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Practice comment

“Adopt ambulatory emergency care to cut hospital admissions”

Ambulatory emergency care (AEC), or same-day emergency care, is an evolving approach in which appropriate adult emergency patients can be diagnosed, treated and discharged from hospital on the same day.

A significant number of emergency patients can be managed using AEC, and up to 30% can be autonomously managed by nurses with the appropriate knowledge and skills.

Many nurses have engaged with this new approach and acquired the knowledge and skills to take on nurse practitioner roles in AEC, managing clearly defined emergency care pathways without the need for medical intervention. The NHS Institute for Innovation and Improvement’s (2010) Directory of Ambulatory Emergency Care for Adults lists 49 ambulatory emergency conditions ranging from the management of deep vein thrombosis to the replacement of percutaneous endoscopic gastrostomy (PEG) tubes.

When the first edition of the directory was published in 2007, the national clinical director for urgent and emergency care, Matthew Cooke, likened the advent of AEC to the changes that led to the introduction of day case surgery. Ian Smith, president of the British Association of Day Surgery, supports this view, saying there are many similarities between nursing roles in the two specialties. Like AEC nurses, day surgery nurses present a positive, pragmatic approach when managing same-day, patient pathways. The nurses are confident practitioners in their area of expertise. They have developed protocols and checklists to actively manage common, high-volume pathways, often discharging patients on a criteria basis, negating the need for medical sign-off before discharge.

This view was borne out recently at an event for AEC nurses organised by the NHS Institute and delivered in collaboration with the Royal College of Nursing at Warwickshire University Campus. Nurses identified core skills including: good knowledge of AEC conditions, excellent communication skills, the ability to prioritise care, and experience in discharge planning.

Nurses were also keen to extend their skills into areas such as non-medical prescribing, ordering and interpreting X-rays and scans, and undertaking interventional treatments such as abdominal paracentesis, to enable them to effectively manage more pathways. On reviewing the directory of AEC, nurses felt they could autonomously manage approximately a third of the conditions listed.

It is vital that clinical teams delivering emergency care adopt AEC as an alternative to hospital admission. Nurses must continue to pioneer this approach and acquire the right knowledge and skills for this, as they play a crucial role in AEC, to reduce the number of hospital admissions and, more importantly, improve the patient experience.

Deborah Thompson is associate director, Weston Area Health Trust and part time secondee, NHS Institute for Innovation and Improvement

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Readers' comments (1)

  • In some ways AEC could be regarded as a "councel of perfection" which many centers wil not be able to achieve.

    For example the discharge of the elderly and the chronically sick is highly dependent on adequate social arrangements being in place and the time of day. Many admissions are still made for essentially social reasons.

    For AEC to be fully effective requires avialble Senior Medical decision making and rapid access to diagnostic procedures / investigation. (CT scans,Ultrasound and MRI being particular potential "bottlenecks")
    Laboritory investigations take time even when fast tracted and can be a source of delay especially if investigations need repeating. Expansion of in Dept or bed side testing may alleviate some delay and is possible given adequate technical support.
    Some A&E departments will find AEC a significant challenge especialy at week ends and during unsocial hours.

    I do however fully support the concept and the role of nurses in facilitating AEC.

    Unsuitable or offensive?

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