All in a day's work: the drive for better ambulatory care

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In an effort to reduce the number of bed days used in hospitals, trusts have focused on making same-day ambulatory emergency care the default option for emergency patients. By Deborah Thompson and Vincent Connolly

Young boy using an inhaler for treatment of asthma

Royal colleges and clinical teams across England have recognised that a new approach is needed to transform emergency care and reduce pressure on the system.

The College of Emergency Medicine made 10 recommendations in the report Drive for Quality published earlier this year.

One recommendation was that clinical decision units and ambulatory emergency care are important components of the emergency systems.

‘Pioneers of ambulatory emergency care have achieved amazing results with growing evidence of impact’

The Future Hospital report published last year by the Royal College of Physicians recommends that “care will be organised so that ambulatory (day case) emergency care is the default position for emergency patients unless their clinical needs require admission”.

It continues: “Systems will ensure ambulatory care patients continue to receive prompt specialist care aligned to their needs, maximising alternatives to acute hospital admission and improving safety, outcomes and experience of patients in ambulatory care.”

What is ambulatory emergency care?

The RCP defines ambulatory care as: “Clinical care which may include diagnosis, observation, treatment and rehabilitation not provided within the traditional hospital bed base or within the traditional outpatient services that can be provided across the primary/secondary care interface.”

The ambulatory emergency care approach is based on the Directory of Ambulatory Emergency Care for Adults, a publication that lists 49 emergency clinical scenarios suitable for ambulatory or same-day emergency care inpatients that are traditionally admitted to a hospital bed overnight.

The directory was first published by the NHS Institute for Innovation and Improvement in December 2007 and has been reviewed regularly, with the third version published in November 2012.

Using ambulatory emergency care, appropriate emergency patients are diagnosed and treated on the same day and sent home with ongoing clinical support and supervision as needed.

‘The shift is moving patients from two or three nights hospital stay to zero without affecting the quality or safety of their clinical care’

This approach has improved both clinical outcomes and patient experience, and reduced costs and pressures in the urgent care system.

Ambulatory emergency care or same day emergency care is achieved by creating a whole system approach across primary and secondary care.

This ensures that, where appropriate, emergency patients presenting to hospital for admission are rapidly assessed and streamed to ambulatory emergency care to be diagnosed and treated on the same day and then sent home with ongoing clinical supervision as needed.

Clinical teams adopting this new way of working say that by managing significant numbers of emergency patients on the same day without the need for full admission, they convert at least 20-30 per cent of emergency admissions to same-day care.

The shift is moving patients from two or three nights hospital stay to zero without affecting the quality or safety of their clinical care.

The perceived benefits of this approach are:

improved patient experience;
reduced emergency admissions and bed days used; and
vastly improving the satisfaction of staff working in the ambulatory emergency care environment.

Models of care

While the directory has been helpful in identifying and analysing the case mix, pioneer sites are now moving away from a pathway approach and adopting a process method.

This means creating a system where all patients are considered for ambulatory care, unless clinically unstable or until proven otherwise. This approach ensures the maximum number of patients benefit from rapid access to the right treatment.

Whittington Health Trust, based in north London, leads the way with this approach. Following a successful pilot of ambulatory emergency care over 2012-13, Whittington staff collected evidence to support a case for change that resulted in investment to build a purpose built unit located within the emergency department that will open this year.

Early adopters achieve

Pioneers of ambulatory emergency care have achieved amazing results, with growing evidence of impact.

Nottingham University Hospitals Trust transformed its emergency pathway and uses ambulatory care as a filter, meaning admission is now not the first option for sick patients.

This is a philosophy that has resulted in 50 per cent of GP referrals for emergency admissions now being rapidly treated and discharged on the same day.

‘The principles of ambulatory emergency care are transferable to any setting and can be implemented rapidly’

The principles of ambulatory emergency care are transferable to any setting and can be implemented rapidly. Milton Keynes Hospital Foundation Trust set up an ambulatory emergency care unit in six weeks and now provides rapid assessment and treatment, avoiding admissions every day and providing a much calmer environment for staff to report on medical assessments, as the unit has empty beds, ready to receive admissions.

The principles of ambulatory emergency care

Senior clinical input is needed at the point of referral to redirect suitable patients to ambulatory care.
Clear exclusion criteria based on the national early warning score should be developed to maximise patient flow to ambulatory care.
Where possible the ambulatory emergency care service should be closely located to the accident and emergency department.
Staffing and resources should be organised to provide rapid assessment, diagnosis and treatment on the same day.
The time standards for time to initial assessment, time to medical assessment and completion within four hours should match the A&E clinical quality indicators.
Patients should be informed early in their journey, ideally in A&E or by their GP, that they are likely to receive treatment on the same day and are unlikely to be admitted overnight to manage their expectations and those of their family.
Secondary and primary care services should be geared around patient needs and work together to provide ongoing care outside of hospital to avoid full admission.
Staff training is needed across the local healthcare system to ensure appropriate patients are streamed to ambulatory care.
Comprehensive records must be kept and discharge summaries sent to primary care within 24 hours.
Providers must work with commissioners to agree how ambulatory emergency care activity will be recorded, reported and funded.
Clear measures must be adopted and monitored to assess the impact, quality and efficiency of ambulatory emergency care.

John Saxby, chief executive at Pennine Acute Hospitals Trust, also supports the development and rapid rollout of ambulatory care at the trust.

So far six case studies have been published sharing transformation stories of sites that have implemented AEC. The case studies are from:

Milton Keynes Hospital Foundation Trust
Nottingham University Hospitals Trust
Pennine Acute Hospitals Trust
South Tees Hospitals Foundation Trust
Whittington Health Trust
Weston Area Health Trust

Lessons learned

A combination of strong clinical leadership and managerial support is needed to be successful implementing ambulatory emergency care.

It is very important to analyse your data to understand how patients flow through your emergency system. This analysis will reveal the potential demand for the model in your local health community.

To maximise the potential for ambulatory emergency care it is important that you work in partnership with primary care and clinical commissioning group colleagues to make sure there is a good understanding of services available outside of the hospital setting, and to use their expertise and knowledge in the service redesign.

Finally the creation of an ambulatory emergency care model may be slightly different in each health community, but the principles remain the same.

Read the reports:

Deborah Thompson is programme director of the Ambulatory Emergency Care Delivery Network and Dr Vincent Connolly is an acute physician at South Tees Hospitals Foundation Trust and clinical lead at the network