Revamping front door medicine in a busy tertiary care hospital
Introduction
The Royal College of Physician's vision for future hospitals proposes that patients be reviewed by a senior clinician as soon as possible after arriving at hospital.1,2 It encourages specialist medical teams to work together with emergency teams, to diagnose patients swiftly and to facilitate early discharge.3 In our hospital, ambulatory emergency care (AEC) was established in October 2015. All non-ambulatory medical patients referred by general practitioner (GP) were directed to the emergency department (ED). The ED referred patients, who would also wait long hours for medical beds. All non-ambulatory, same-day care was managed in the ED, acute medical unit (AMU) or frailty emergency assessment unit (FEAU). This increased workload and length of stay (LOS) in ED and elevated bed pressure in AMU and FEAU.
Standard of care was for patients to be reviewed by the consultant physician within 12 hours of admission, leading to delay in diagnosis and treatment. To tackle these challenges, we proposed a consultant-delivered rapid assessment pathway supported by a dedicated unit, to assess all ED- and GP-referred medical patients not suitable for AEC. Our aim was an earlier contact with a consultant physician to improve patient experience and outcome by reducing time to reach definitive diagnosis and treatment initiation. This would avoid unnecessary admissions and reduce overall LOS by optimising same-day emergency care.
Materials and methods
In October 2018, front door medicine was redesigned to direct all medical referrals from the ED to a consultant physician-led acute medical rapid assessment triage (AMRAT) process, which aimed to review patients within 30 minutes of referral. Patients seen in the ED would transfer to a dedicated 14-trolley area called the acute medical rapid assessment unit (AMRAU) adjacent to the ED, for further assessment and treatment. All non-ambulatory GP patients are also received in AMRAU, with an aim to be reviewed within 30 minutes of arrival.
Results
During the first 6 months, 7,747 patients were assessed and treated by AMRA team. Of these, 48% (3,700) were discharged home either directly from the ED or after a period of treatment in AMRAU; 38.5% (2,983 patients) were managed physically in AMRAU. Patients were reviewed by consultant with median time of 40 minutes. From October 2018 to March 2019, although ED attendance was increased by 12.5% (7,691 patients) when compared with same months the year before, there was only a 1.3% (89 patients) increase in ED referral to medicine, hence showing relative reduction in referrals. This highlights the impact of AMRAU taking direct referrals from GPs. Average reduction of 522 minutes (70%) in LOS in the ED was recorded, and a 26% increase (2,077 patients) was noted in the number of patients treated on the same day by medicine. Short stay admissions (0–2 LOS) observed a 16.7% reduction. Overall, 5.7% less admissions to medical beds were observed in the first 6 months of establishing the unit. There has been an overall 3% reduction in beds used by medicine. There was no evidence of increased readmission rate.
Conclusion
Early contact with the consultant physician reduces admissions and length of stay. An independent, purpose-built unit, separate from the ED and AMU, is a highly efficient way of delivering such a service.
Conflicts of interest
None declared.
- © Royal College of Physicians 2020. All rights reserved.
Article Tools
Citation Manager Formats
Jump to section
Related Articles
- No related articles found.
Cited By...
- No citing articles found.