Ambulatory Emergency Care in South Wales
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1 Ambulatory Emergency Care in South Wales The Ambulatory Care Score ( Amb Score) Les Ala Consultant Acute Physician Royal Glamorgan Hospital LLantrisant, South Wales
2
3 ROYAL GLAMORGAN HOSPITAL
4 Format Our current practice and challenges Developing the Amb Score Using the Amb Score Future (near future) plans
5 Our current practice and challenges
6 Challenges of delivering Acute Medicine services at RGH Increase demand Increase referrals for assessment / admission Increase A&E attendance (5% increase every year) Resource constraints Lack of rapid access OPD/Hot specialty-based clinics Lack of staff Reduction in in-patient beds Poor physical planning Inefficiencies End to end walk 30-50% day-time admissions discharged same day from AMU Inappropriate referral to AMU or Ambulatory Care or vice versa
7 How it worked at RGH
8 Acute Medical Unit (AMU) Acute Admissions per day Medical Day Unit (MDU) Ambulatory Care new pts per day M F (9am 5 pm), Acute Physicians cover both: A&E AMU MDU
9 Appropriate place for the patient How to decide Admission vs- Ambulatory Why does it matter? Appropriate use of resource What to bring to hospital No expectation to stay Arrangement for work, carers, family Bed management planning Early senior review in AMU for discharge Possible diversion to rapid access clinics next day
10 Developing the Amb Score
11 Who can be managed in Ambulatory Care Strang, G. The concept, delivery and future of medical ambulatory care. Clin Med 2008; 8:
12 OUR STUDY: Selecting AEC patients from the unselected general medical emergency in-take Phase 1: Derivation of the Amb Score Phase 2: Internal Validation
13 Phase 1 Derivation: May / June 2010 What factors determine whether an emergency-referred GP patient is discharged within 12 hours of arrival in hospital? 282 Emergency GP referrals to on-call medics Discharge within 12 hours (Ambulatory Group) 143 Admitted for 48 hours (Admission Group) 139
14 Variable Admission group (%) n=139 Ambulatory group (%) n=143 Odds Ratio (95% CI) P value Adjusted OR (95%CI) Mean age (SD) 71.2(16.2) 57.2(17.5) <0.01 Age (3.6) 16 (11.2) 0.3 ( ) <0.01 Age (4.3) 20(14.0) 0.3( ) <0.01 Age (7.9) 23(16.1) 0.4( ) <0.05 Age (37.4) 13(9.1) 6( ) < ( ) Male sex 61(43.9) 41(28.7) 1.9( ) < ( ) Can eat / drink normally 132 (95) 143 (100) Undefined Ambulant 124 (89.2) 143 (100) Undefined Access to transportation 54 (38.8) 127 (88.8) 0.07( ) < ( ) Family support or carers available 102(73.4) 128 (89.5) 0.3( ) <0.01 IV treatment not anticipated 74 (53.2) 139(97.9) 0.02( ) < ( ) Not acutely confused 121 (87.1) 141(98.6) 0.05( ) < ( ) No new sphincter problems 131 (94.2) 143 (100) Undefined If chest pains, ACS not suspected 128 (92) 131 (91.6) 1.07( ) 0.44 Significant bleed not suspected 136 (97.8) 131 (98.6) 0.5( ) 0.05 No new neurological deficit 119 (85.6) 134 (93.7) 0.4( ) <0.05 Normal temperature 118(84.9) 129(90.2) 0.1( ) <0.01 Normal respiratory rate 128 (92.0) 103 (72.0) 0.9( ) <0.05 Normal oxygen saturation ( 93%) 112(80.6) 126(88.1) 0.15( ) <0.01 Heart rate bpm 135 (97.1) 133 (93.0) 0.5( ) 0.50 Systolic BP mmhg 121 (87.1) 139 (97.2) 0.2( ) <0.01 MEWS 0 70 (50.4) 104 (72.7) 0.4( ) < ( ) MEWS 2 17(12.2) 5 (3.5) 3.8( ) <0.01 MEWS 3 12(8.6) 4 (2.8) 3.3( ) <0.05 MEWS 4 11(7.9) 2 (1.4) 6( ) <0.01 GCS (92.8) 143 (100) Undefined No past history coronary artery disease 74 (53.2) 85 (59.4) 0.8( ) 0.25 No past history of heart failure 87 (62.6) 97 (67.8) 0.6( ) 0.45 No past history of arrhythmia 77 (55.4) 91 (63.6) 0.6( ) 0.12 No past history of diabetes 74 (53.2) 89 (62.2) 0.5( ) 0.07 No past history of stroke or TIA 82 (59.0) 93 (65.0) 04( ) 0.08 No past history of renal disease 79 (56.8) 94 (65.8) 0.5( ) 0.07 No past history of chromic lung disease 65 (46.8) 79 (55.2) 0.6( ) 0.07 Not discharged within previous 30 days 101 (72.7) 125 (87.4) 0.2( ) < ( )
15 Independent variables Variable Admission group (%) n=139 Ambulator y group (%) n=143 P value Adjusted OR (95%CI) Age (37.4) 13(9.1) < ( ) Male sex 61(43.9) 41(28.7) < ( ) Access to transportation 54 (38.8) 127 (88.8) < ( ) IV treatment not anticipated 74 (53.2) 139(97.9) < ( ) Not acutely confused 121 (87.1) 141(98.6) < ( ) MEWS 0 70 (50.4) 104 (72.7) < ( ) Not discharged within previous 30 days 101 (72.7) 125 (87.4) < ( )
16 The Ambulatory Care Score (Amb Score) Sex Female 0 Male -0.5 Age < Access to personal transport / can take public transport Agree +2 Disagree 0 IV treatment NOT anticipated Agree +2 Disagree 0 NOT acutely confused Agree +2 Disagree 0 MEWS = 0 Agree +1 Disagree 0 NOT been discharged from hospital in the last 30 days Agree +1 Disagree 0 TOTAL Amb Score (Max 8) The higher the Score, the greater likelihood of 12 hour discharge, therefore potentially for Ambulatory Care management.
17 Oral Presentation: 4 th International Conference, Society for Acute Medicine, Edinburgh October 2010
18 Phase 2: Internal validation May/June 2011 Can the Amb Score predict discharge within 12 hours of hospital assessment? 343 Emergency GP and A&E referrals to on-call medics Discharge within 12 hours (Ambulatory Group) 115 Admitted for 48 hours (Admission Group) 228
19 Verification of Amb Score Admission group (%) n=228 Ambulatory group (%) n=115 OR (95% CI) Female sex 97 (42.5) 75 (65.2) 0.4 ( ) p<0.01 Age < (59.6) 108 (93.9) 0.2 ( ) p<0.01 Access to personal / public transport 132 (57.9) 109 (94.8) 0.1 ( ) p<0.01 IV treatment NOT anticipated 82 (40.0) 106 (92.2) 0.1 ( ) p<0.01 NOT acutely confused 198 (86.8) 113 (98.3) 0.1 ( ) p<0.01 MEWS score = 0 72 (31.6) 77 (67.0) 0.2 ( ) p<0.01 NOT discharged within last 30 days 187 (82.0) 106 (92.2) 0.5 ( ) p<0.01 Mean Amb Score (SD) 4.2 (1.8) 7.1 (1.1) p<0.01
20 sensitivity 1 Receiver Operator Curve AUROC 0.91 ( ) specificity If Amb Score 5, patient is more likely to be discharged within 12 hours! Sensitivity: 96% (90-98) Specificity: 62% (55-68)
21 Oral Presentation: 5 th International Conference, Society for Acute Medicine, London, October 2011
22
23 Using the Amb Score
24 BUT DOES IT WORK IN PRACTICE?
25 200 Random patients from General Medical Take May 2012 (AMU patients) Duration of Stay Number Mean Amb Score SD < 12 hours * hours hours >48 hours 128 4* 2.0 Died within 48 hrs p < 0.01 (ANOVA) * P < 0.01 Admitted < 12 hours: 78% had Amb Score 5 Admitted > 48 hours: 42% had Amb Score 5
26 Has the Amb Score enhanced our existing ambulatory care service? Our existing Ambulatory Care Unit is called The Medical Day Unit (MDU)
27 Medical Day Unit 2 Bays in a Ward -5 Trolleys (New Patient Area) - (Red Bay) -2 Trolleys & 3 Chairs (Blue Bay) Opens 8:30 am - 4:30 pm weekdays Office hours ONLY Staff 1 FP1* 1 CT* 1 SpR* 1 Consultant Ward Manager Nursing staff 1 clerical staff / HCSW * Not there all the time (eg..on call)
28 Blue Bay MDU Review of recent discharge from wards INR management in early stages of Rx IV Treatment (Ambulatory) Routine blood transfusion Day Liver / Lung biopsy Endocrine investigations Stable COPD DCCV / AF reviews.etc etc
29 What do we see in (Red Bay) Ambulatory Care (MDU)?
30 What happens when Amb Score introduced? Amb Score after arrival in AMU / A&E: Another 10% diverted to Ambulatory Care (MDU) Amb Score before arrival in AMU (GP referrals): Another 10-20% diverted to Ambulatory Care (MDU)
31 MDU numbers (2012) New Red Bay Reviews Total Blue bay Total July Aug Sep Oct Nov Dec
32 What happens next? FRONT DOOR EARLY ASSESSMENT.
33 What next?...as of July Trolleys near A&E All medical on call patients pass through 4 hours max. stay
34 Acute Medical Unit (AMU) Acute Admissions per day Medical Day Unit (MDU) Ambulatory Care new pts per day The New MCDU A&E
35 How it should work AMU / CCU / ITU Unwell Amb Score < 5 -On call junior team -Physician for the day (Acute Physician advice if necessary) A&E GP General Medical in-take MCDU (8-6 M-F) Triage NEWS Amb Score Rapid Assess Acute Medicine Team Clinically well Amb Score 5 Direct referral if obvious AEC patient MDU ( , M-F) Acute Medicine Team
36 But beware of other decisions..
37 In RGH, lost 125 Acute and Rehab beds
38 In reality now AMU / CCU / ITU / Ward In reality.patients for admission wait in MCDU and A&E (including Corridors) Admission ONLY IF BED EXISTS!! A&E GP General Medical in-take MCDU Opens 24 / 7 Triage Amb Score Quick Assess MCDU Opens 24 / 7 Clerked PTWR ACP (9-5 M to F) POD (after hours) Discharge Direct referral if obvious AEC patient Clinically well Amb Score 5 MDU ( , M-F) Acute Medicine Team
39 Then what.? Role out Amb score to GPs Robust data systems to monitor outcomes Cost savings Impact of workload of AMU / AEC patients Readmission rates Patient / staff feedback What else? Larger study, different locality and geographical areas
40 Summary Our process (somewhat rather inefficient, in my view) in managing Acute Medicine patients Simple tool that MAY help in AEC management in OUR locality If you think it might help you, please try it out.
41 Diolch yn fawr Questions?
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