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Ambulatory emergency care – improvement by design

Mahir Mustafa Abdel Aziz Hamad and Vincent M Connolly
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DOI: https://doi.org/10.7861/clinmedicine.18-1-69
Clin Med February 2018
Mahir Mustafa Abdel Aziz Hamad
AJames Cook University Hospital, Middlesbrough, UK
Roles: consultant physician and clinical director for acute medicine
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Vincent M Connolly
BNHS Improvement North, Quarry House, Leeds, UK
Roles: regional medical director
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  • Article
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Article Figures & Data

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    Fig 1.

    Models of ambulatory care – the 4 Ps.

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    Fig 2.

    Example of an ambulatory emergency care (AEC) model. AEC = ambulatory emergency care

Tables

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    Box 1.

    Selection of clinical diagnoses appropriate for ambulatory care

    Gastroenterology
    > Upper gastrointestinal bleed with Rockall score of 0
    > Lower GI bleed with no haemodynamic compromise
    > Painless obstructive jaundice
    > Non-acute abdominal pain
    > Gastroenteritis
    > PEG related complications
    Endocrinology
    > Hyperglycemia without ketosis
    > Hypoglycemia with full recovery
    > Type 1 diabetes without ketosis
    > Electrolyte imbalances
    > Thyroid disease
    Infectious diseases
    > Cellulitis
    > Osteomyelitis
    > Urinary tract infections
    Respiratory disease
    > Pulmonary embolism
    > Pneumothorax
    > Pleural effusions
    > Asthma
    > COPD
    > Community acquired pneumonia
    > Lower respiratory tract infections without COPD
    Neurology
    > Transient ischaemic attack
    > First seizure
    > Seizure in known epileptic
    > Acute headache
    Oncology 19
    > Eg low risk febrile neutropaenia as determined by the MASCC score 20
    Miscellaneous conditions
    > Falls including syncope or collapse
    > Self-harm and accidental overdose
    > Anaemia
    COPD = chronic obstructive pulmonary disease; GI = gastrointestinal; MASCC = Multinational Association for Supportive Care in Cancer; PEG = percutaneous endoscopic gastrostomy
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    Box 2.

    Potential pathways from telephone streaming – the 6 As

    Advice
    Access to outpatients
    Ambulatory emergency care
    Assessment unit
    Acute frailty unit
    Admission to specialist bed
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    Box 3.

    Advantages of developing emergency care in an ambulatory setting

    > Patient acceptability
    > More specialist care for patients
    > Structure and predictability to the emergency process
    > Training opportunity
    > Clinical and cost effective
    > Alleviates bed pressures
    > Reduces A&E attendances
    > Compliance with A&E national 4 hour target
    A&E = accident and emergency
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    Box 4.

    Services which can be linked to ambulatory care

    > Chronic obstructive disease outreach
    > Pleural diseases clinics
    > Rapid access chest pain clinics
    > Transient ischaemic attack/stroke clinics
    > Epilepsy clinic
    > Pain management service
    > Functional assessment and support teams
    > Diabetes nurse specialist
    > Falls clinic
    > Macmillan nurses
    > Outpatient parenteral antibiotics team
    > Home parenteral antibiotics team
    > Endoscopy services
    > Heart failure team
    > Mental health liaison team
    • View popup
    Table 1.

    Risk stratification tools to support patient streaming and early discharge

    ConditionRisk stratification tool
    Pulmonary embolismPulmonary embolism severity index (PESI), simplified PESI, Hestia criteria
    Transient ischemic attack and/or cerebrovascular accidentABCD2 and Rosier Scores
    AsthmaAsthma severity (BTS guidelines 2016)
    Chronic obstructive pulmonary diseaseBODE index and DECAF21 score
    SyncopeSan Francisco Syncope Rule
    Chest painTIMI Score and GRACE Score
    PneumoniaCURB score
    Acute upper gastrointestinal bleedGlasgow-Blatchford Bleeding Score, Rockall Score
    • View popup
    Table 2.

    Sample table for calculating the required physical ambulatory emergency care (AEC) capacitya

    Arrival timeNo. of patientsJunior doctor time (based on 1 h per assessment)Consultant review time (based on 15-min review)Consultant follow-up time (based on 7.5 min)Trolley spaces (approx. 40% of patients using trolley)Chair or consultant room (approx. 60% of cases use chairs)
    08.00–12.00661.50.752–33–4
    12.00–16.0010102.51.2546
    16.00–20.004410.522
    • ↵aThe table is based on 14 new AEC patients per day, and indicates a requirement of four trolley spaces and six chairs to maintain flow during peak demand.

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Ambulatory emergency care – improvement by design
Mahir Mustafa Abdel Aziz Hamad, Vincent M Connolly
Clinical Medicine Feb 2018, 18 (1) 69-74; DOI: 10.7861/clinmedicine.18-1-69

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Ambulatory emergency care – improvement by design
Mahir Mustafa Abdel Aziz Hamad, Vincent M Connolly
Clinical Medicine Feb 2018, 18 (1) 69-74; DOI: 10.7861/clinmedicine.18-1-69
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  • Article
    • ABSTRACT
    • Key points
    • Introduction
    • Why ambulatory emergency care?
    • Patient selection
    • Designing the service
    • Patient education and experience
    • Interface with other departments and directorate
    • Models of ambulatory care services (the 4 Ps)
    • Conclusion
    • References
  • Figures & Data
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