Towards more ambulatory emergency care

The Directory of Ambulatory Emergency Care for Adults is designed to help local health and social care communities deliver more care closer to patients’ own homes by focusing on effective healthcare delivery, thereby improving patient safety and outcomes and freeing up more acute hospital beds for those patients who need them most.

Ambulatory care is defined as clinical care, including diagnosis, observation, treatment and rehabilitation, that is not provided within the traditional hospital bed base or within the traditional outpatient services and that can be provided across the primary/secondary care interface.

The directory, which draws together ideas from specialists across the field of emergency care, details a number of conditions that can be effectively managed using ambulatory emergency care and the future potential for doing so in percentage terms, and provides links to supporting clinical evidence and best practice. It embraces conditions from the fields of general medicine, general surgery, urology, obstetrics and gynaecology, trauma and orthopaedics.

PATIENT GROUPS

In addition, the directory outlines four specific groups of patients for whom ambulatory care could be the norm. It is reported that these patients could be managed in a range of settings from day treatment and acute assessment units, to urgent care outpatient settings and community-based services. The four groups are: patients for whom referral requires the exclusion of a specific diagnosis (diagnostic exclusion group), those suffering from a second group of conditions for which senior review can enable early discharge (low risk stratification group), patients who require a specific treatment (specific procedure group), and patients with conditions that have traditionally been managed in an inpatient environment but can now be managed without a hospital stay (infrastructure required group).

The diagnostic exclusion group is made up of patients for whom the referral requires the exclusion of a specific diagnosis, meaning that they can be discharged with a length of stay of zero. Conditions such as chest pain indicating a possible myocardial infarction, or breathlessness indicating a possible pulmonary embolism are included. A patient only evolves from primary care to ambulatory emergency care when it is decided that he or she needs a diagnostic procedure or an opinion that is not available in the community; many of these patients may already be assessed and managed in accident and emergency departments.

However, from a quality perspective, even once a specific condition has been excluded, there is still a need to explain the patient’s symptoms to them through the diagnostic process. The low-risk stratification group is made up of patients suffering from a second group of conditions for which senior review with risk stratification can enable early discharge. Such conditions include non-variceal upper gastrointestinal bleed with a low Rockall score and communityacquired pneumonias with a low CURB65 score. However, appropriate treatment plans should be in place.

The specific procedure group consists of patients who require a specific procedure or treatment in order to be discharged, for example, the replacement of a percutaneous endoscopic gastrostomy (PEG) tube, drainage of effusion/ascites, a blood transfusion or rehydration in gastroenteritis. Key to implementation is how ambulatory care for this group of patients can be delivered when they present out of hours.

The final group – the infrastructurerequired group/outpatient group with supporting infrastructure following appropriate risk stratification – comprises patients suffering from those conditions that have traditionally been managed in an inpatient environment but that can now be managed without a hospital stay. They include patients with deep vein thrombosis (DVT), pulmonary embolism (PE), cellulitis and acute exacerbation of chronic obstructive pulmonary disease (COPD).

These are distinct from the conditions listed previously because the infrastructure required to manage them is very different. All four of these diagnostic groups could be managed in a range of settings, from day treatment units linked to acute assessment units, to urgent care outpatient settings and full communitybased services. The setting for each condition where this model of care can be delivered is not specified as it will vary to some extent depending on the locality. Regardless of what the location is, however, patient safety and the quality of the outcome are the paramount determinants.

JOINT WORKING PRACTICES

According to Professor Sir George Alberti, national clinical director for Emergency Access, the challenge now is to implement these ideas. “This will require true joint working across Local Health and Social Care Communities (LHSCCs). They will have to concentrate on the outcome for the patient and the patient’s safety and experience, rather than being constrained by organisational boundaries. Implementation will require the examination of new ways of working across the traditional health and social care structures within a joint governance framework. This horizontal integration will focus on the patient’s journey, in contrast to the current vertical professional and organisational structures. It will aim to facilitate the real-time exchange of information, enabling clinical assessment, diagnostics and therapeutic interventions to take place in a timely manner commensurate with the needs of the patient. This will be the key to effective delivery of the recommendations in this directory.”

This need to integrate and develop the streaming assessments currently utilised by ambulance, out-of-hours primary care, mental health and social care services is vital for the provision of consistent and safe signposting to the appropriate urgent or emergency care process. Face-to-face contact is required to assess the problems, illness severity, associated co-morbidities and complications, and the social circumstances for each patient. The assessments will also need to encompass a brief analysis of the patient’s dependency in order to assist the streaming to intermediate care services using the appropriate tools.

The following points, which focus on the integrated approach to assessment that is necessary if the guidelines are to be successful, should be noted.

• The use of appropriate validated assessment systems, be they generic, such as the modified early warning score or standardised early warning score, or specific, such as the Rockall score, are recommended. However, these are not a substitute for comprehensive clinical assessment.

• The provision of high-quality guidance on the case management of disabilities/comorbidities and support for clinical decision-making on the transition of care is necessary. There are some products that provide this level of sophistication, for example the InterRAI range of instruments. The combination of these tools with an illness severity score for the relevant condition can be used to support case management decisionmaking around ambulatory care.

• The presence of an on-going chronic illness (unless with acute exacerbation requiring admission on its own merit) or social support instability requires appropriate community-based responses and support through collaborative working rather than defaulting to admission.

STAFFING AND FACILITIES

Ambulatory emergency care is a relatively new concept and there needs to be consideration of the facilities and staffing required to deliver this model of care.

Clinical leadership in the development of ambulatory emergency care will be crucial for its safe and effective delivery. Senior clinical personnel with expertise in illness severity, co-morbidity and functional assessment, and with the experience to make balanced risk decisions, will be needed. Many of these personnel can be drawn from current establishments involved in primary, community, secondary, mental health care, and ambulance services. The key to success will be ensuring that the team works in an integrated emergency health and social care system. Patients for whom ambulatory emergency care could be the preferred model of care can be identified from a range of settings, but the setting in which the completion of their assessment and initiation of treatment takes place will depend on the specific diagnostic and therapeutic interventions required. It is for each LHSCC to decide on the appropriate configuration of facilities for the delivery and further development of the ambulatory model. This will be a similar local developmental process as has been put in place for elective day surgery.

It will be the responsibility of the senior clinical team members to ensure that there are well documented and clear case management plans with transparent lines of clinical responsibility, and clear descriptions of what to look for which might signify a change in the patient’s condition. This might involve monitoring by either telephone consultation or electronic communication, at home by the community healthcare team, or through attendance at primary care, a day treatment unit or outpatients, depending on the clinical situation.

PATIENT INFORMATION

Patients should be provided with clear and easy-to-read information with details of their condition, the case management plan, what to look out for that indicates any deterioration, the monitoring process, and a specific contact point if there is any concern.

The contact point is a key element in maintaining patient confidence. Local implementation teams will need to consider how best to maintain this important safety factor 24 hours a day, seven days a week. Integration of this contact point with out-of-hours services or with the ambulance service could be one possible solution.

OUTCOME MEASURES

The LHSCC will need to monitor the effect of delivering the directory on patient flows and its impact on the local health and social care economy.

A range of outcome measures will be required, including:

• Patient morbidity.
• Patient mortality (28 days – not just in-hospital mortality rates).
• Institutionalisation rate (the percentage of patients not discharged to their usual address).
• Lost work days.
• Re-admission rates (7 day and 28 day).
• Patient experience – for example, the efficacy and availability of the contact point can be monitored by patient satisfaction surveys and recording any unprompted 999 calls or attendances at accident and emergency departments.

The most critical factors in ensuring that patients receive high-quality and safe care include:

• Engaging with clinicians in a shared quality agenda to achieve system-level improvement in emergency care.
• A high degree of involvement from patients and the public.
• Effective whole-system planning and delivery within a joint governance framework (clinical, managerial and financial) between health and social care. This should include identifying a manageable number of scenarios, sustaining and learning from the improvement process and building confidence before moving on to delivering subsequent sets of scenarios.
• Alignment of financial incentives in delivering ambulatory emergency care pathways to achieve optimal patient outcomes.

CONSIDERABLE IMPROVEMENTS

Dr Ian Sturgess is the senior doctor leading the NHS Institute work on the directory.

He commented: “Access to emergency care has improved considerably over the last few years with the majority of Trusts consistently achieving the target of four hour access times. However given that emergency admission to a hospital bed should only take place where a patient has an acute illness that requires inpatient care, further work is still required to ensure that only those patients who actually require admission are admitted and their length of stay is commensurate with their acute care needs.

“Delivering more care closer to patients’ own homes by offering alternatives to bed-based acute care will undoubtedly bring significant improvements in the quality of care and enhance patient experiences and outcomes. Crucially, effective, efficient and safe delivery of ambulatory emergency care will also help avoid the potential complications that can occur as a consequence of admission to a hospital bed, such as healthcare-acquired infections and functional deterioration in frail older people.”

Professor Bernard Crump, Chief Executive of the NHS Institute for Innovation and Improvement, added: “The argument for treating more patients in an ambulatory manner couldn’t be more compelling. While the implementation of this new guidance will require considerable co-ordination and joint working between local health and social care communities as well as the examination of new ways of working, we are confident it can be successfully adopted and implemented across the NHS leading to improved emergency care for all.”

The directory is one of the first products to come out of the NHS Institute’s Focus On: High Volume Care programme, a series of guides aimed at local health and social care communities, which set out to encourage greater efficiency and enhance patient care in a number of fields (including short stay emergency care) by identifying key characteristics of high performing organisations and outlining optimised pathways for the management of patients.