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Acute Medicine – an out-patient specialty? Dr Vincent Connolly The James Cook University Hospital Middlesbrough VConnolly Trust Cumulative Position % of A&E Attenders Waiting less than 4 Hours 2008/09 YTD % seen within 4hrs 98% Target 2007/08 % seen within 4hrs 100.0% 99.0% 98.0% Percent 97.0% 96.0% 95.0% 94.0% 93.0% 92.0% 91.0% 90.0% Apr May Jun Jul Aug Sep Oct Month VConnolly Nov Dec Jan Feb Mar Non-Elective, Medical and Non- Medical (Other) Admissions JCUH 2006/07 - December 2008 Non Medical Admissions 2006-07 Non Medical Admissions 2007-08 Non Medical Admissions 2008-09 Medical Admissions 2006-07 Medical Admissions 2007-08 Medical Admissions 2008-09 April July Oct 1900 1800 Number of admissions 1700 1600 1500 1400 1300 1200 1100 1000 May June Aug Month VConnolly Sept Nov Dec What is Ambulatory Emergency Care? RCP (L) Acute medicine taskforce:- Ambulatory care is 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. VConnolly Categories of Ambulatory Emergency Care 1.Diagnostic exclusion group Eg chest pain rule outs etc (many already in place) 2.Low risk stratification group Eg low Rockall score GI bleed 3.Specific procedural group Eg effusion drainage 4.Infra-structural group Eg care home admissions VConnolly Selection of clinical diagnoses appropriate for ambulatory care Gastroenterology – – – – – Upper gastrointestinal (GI) bleed with Rockall score of 0 Lower GI bleed with no haemodynamic compromise Painless obstructive jaundice Non-acute abdominal pain Diarrhoea and vomiting Endocrinology – – – – – Hyperglycaemia without ketosis Hypoglycaemia with full recovery Type 1 diabetes without ketosis Electrolyte imbalances Thyroid disease Infectious diseases – Cellulitis – Osteomyelitis VConnolly Services which can be linked to Ambulatory Care Chronic obstructive pulmonary 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 Endoscopy services Heart failure team VConnolly How to get started Location, location, location – – – – Ideally close to A&E & AAU Waiting facilities Consulting rooms Trolleys People – Enthusiastic capable clinicians, nurse practitioners – HCAs/generic workers – Senior management Diagnostic support – Pathology – Radiology Clinical guidleines/algorithims/patient flow – Agreed Clinical Outcomes & Process Measures – Activity VConnolly Developments In Acute Medicine Environment changes in collaboration with the PCT Funded clinic facility – 4 trolleys – 4 consulting rooms – Staff room – Storage area – Waiting area – Discharge lounge Out of Hours Primecare centre VConnolly Nursing Staff Sister on every shift Nurse practitioners – Clerking patients & developing management plan – Specialty links Training – Clinical skills – ALS - ALERT course (identification and management of the critically ill patient). Develop health care assistants & generic workers VConnolly This slide (containing an example of good practice) has been removed to reduce the size of the presentation. To receive an email copy of the complete presentation, please email [email protected] VConnolly What are the 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 & cost effective Alleviates bed pressures Reduces A&E attendances VConnolly Fast AccesS to Therapist team Activity 8% Transfers to non acute beds 1721 patients referred 4% Unsuitable patients Patients discharged home via FASTeam Patients 22% remaining in acute hospital bed 66% VConnolly Space…Space….Space AAU clinic activity On average the AAU clinic receives 23 patients per day Procedure room - development 7000 6000 5000 4000 3000 2000 1000 0 6300 5266 5526 3600 4223 4642 2003 2004 2005 2006 2007 Sep08 Day AM PM Monday 1.Nurse Led DVT / PE clinic 2. Gastro clinic 1. TIA clinic 2. Dr Nag Diabetes and GM clinic Tuesday 1. Nurse Led DVT / PE clinic 2. Dr Hamad Thromboembolic Disease and Heat Failure clinic 1.TIA clinic 2. Dr Guhan Pleural Disease clinic Wednesday 1. Nurse Led DVT / PE clinic 1.TIA clinic 2. Dr Guhan Chest clinic 3. Dr Whitfield GM clinic Thursday 1. Nurse Led DVT / PE clinic 2. Dr Hamad Thromboembolic Disease and GM clinic 1. TIA clinic 2. Dr Whitfield Chest and GM clinic Friday 1. Nurse Led DVT / PE clinic 1. TIA clinic 2. Dr Connolly- Dr Hamad GM clinic VConnolly Activity Acute Medicine Directorate Emergency admissions by year 25000 20463 19082 Number of admissions 20000 18508 16033 15916 14000 15000 10011 10650 11084 10000 5000 0 2000 2001 2002 2003 2004 2005 2006 2007 Aug-08 AAU 24 hour discharge rate (%) 60 As the activity continues to rise, so too does the number of patients discharged from the directorate. 50 40 30 20 10 0 1996 VConnolly 1998 2000 pre-ambulatory care 2002 2004 2006 post-ambulatory care Risk adjusted mortality – trust overview VConnolly Risk adjusted length of stay VConnolly Ave Length of Stay – General Medicine 14 12 10 8 6 4 2 0 1 8 15 22 29 36 43 50 57 64 Provider values 71 78 85 Quartiles VConnolly 92 99 106 113 120 127 134 141 148 STHT 5/6 HES Community Primary Care A&E dept Self Referral Self Care Intermediate / Community beds Primary care Mental Health Medical Assessment Unit Social Care AMBULATORY EMERGENCY CARE ITU/HDU Specialist care General care Acute VConnolly FASTeam DVT/PE OHPAT Rapid Access Clinic Chest Pain Clinic Heart Failure Team Diabetes Team COPD Outreach Macmillan Team Thank you Any questions? 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