A foundation trust implemented a pilot project using ambulatory emergency care pathways to reduce its increasing admissions and improve the patient experience
Evidence shows many conditions can be effectively managed out of hospital, with greater patient satisfaction and fewer hospital admissions. South Tyneside Foundation Trust ran a pilot project in which an ambulatory emergency care (AEC) department saw patients admitted to hospital via their GP, producing the benefits stated above.
Citation: Hattrick G et al (2012) Using ambulatory A&E care to cut admissions. Nursing Times [online]; 108: 14/15, 14-15.
Authors: Gemma Hattrick is emergency nurse practitioner; Ceri Bentham is clinical business manager; both at South Tyneside Foundation Trust
- This article has been double-blind peer reviewed
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The NHS Institute for Innovation and Improvement (2007) defines ambulatory emergency care (AEC) as follows:
“The treatment of a condition that the patient or referrer deems urgent, which is not provided within the traditional bed base or outpatient services. It requires prompt clinical assessment, undertaken by a competent decision-maker and will very often require prompt access to diagnostic support.”
Interest in AEC as a way of dealing with rising attendances in accident and emergency departments is growing. Many conditions can be managed out of hospital safely and effectively, with greater patient satisfaction and fewer hospital admissions (McCallum et al, 2010). Conditions currently treated in this way include deep
vein thrombosis, pulmonary embolism, headaches, palpitations and cellulitis (NHS Institute, 2007). The following four main groups of patients for whom AEC can be developed have been identified by the institute:
- Diagnostic exclusion - patients who need a specific diagnosis to be excluded (for example, a patient with chest pain needs a possible myocardial infarction to be ruled out);
- Low-risk stratification - those for whom an early senior review with risk stratification will promote early discharge (for example, a non-variceal gastro-intestinal bleed with low Rockall score);
- Specific procedure - patients who need a specific procedure or treatment, such as a blood transfusion;
- Infrastructure required - those who have historically been admitted but can be managed safely as outpatients (for example, a patient with a DVT).
The pilot project
South Tyneside Foundation Trust has seen increasing attendances in A&E recently. Jones (2009) discussed reasons for this including an ageing population, readmissions and patients’ increasing expectations of medicine. These rising admissions have put greater pressure on the trust’s activity, and led to many elective operations being cancelled, meaning longer waiting lists and dissatisfied patients (Chamisa, 2008). The number of A&E patients staying overnight has also risen from just over 2,000 to around 3,600 per year. It is mainly this group that could be managed via AEC pathways.
From April 2011, the four-hour emergency care standard was replaced with eight clinical quality indicators, measuring flow through emergency pathways; one of these requires trusts to have AEC pathways in place (Department of Health, 2010). To help tackle these issues the trust set up an AEC pilot to reduce hospital admissions, releasing beds and improving patient experience. The pilot, which began in January 2011, was initially for three months but has now become a permanent service.
The trust’s AEC service employs three emergency nurse practitioners (ENPs) and two healthcare assistants. The ENPs have several symptom-driven care pathways to follow including: cough; hypertension; headache; loss of consciousness; palpitations; pleuritic chest pain; seizure; shortness of breath; leg oedema; and loin pain. All patients must be stable and fully ambulant to be seen by the AEC service. The majority have had an admission to hospital arranged by their GP, who refers them direct to the AEC. A small number of A&E patients are also seen if they fit the pathway criteria.
The ENP completes a history and arranges appropriate investigations for all patients assessed as suitable, including blood tests, electrocardiogram, X-ray and ultrasound scans. Once all results are available, the consultant reviews patients and develops a management plan; follow-up is available in acute access clinics with the consultant if needed.
A rapid-response team is also available, incorporating a re-enablement specialist nurse, occupational therapist, physiotherapist and access to an on-call social worker. This means patients can have assessments for mobility or care services as soon as they are needed. Equipment or services can be arranged for the same day, which avoids any unnecessary social admissions.
The pilot produced several benefits, such as improved patient experience and fewer emergency admissions to hospital. Table 1 shows the number of patients assessed using the AEC pathway and those safely discharged.
During the pilot period, 92% of patients were referred by their GP for admission; the other 8% had attended A&E and were identified by ENPs as being suitable for AEC. Before the AEC service was introduced, all patients referred for admission by their GP would have been admitted to hospital but, during the pilot, only 179 needed to stay in hospital. Many of those admitted could be discharged due to the accessibility of diagnostic tests, a consultant review and management plan.
During the pilot there were no clinical incidents reported in relation to the AEC service or pathways and only four readmissions. On further investigation these patients returned to hospital because of a different condition or injury.
To evaluate the service fully and help further development, patient satisfaction surveys were posted to all those managed through the AEC service during the pilot period. Questionnaires rather than other data collection methods were used so patients could answer specific questions and give their views anonymously. Eight multiple-choice questions rated patients’ experiences at different points during their AEC journey:
- How were you greeted on entering the department?
- How was your wait to see the ENP?
- How was your consultation with the ENP?
- How would you rate your visit to radiology?
- How would you rate your visit to cardiology?
- How would you rate your consultation with the consultant?
- How would you rate your overall experience?
- If you have been admitted to hospital before, how did this attendance compare?
The responses available were unsatisfactory, satisfactory, neither/not applicable, good or outstanding.
The following results are taken from all surveys received during February 2011, (n=54; there were three non-responders). All responses were either good or outstanding for experiences with the ENP, radiology, cardiology and consultant review. Twenty-six patients had previously been admitted to hospital via their GP; 7% of these rated this visit as being of the same standard, 7% as “better” and 86% as “much better”. Fig 1 shows the sample’s rating of their overall experience in AEC - 52% rated it outstanding.
Patients could write more comments or recommendations - again, the feedback received was extremely positive. Patients said the service: “Could not be improved”, was “Professional, caring, very in tune [with] patients’ and relatives’ needs”, and that “…the ambulatory emergency care service works really well and I could not fault the treatment I had”.
Recommendations included better signage in corridors and more comfortable trolleys. In response to the results and the fact that the service is now permanent, patient feedback was used to help decide on its location and the equipment used in the new accommodation. Unfortunately non-responders could not be followed up due to time constraints and limited numbers of available staff.
Patient evaluations and data from the pilot strongly suggest the service is safe, effective and results in:
- A positive patient experience;
- Fast diagnosis and management plan;
- Fewer admissions;
- Fewer cancellations in elective activity due to bed shortages;
- Improved staff morale;
- Significant financial savings.
Creating further pathways will increase the number of patients who can be seen. We are currently starting a once-a-day intravenous antibiotic service for those with cellulitis and plan to develop new pathways to treat conditions including self-poisoning, pyelonephritis and vaginal bleeds. We also hope to expand the service; to facilitate this we recently moved into a specific AEC department with two consulting rooms, five treatment rooms and a waiting room, which will give more capacity to continue to increase financial savings and improve patient experience
- Ambulatory emergency care is an area of growing interest
- A number of conditions can be safely and effectively managed outside hospital
- The system can improve patient experience and cut emergency admissions
- It can provide a rapid diagnosis and management plan
- Other benefits include better staff morale and cost savings
Chamisa I (2008) Why is surgery cancelled? South African Journal of Surgery; 46: 3, 79-81.
Department of Health (2010) Accident and Emergency Clinical Quality Indicators: Implementation Guidance and Data Definitions. London: DH.
Jones R (2009) Trends in emergency admissions. British Journal of Healthcare Management; 15: 4, 188-196.
McCallum L et al (2010) National Ambulatory Emergency care survey: current level of adaption and considerations for the future. Clinical Medicine; 10: 6, 555-559.
NHS Institute for Innovation and Improvement (2007) Directory of Ambulatory Emergency
are for Adults. tinyurl.com/NHSInstitute-AEC-directory