 Which factors WERE significant?

11 Which factors WERE significant?

12 Independent factors Independent Factor Ambulatory or Admission Adjusted Odds Ratio (95% CI) Male sex Admission 1.9 ( ) Age 80 Admission 2.4 ( ) Access to transportation Ambulatory 0.1 ( ) IV treatment not anticipated Ambulatory 0.1 ( ) Not acutely confused Ambulatory 0.1 ( ) MEWS zero Ambulatory 0.5 ( ) Not discharged within last month Ambulatory 0.3 ( )

13 The Amb Score

14 Amb score Admission group. Number (%) Ambulatory group. Number (%) Odds Ratio (95% CI) p 0 1 (0.7) 0 (0.0) undefined (2.2) 0 (0.0) undefined (8.6) 1 (0.7) 13.3 ( ) < (20.1) 1 (0.7) 35.6 ( ) < (25.2) 6 (4.2) 7.6 ( ) < (22.3) 12 (8.4) 3.1 ( ) < (14.4) 53 (37.1) 0.3 ( ) < (6.5) 69 (48.3) 0.1 ( ) < An Amb Score of 6 or 7 is associated with a likelihood of being in the Ambulatory group An Amb Score of 5 or below is associated with a likelihood of being in the Admission group.

15 Conclusions Simple, readily available parameters Does not require extra information from hospital tests Useful guide for GPs and patients to predict likelihood of same day discharge, before arrival in hospital BUT: Informed clinical judgement of referring GP takes precedence

16 Limitations Small pilot, limited numbers Specific local setting (in hospital) Ideally, need larger community-based study to: Verify the factors Validate the scoring system Within current locality Within different locality (eg urban area, different rural area)

17 Any questions?