Awareness and utilisation of ambulatory and admission avoidance pathways
Aims
National trends have promoted admission avoidance services and utilisation of ambulatory care pathways where possible, providing better care for patients and more effective hospital services. In busy emergency and acute units, it is often challenging to consider all the potential services that may be considered an alternative to admission. The experiences and opinions of staff towards admission avoidance services is unknown and, if explored, would enable improvements to patient pathways.
Methods
At a busy south London integrated care organisation, a survey was administered exploring which of the hospitals many ambulatory and community services have been used by acute staff in place of formal admission over the past 6 months. Individuals were asked which service would be most appropriate for a series of eight clinical cases, to explore consensus amongst use of services.
Results
23 doctors completed the survey – nine from the emergency department (ED) (three consultants, five SpR/middle grade), four acute medicine consultants, 10 from the wider medicine specialties, including geriatric medicine (two consultants, four SpR, three SHO, one FY1).
All doctors were familiar with traditional admission pathways. All teams were least experienced in referring for support from the community multidisciplinary rapid response team. Emergency department doctors were inexperienced in referring to specialist nurse service instead of admission, contrasting with acute and general medical colleagues.
For each of the clinical scenarios presented, there was considerable variation in proposed actions across all doctors. Emergency medicine doctors appeared more likely to choose an admission pathway in cases with significantly abnormal blood tests (for example, hyponatraemia or deranged international normalised ratio in a patient taking warfarin with complications) than their medical colleagues. Admission was the most cited pathway for a patient with uncomplicated lower-limb cellulitis, despite a clear ambulatory pathway being in place with the ability to administer intravenous antibiotics in the community.
Conclusions
Doctors of all specialties have varying experience of ambulatory and admission avoidance pathways in the hospital, and supporting them to use such pathways may be of benefit to patients and the organisation. There is a varying opinion across all specialties and grades on appropriate pathways for clinical scenarios. This may represent a lack of knowledge of existing pathways or a lack of clarity regarding the complexity and support such services can offer. Services should develop clear pathways for acute services to follow and support their use in the ED and acute medical unit.
Conflict of interest statement
Nil to declare.
- © Royal College of Physicians 2015. All rights reserved.
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