Ambulatory care directory for adult patients Provided by: NHS Institute for Innovation and Improvement Summary The NHS Institute for Innovation and Improvement has produced a directory of 50 clinical presentations that could be managed by ambulatory care. It includes measures to reduce the rate of accident and emergency (A&E) admissions and increase early discharges. Widespread implementation could produce estimated savings of over 1 billion across the NHS. Evidence summary The intervention has been successfully implemented The intervention is linked to standards or guidance The intervention is supported by one or more national organisations An evaluation of the effects of the intervention has been carried out The proposal Proposal description The proposal is for the implementation of the improvements outlined in the NHS Institute s Directory of Ambulatory Emergency Care for Adults. The directory offers an evidence-based guide to the range and proportions of up to 50 clinical presentations that could be managed in an ambulatory manner (i.e. without admission to an acute hospital bed). It describes how implementation needs to involve looking at new ways of working across traditional health and social care structures, focusing on the patient s safety, outcomes and satisfaction. This needs to be embedded within joint strategic development plans, with clear ownership and leadership. Purpose of change The demand for adult emergency care in England continues to rise, placing greater pressure on all emergency services. In 2008/09 there were 5,451,133 emergency admissions to acute hospitals in England. The total non-elective tariff was in excess of 9 billion. Of the total emergency admissions, 1,502,591 had a length of stay (LoS) of zero (an episode of care without an overnight stay), suggesting that these patients are suitable for alternatives to acute care. In 2008/09, over 1.7 million emergency admissions had an LoS of between 1 and 2 days, and over 2. 2 million had an LoS of over 2 days (Dr Foster Intelligence 2008/09). Page 1 of 5
Potential scalable benefits By reducing the LoS of 1- and 2-day stay patients by an average of half a day, savings of at least 683.8 million could be made (excluding lengths of stay of zero). The savings could be at least 532.3 million if the LoS for patients staying more than 2 days is reduced by 1 day (based on an average of grouped Healthcare Resource Groups of admitted patients). Long periods of inpatient stay not only consume huge NHS resources, but also place the most vulnerable patients at greatest risk. The mortality rates, LoS and institutionalisation rates are all highest for frail older people (who are the largest group of adult emergencies). England has an ageing population. By 2033, the number of people aged 85 and over is anticipated to double to 3.2 million. (Office for National Statistics, Ageing Times, autumn 2009). Pathway group Type of change Related standards and guidance Other information Acute care Service redesign/pathway focusing on the adult emergency clinical pathway All national guidance on emergency care, most recently the Emergency Services Review, October 2009 (Department of Health website). The Directory of Ambulatory Emergency Care for Adults enables service providers and commissioners to tackle the challenges of managing adult emergency care more efficiently and effectively. Ambulatory emergency care is a transformational change in care delivery, similar to that seen with the development of elective day surgery. The directory itself identifies conditions from across a range of specialties, along with their potential for ambulatory emergency care (i.e. 60 90% of admissions). It highlights any key associated considerations or risks, and provides links to further clinical evidence or best practice guidelines. Patients with the conditions found in the directory are currently predominantly admitted to acute hospital bed-based care. The underlying principle of ambulatory emergency care is that admission to a hospital bed should only take place in the context of an acute illness that requires inpatient care. Ambulatory models create a virtual ward of patients under ongoing clinical supervision, but only using services that truly add value to their treatment. The directory is intended to help acute trusts and primary care Page 2 of 5
trusts design and commission ambulatory emergency care pathways, by providing a comprehensive list of the key opportunities for ambulatory care. It was also designed to help individual clinicians consider new possibilities in how they deliver care to their patients. The objectives are to : improve patient experience and outcomes; transform emergency care processes; and release acute-care beds. Evidence of implementation Organisations where the proposal has been implemented Effect on quality of care Homerton University Hospital NHS Foundation Trust North Tees and Hartlepool NHS Trust Safety, effectiveness and patient experience improved through the effective management of adult emergency care. Key gains are observed in the following areas: Significant reductions in the actual number of beds required to deliver emergency care. The desired position is to be managing more patients in an ambulatory manner (without admission to an acute hospital bed) and for an increased proportion of the total number of admitted patients to require only a short stay. Reduction in unnecessary hospital stays and unnecessary admissions (usually addressing the most vulnerable patients, who are at greatest risk). The mortality rates, LoS and institutionalisation rates for frail older people (who are the largest group of adult emergencies) can be reduced. Frequently, older people with multiple co-morbidities (often including dementia) and fragile social support require early identification (at the time of admission) by clinical teams with the appropriate skill sets to implement assertive casemanagement plans. Coordinated effective discharge planning, commencing at the point of admission and with community health and social services aligned to pull these patients back into the community is crucial to delivery. This group of patients, if not proactively managed from the point of admission, decompensate rapidly, with resultant prolonged lengths of stay and poor outcomes. The delivery of high-quality care through prompt senior clinical decision-making, timely diagnostics and documented care pathways achieves: improved patient experience and outcomes; transformed emergency care processes; and Page 3 of 5
released acute-care beds. Effect on productivity Based on the observation that many of its emergency admissions had an LoS of less than 48 hours, Homerton University Hospital NHS Foundation Trust in London has doubled the size of its Medical Admissions Unit. The newly titled Acute Care Unit (ACU) opened in January 2007, when it began to accept surgical patients. Since August 2007, all admissions for surgery, orthopaedics, urology and medicine have taken place through the ACU and been looked after by its team of junior doctors and consultants in all those specialties, with the majority being physicians. Before the changes, around 22% of patients from A&E were being admitted. Following the opening of the new ACU, this fell to approximately 18%, and the trust is predicting further reductions (based on prompt assessment of patients by senior doctors). Before the August 2007 changes, approximately 40% of admissions were discharged in under 48 hours. Now the number has increased to 50%, making a significant contribution to bed reduction in the trust. At North Tees and Hartlepool NHS Trust, a multidisciplinary Optimising Discharge Group was created to focus on patients who stayed between 3 and 7 days. The group includes medical and nursing staff, physiotherapists, occupational therapists, a pharmacist, a social worker, community matrons and information analysts. By concentrating its efforts on eradicating delays for patients, the team has consistently reduced the LoS on all the medical wards, across both the trust s sites: The overall LoS in general medicine is currently 3.9 days. A traffic-light system reinforces the need for safe, efficient and cost-effective discharge. Nurses and allied health professionals are now empowered to challenge discharge decisions, in order to optimise the pathway for the patient. Evidence base drawn from the NHS Institute s Focus On: Short Stay Emergency Care and Focus On: Frail Older People. Timescales for realisation of benefits Additional costs Homerton University Hospital NHS Foundation Trust 6 months. North Tees and Hartlepool NHS Trust 12 months. There are implementation costs for each trust, involving a support package of expertise, training, tools and methodologies. At a trust level, this equates to: 15,000 to release staff to lead the improvement Page 4 of 5
programme; and 30,000 invested for additional expertise and support. Further evidence Evaluations Focus On: Short Stay Emergency Care, available at: www.institute.nhs.uk/option,com_joomcart/itemid,26/main_page,d ocument_product_info/products_id,192.html Focus On: Frail Older People, available at: www.institute.nhs.uk/option,com_joomcart/itemid,194/main_page, document_product_info/cpath,71/products_id,189.html Support from national organisations Royal College of Physicians Society for Acute Medicine NHS Alliance Department of Health Improvement Foundation British Geriatric Society Emergency Services Intensive Support Team Implementation advice Implementation guidance Contacts and resources This requires integrated working across primary and secondary care. There is a potential impact of an increase in demand in primary care: this needs to be carefully considered and planned for (e.g. expansion of community teams). Julia Taylor, Programme Director of the Organising for Quality and the Delivering Quality and Value programmes. NHS Institute Delivering Quality and Value, High volume care update document (January 2008), available at: www.institute.nhs.uk/quality_and_value/high_volume_care/high_v olume_care_update.html Directory of Ambulatory Emergency Care for Adults, available at: www.institute.nhs.uk/index.php?option=com_joomcart&itemid=19 4&main_page=document_product_info&cPath=71&products_id=1 81 ID: 1050 Page 5 of 5