AMBSCORE in action. Karen Smith AEC Advanced Nurse Practitioner Good Hope Hospital Heart of England NHS Foundation Trust

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1 AMBSCORE in action Karen Smith AEC Advanced Nurse Practitioner Good Hope Hospital Heart of England NHS Foundation Trust Damian Perrin Consultant Physician and Clinical Lead AEC Good Hope Hospital Heart of England NHS Foundation Trust

2 Good Hope Hospital Medium sized district general hospital Located in Sutton Coldfield on outskirts of Birmingham One of four sites within Heart of England NHS FT Offers full range of Acute and General medical, as well as general surgical services The catchment population is about 450,000. Semirural, rural and inner city catchment Average medical take patients per day

3 Our AEC 2 ANPs soon to expand team 2 ACPs in AEC training Trust Grade 9-9 Dedicated consultant 9-8pm Band 2/5/6 Nursing Complement Excellent specialty, community nursing and GP links New Patient activity 3800 new patients in 2015/16 Facilitated Early Discharge Clinic/AEC follow up Approx 400 patients visits per month Achieved local AEC CQUIN 2015/16 ( 3 million) across trust

4 How did we get here?

5 The Story so far. Evolved as part of the Acute medical unit Until 2013 was a section on the ward and saw all GP referrals whatever the presentation Cramped conditions Poor environment for patients and staff Frequently ran at capacity overflowing with patients awaiting admission

6 History of AEC Staffed by ANPs Band 6 Nursing Complement Complement of Trust grade doctors No dedicated consultant No specific metrics / data collection Few dedicated processes Some excellent early pathways e.g. cellulitis / DVT Evolving community links e.g. OPAT / VTE

7 History of AEC Moved to new accommodation 2013 Much better environment for patients and staff Co-located with Emergency Department, CDU, Frailty Unit and AMU Opening Hours pm Mon-Fri, 9-6 Sat-Sun Integrated AEC follow up / Facilitated early discharge clinic

8 AEC facilities and location

9 AEC facilities and location

10 Patient literature Tea/Coffee/TV Procedures Area RECEPTION WAITING AREA OFFICE Clinic Rooms Triage

11 HIGH CONVERSION RATE

12 What did we do?

13 AMBSCORE Decision to stick with process based approach Some pathways OPAT, cellulitis, heart failure, DVT, PE AMBSCORE to get us back on track?? Engagement with medical staff, nursing staff ED not that interested initially AMU happy to try Decision aid introduced March 2014

14 Decision tool should rule out: Those likely to be admitted Potential acute Stroke Potential high risk ACS Infection risks? Pyjamagate BUT capture EVERYONE else Common Sense essential

15 Pros and Cons Conversion rate now much better People thinking of ambulatory care We now have flow!! Patient experience fantastic GP referrals hampered by referral through Single Point of Access Activity reduced Image courtesy of arztsamui at FreeDigitalPhotos.net

16 ED Pull Trialled Oct 2014 Comfortable with our capabilities, resources and patient selection Promoted Ambulatory Care Week Now actively seek out the patients from ED ANPs/SpRs Concern conversion rates may go up again. It didn t and activity now higher than ever

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18 ED Pull considerations Need to monitor ED conversion rate Are you doing EDs work?? Would they have referred/pulled if AEC didn t exist? When might this be appropriate?? If ED congested maybe?

19 AEC engagement events ED/Hospital engagement events Presentations on ED staff study days Local GPs included via Partnership event Evening tours of unit Discussion of benefits How to contact us for advice Opportunity to network GPs immediately requested the score!!

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21 AEC Data

22 AEC Dashboard

23 Data timeline Mar-14 AEC Admission Rate AEC Activity AMBSCORE introduced Sep-14 Oct-14 Dec-14 AEC Sensitive HRG Admission Rate AEC Sensitive HRG Admission Rate AEC Activity AEC Sensitive HRG Admission Rate ED Pull introduced

24 SPC Charts AMBSCORE introduced AEC Weekly Activity UCL= _ X=71.11 Patients UCL=77.78 _ X=51.94 UCL=72.52 _ X= /07/13 09/09/13 11/11/13 LCL= /01/14 17/03/14 19/05/14 LCL= /07/14 22/09/14 24/11/14 LCL= /01/15 30/03/15 Week Begining Date ED Pull introduced

25 SPC Charts AMBSCORE introduced AEC Admission Rate UCL=55.96 _ X=34.89 Percentage UCL=36.09 _ X=19.20 UCL=23.60 _ X= /07/13 09/09/13 11/11/13 6 LCL= /01/14 17/03/14 19/05/14 21/07/14 22/09/14 LCL= /11/14 26/01/15 LCL= /03/15 Week Begining Date ED Pull introduced

26 AMBSCORE Benefits Makes people think of AEC every time Easy to use Good filter to allow a process based approach Helps rule out the serious stuff that may slip through May not be used much once referral and selection processes embedded but useful to fall back on if start getting inappropriate referrals

27 Top Tips Engage primary care if you can Make sure you modify according to local service provision Monitor the data/activity Consider ED Pull when comfortable with patient selection Think about pyjamas

28 Thank You Karen Smith AEC Advanced Nurse Practitioner Dr Damian Perrin Acute physician and Clinical Lead AEC