Ambulatory Emergency Care The role of the ED - a journey travelled!
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1 Ambulatory Emergency Care The role of the ED - a journey travelled! Dr Taj Hassan President RCEM Twitter
2 WHERE? WHAT? HOW?
3
4 Drivers for change Demand Value for money Patient centred care Delivering quality Expectations
5 The system
6 Streaming & ambulatory care strategies ED & CDU The Emergency Dept 999 Resuscitation ITU/HDU Self referral 111 GP referrals HOME Paediatric ED Clinical assessment (majors) CDU / Observation Unit Minors / ambulatory In-hospital bed base M.A.U 6
7 Ratios of patient age by ED attendances RCEM Drive for Quality 2012
8
9
10 Finding the target population for ambulatory assessment and management Critically ill or Injured ITU care Clinically unstable - likely acute severe illness/injury (LOS >4days) specialty care Clinically stable - Moderate / high risk of significant illness. (LOS 1-4 days) specialty care / Acute Medicine / surgery Increasing use of resources Clinically stable - possible occult illness /injury with likelihood of early discharge ( 6-24hrs) Obs Med (CDU or ED ambulatory care. 10
11 The quality issue
12 The existing 4 hr ECS standard why we need to change? Domain Metric Quality assurance Safety Clinical care 4hr transit through ED performance metric System performance
13 Quality Indicators in the Emergency Dept Domain Metric Quality assurance Safety Initial assessment (pain and EWS) Timeliness of ED care and overall Length of stay Patient surveys Left without being seen Unplanned re-attendance Clinical care ED consultant sign off for high risk presentations Summary hospital mortality Indicators Clinical care e.g. trauma Ambulatory emergency care System performance Clinical care, e.g. stroke Staff surveys Staffing levels adhering to national standards Clinical staff Completion of CEM CRM course
14 Quality matters.
15 Solutions
16 Ambulatory emergency care Ambulatory emergency care is clinical care which may include diagnosis, observation, treatment and / or linkage to rehabilitation, following an attendance to the Emergency Department, not requiring access to an inhospital bed and can be provided across the primary / secondary interface. Same Day Emergency Care submission RCEM & RCP 2012 to DH RCEM 2010
17 LEAN theory Womack & Jones (1990 & 1996) Specify the value desired by the customer Identify the value stream for each product Challenge all of the wasted steps (generally nine out of ten) Make the product flow continuously through remaining value-added steps Introduce pull between all steps where continuous flow is possible Manage toward perfection
18 Applying to AEC in the ED Recognise value what does the patient really need? What are we doing now? ( current state visual source mapping CS-VSM) How can we make it better? ( future state FS VSM) Implementation plan with regular recalibration
19 Why else is it important? Clinical risk issues for Emergency Medicine. Common claims Missed fractures 42% Misdiagnosis 9% Poor fracture management 7% Nerve, tendon/ ligament injury 6% Wound healing/fb 5% Missed dislocation 3% Misdiagnosis of life threatening conditions. Acute coronary syndromes Occult head injury Sub-arachnoid haemorrhage Venous thrombo-embolic disease Suicidal risk following self harm Elderly polypathology /polypharmacy Syncope (arrhythmias) Ectopic pregnancy Abdominal aortic aneurysm
20 Competency defined as : Implies integration of knowledge, skills, judgement and attitudes. Context specific Linked to professional roles Linked to process and outcome Require experience of and reflection on professional practice. Applies at any level of experience. Ongoing competence development needed due to changes in practice Marjan Govaerts Med Educ
21 Teaching clinical judgment and decision making in a dynamic ED setting. edecision support, Expert systems, Neural nets Designing safe ED systems Cognitive Psychomotor Judgment in ED clinical decision making Attitudinal Guidelines, Protocols, Care pathways SOPs Professional & neurolinguistic skills Training & evaluation Emotional intelligence Deliberate practice Experiential learning Metacognition, reasoning strategies & calibration
22 Delivering quality in Emergency Medicine Emergency assessment in certain groups of patients with stable physiology requiring diagnostics, observation and/or treatment with a likely completed episode <24hrs. Consistent diagnostic work-up and observation Clinical decision making- based upon evidence based approach
23 Delivering ambulatory care in the ED a virtual Clinical Decision Unit concept Collapse with probable first fit Chest pain -?PE Asthma Cellulitis Self harm - review?dvt assessment Conscious sedation & MUA Limping child Head injury - child Pneumothorax Head injury - adult TIA Chest pain -?ACS COPD exacerbation Medically fit elderly requiring Community system support Low risk GI bleed Renal colic Diagnostics Therapy Observation
24 Limitations of running Obs Med function / ambulatory care in a Majors area Process time issues Lack of observation facilities Access to diagnostics Consistency of pathway delivery Local resource issues Culture
25 What does an ED based CDU provide? A change in philosophy Focus on needs of patients who will benefit from rapid interventions - diagnostics, therapy or short term observation and review Being an active player in the systems solution A new paradigm for Emergency Medicine in the UK? Hassan TB - Clinical decision units in the emergency department: old concepts, new paradigms, and refined gate keeping. EMJ 2003
26 Systematic reviews Use of emergency observation and assessment wards: a systematic literature review M W Cooke, J Higgins, P Kidd. EMJ 2003 Conclusion: All types of assessment/admission wards seem to have advantages over traditional admission to a general hospital ward. A successful ward needs proactive management and organisation, senior staff involvement, and access to diagnostics and is dependent on a clear set of policies in terms of admission and care.
27 Short-stay units and observation medicine: a systematic review Daly et al Med J Aust 2003 Conclusion: ED based Observation Units have the potential to increase patient satisfaction, reduce length of stay, improve the efficiency of emergency departments and improve cost effectiveness.
28 Observation Medicine in the ED The Healthcare System's Tincture of Time Louis G. Graff et al American College of Emergency Medicine 2004
29 Delivering ambulatory care on the CDU Key pathways Chest pain -?ACS Chest pain -?PE Renal colic Abdominal pain Conscious sedation Post MUA TIA Collapse with probable first fit Acute headache Excl SAH Low risk GI bleed The CDU / OU?DVT assessment Medically fit elderly requiring Community system support Diagnostics Therapy Observation Self harm - review Asthma Head injury observation Cellulitis Pneumonia Pneumothorax
30 Mapping ambulatory pathways Governance & safety Tailored informatics Robust QI systems Leadership & cultural change track record Condition X Initial contact & assessment ( GP, ED self referral, GP to ED or AcMed Secondary contact Assessment EB risk stratification or general assessment Diagnostics - EvidBase?, location, access, type, reporting, turnaround time, QA Management pathway EB?, ED ambulatory, ED/CDU ambulatory, AcMed ambulatory, OPD, inhospital admit, location, access, type, reporting, turnaround time, QA Governance & safety systems
31 Stages 1. Ensure local engagement and drive 2. Set objectives with end in mind 3. Review evidence base 4. Evaluate local resources 5. Identify key stakeholders (clinicians, diagnostics, commissioners) 6. Draft the pathway 7. Circulate & test 8. Launch & recalibrate constantly
32 Key points Observation Medicine & ambulatory emergency care is a vital function of main ED activity Integrate into emergency and acute care system ED Clinical Decision Units produce a significant step forward in : Ideal platform for ambulatory emergency care Gatekeeping the in-hospital bed base Improving safe discharge from the ED Meets the QIPP criteria DELIVERS what commissioners want.
33 The future!
34
35 Safe SMART ED STPs, emergency care, transformation & the MONEY RCEM Vision
36 Safer staffing depth & breadth Metrics that matter Training Creating the Safe SMART ED RCEM Vision 2020 Patients Resilience of systems to minimise exit block Alignment of hub services
37 Positivity Policy Predicaments Pride People Pain Passion Pact Politicians Patients #makingemgreat
38 Celebrate in 2017 Golden Jubilee 50 th anniversary of inception of the specialty In UK & Ireland
39 WHERE? WHAT? HOW?
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