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Dr Ian Sturgess Clinical Lead, Intensive Support Team Urgent and Emergency Care

WORKSHOP How do we manage acute care as safely as a day case. The hospital without walls – delivering ambulatory emergency care. Dr Ian Sturgess Clinical Lead, Intensive Support Team Urgent and Emergency Care. Ambulatory Emergency Care - Concept.

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Dr Ian Sturgess Clinical Lead, Intensive Support Team Urgent and Emergency Care

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  1. WORKSHOPHow do we manage acute care as safely as a day case.The hospital without walls – delivering ambulatory emergency care Dr Ian Sturgess Clinical Lead, Intensive Support Team Urgent and Emergency Care

  2. Ambulatory Emergency Care - Concept • Ambulatory emergency care (AEC) vs ambulatory care sensitive conditions (ACS) • AEC is a different way to manage patients who have an acute illness. • AEC is to emergency care, as day case surgery has been to elective care. • ACS conditions are where better long term condition management or preventative healthcare avoids the development of the acute condition. • They are complementary but the impact is at a different point in the care continuum.

  3. A whole system perspective Focus on CDM and more effective responses to urgent care needs – ACS condition management Clear operational performance framework and integrated in to primary care Improved integration with primary care responders Front load senior decision process incl primary care General Practice & GP OOH Ambulance Service & GP OOH Inpatient Wards MAU/SAU/ Short Stay Community Support A+E Redesign to left shift LOS Optimise ambulatory emergency care Health Promotion Information flow converting the unheralded to the heralded Preventative/ Predictive care Disease management Managed populations Alternatives to acute admission settings Alternative access for diagnosis Alternative settings for therapy Alternative sites for discharge Alternative sites for readmission Discharge Process

  4. Categories of Ambulatory Emergency Care • Diagnostic exclusion group • Eg chest pain rule outs etc (many already in place) • Low risk stratification group • Eg low Rockall score GI bleed • Specific procedural group • Eg effusion drainage • Infra-structural group • Eg advanced care planning for nursing homes

  5. Ambulatory Emergency Care How to do it: Opportunities Implementation Structure – physical and organisational People and behaviours Processes Bundles Reliability Measurement Outcome metrics Process metrics Balancing metrics

  6. % of total % of total No. of Adj. No. of Ad. Clinical Scenario admissions admissions Ad. - Low Ad. - Upper (low) (upper) Total admissions 368,762 368,762 GM11 Chest Pain 3,227 3,638 0.88% 0.99% GS01 Acute abdominal pain not requiring operative intervention 2,206 2,553 0.60% 0.69% TO02 Appendicular fractures not requiring immediate internal fixation 3,061 4,453 0.83% 1.21% GM31 Falls including syncope or collapse 2,373 3,339 0.64% 0.91% GM24 Cellulitis 1,977 2,887 0.54% 0.78% GM29 Deliberate self harm 2,094 2,788 0.57% 0.76% GM08 LRTI without COPD 1,262 2,140 0.34% 0.58% GM10 Supraventricular tachycardia 1,422 2,137 0.39% 0.58% GM14 & 15 First seizure and seizure in known epileptic 1,389 1,976 0.38% 0.54% Etc. etc. Total Non-zero LOS Emergency Admissions 32,186 46,111 12.2% 18.1% NHS South East Coast – 2007/08 Opportunities Assessment – Non-Zero LOS Admissions

  7. Phase 1 - Project Set Up

  8. Pick Conditions

  9. Identify Team • Clinical lead(s): clinicians should be willing to take the lead and to think beyond their own specialties • Nursing lead: the lead doctor and lead nurse should work closely together to develop and implement new processes • Senior manager support preferably at executive level: dynamic management is invaluable in coordinating supporting processes • Primary care and/or PCT representation • Assessment Unit - If you have an Assessment Unit, be sure to have at least one representative from this unit in your group. • Stakeholders - diagnostics, AHPs etc

  10. Establish Measures and Objectives

  11. Planning and Implementation

  12. The Reliable Design Strategy Segmentation – volume and engagement High level process map identify the bottlenecks Prevent initial failure using intent and standardization Identify defects and mitigate using redundancy and contingency Measure and then communicate learning from defects back into the design process

  13. The Model for Improvement Clear and measurable aims How much By when How measured Real time measurement Outcome Process Balancing Small tests of change Plan, Do, Study, Act (PDSA) Start tomorrow!

  14. Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? Act Plan Study Do

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