Ambulatory Care Unit Royal Free Hospital Dr Tara Sood Dr Andres Martin
Background Hampstead North London Suburb Merged with Barnet and Chase Farm Hospital in July 2014, 3 site trust. Seeing increasing numbers of patients last 3 months 17% increase The current department was designed to see 60,000 attendances a year, however the ED is currently seeing over 100,000 attendances. The ED is undergoing a major redevelopment over the next two years and by September 2016 there will be a newly opened ambulatory emergency care unit within the department alongside a CDU/23 hour unit. We also have a 9 bedded CDU as part of the ED which runs on conjunction with the AECU.
Getting Started Existing pathways Membership of AEC Network cohort Vi Directory of ambulatory emergency care Visits to established units Existing patient surveys Developed business case for pilot unit
Pathway Driven Approach Local expertise Initially Key stakeholders involved Two way process Support from Trust Exec Moving to process driven with further experience
Ambulatory Work at the Royal Free Ambulatory Emergency Care Unit run by ED CDU TREAT ( over age 80) PITU ( procedures) Benefits of ED Led Ambulatory Care Patients considered for ambulatory management at first stage of patient journey Can flex service to meet demands Easy for other speciality teams to feed into service. Promotes cross speciality learning and development of new skills
Patient presenting to ED with Ambulatory Care Sensitive Condition Discharge home via ED Short stay on CDU AECU TREAT (over 80) Admit under speciality team
AEC pathways DVT / Leg swelling Cellulitis / Bursitis Pyelonephritis Ureteric Colic PE Pneumonia MRI Diabetes related Low risk GI bleed
Pathways run via ED First fit TIA SVT /Dysrhythmia Urinary retention and catheter change Asthma Anaemia ( via PITU ) Pneumothorax
Pathways run via CDU Pubic rami # # not requiring orthopaedic intervention Non traumatic vertebral fractures Hip pain secondary to fall and NWB Head injury Community acquired pneumonia Hypoglycaemia Overdose and poisoning Seizure in known epileptic TREAT patients
Practical solutions
Current facilities
Current facilities
Current facilities
Future facilities
Future facilities
Future facilities
Future facilities Late Summer 2016
AEC Data 10 months data Total Weekdays Total weekend Total N Patients F 607 104 711 N 1175 145 1320 1782 249 2031 Referral Complaint % DVT 35.3% Cellulitis 25.7% Renal Colic 16.8% PE 12.0% Pyelonephritis 5.9% Other 2.7% DVT/Cellulitis 1.4% Pneumonia 0.2%
AEC Data 10 months data Discharge diagnosis % Cellulitis 25.7% DVT 25.6% Renal colic 13.3% Other 7.9% PE 6.5% Non-specific leg pain (e. musculoskeletal) 5.4% Pyelonephritis 5.2% Non-specific chest pain (e.g. Musculoskeletal) 3.8% Non-specific abdominal pain /flank pain 1.6% Mechanical Back Pain 1.0% Non-specific Swollen leg 0.9% Baker cyst 0.8% Pneumonia/chest infection 0.6% Abscess 0.6% Thrombophlebitis 0.5% UTI 0.4% Cellulitis/Lymphoedema 0.2%
AEC Data 10 months data Overall AEC admission rate Admission 6.0% Discharge 94.0% Admission rate 5-main pathways by referral complaint Admission rate 5-main pathways by final diagnosis Referral Complaint Admission rate Referral Complaint Admission rate DVT 2.4% Cellulitis 7.6% Renal Colic 8.6% PE 1.4% Pyelonephritis 14.5% Cellulitis 8.6% DVT 2.3% Renal Colic 9.0% PE 2.6% Pyelonephritis 18% Total Bed days saved 5-main Annualised bed Days saved Actual Beds saved pathways (10 months) 2190 2627 7
Ambulatory Emergency Care- patient experience questionnaire Before you arrive When you arrived When you saw the doctor or nurse During your treatment Next steps/ follow up How did you feel? How did you feel? How did you feel? How did you feel? How did you feel? Please circle the words that best describe your feelings at each stage, or write your own words. What made you feel like this? Was it friendly staff or a long wait- whatever it was, we d like to know. We would also appreciate your feedback on specific parts of our service to help us improve. How was the signage to the unit? Please rate on a scale of 1-5. How were the facilities and the environment of the unit? Please rate on a scale of 1-5. Did you have to wait a reasonable amount of time to be seen? Please rate on a scale of 1-5. Did you feel informed about your treatment? Please rate on a scale of 1-5. Did you understand what was going to happen next? Please rate on a scale of 1-5. Please review the above on a scale of 1-5. 5- very good 4- good 3- satisfactory 2- poor 1- very poor
Patient experience data
Challenges Space Building work slow, loss of momentum on project. Staffing constraints impacting on opening hours. Tariff not yet agreed Data collection
Next steps Implementation of pathways in development Development of surgical pathways Expand scope of nursing practice Introduction of HOT clinics with surgical and medical teams Expand scope to more process driven approach Development of ambulatory dashboard across both sites. Move into new unit and increase hours of operation Integration with community based teams
What have we learnt? Champions required Patient feedback excellent Staff satisfaction Working relationships key Data collection critical Patients over 80 can be ambulated! Keep enthusiasm alive