The Forum

The surprisingly simple approach one UK hospital used to redirect 25% of its ED visits

by Rachel Zuckerman and Liz Jones

Health systems around the world are struggling with unprecedented emergency department (ED) pressures, including increasing volumes and long wait times. In response, many are turning to ambulatory emergency care to divert patients away from the ED. In fact, the new NHS Long Term Plan requires that all acute hospitals with a type 1 Accident & Emergency department move to a comprehensive model of 'Same Day Emergency Care' by 2019/20.

6 steps to ED transformation

Ambulatory care an under-used asset

A notorious problem with ambulatory units is directing the right patients to use them. Ambulatory units are just one of the many options available for providers to refer patients to, and most clinicians assume that patients' needs are too acute to be treated there. While understandable, this confusion and caution means that ambulatory models aren’t used for nearly as many patients as they could reasonably and appropriately treat.

So what can hospitals do to optimise the use of ambulatory care models? Here's the journey that Pennine Acute Hospitals NHS Trust, part of the Northern Care Alliance in the UK, took to identify patients appropriate for ambulatory emergency care.

Traditional ambulatory referral strategies lead to limited uptake

Initially, Pennine implemented a list of pre-approved ambulatory eligible conditions to determine which patients could be referred to the service, but it was difficult for referring providers like GPs and ED staff to keep track of the dozens of conditions that ambulatory care could manage. As a result, a large number of patients who could have been treated in ambulatory care were never referred to the service.

The Trust then began using the AMB score, a seven-element scoring system, to help identify emergency presentations suitable for ambulatory care. But studies have found the AMB score to be ineffective at accurately identifying ambulatory patients, and again, Pennine realised that it wasn't treating as many patients in ambulatory care as it felt it could.

Making ambulatory the default

So Pennine decided to change its approach: It began assuming all patients eligible for ambulatory care unless proven otherwise. To do this, Pennine created a short list of simple exclusion criteria outlining who is not eligible for ambulatory care, rather than who is.

In the new model, all patients over 16 years of age are considered suitable for ambulatory care unless they present with:

  • New confusion or delirium;
  • Cardiac chest pain with new ECG changes;
  • Anticipated length of stay of less than 24 hours;
  • New onset reduced Glasgow Coma Score; and/or
  • Non-medical patients.

All of the relevant stakeholders—clinicians, administrators, commissioners, and referring providers—crafted these criteria during a week-long workshop to ensure consensus and buy-in.

While providers can still use clinical judgment to override the list, the exclusion criteria is hardwired into all referral and triage pathways to the hospital, including GP referrals, the ED, and even the ambulance service. This approach drastically simplifies the referral process, because providers no longer have to remember a long list of specific conditions. It also enables patients to be triaged to ambulatory care before even arriving at the hospital.

As a backup, clinicians visit the ED throughout the day, as well as their day unit each morning, to identify inappropriate admissions that may have slipped through the cracks and redirect those patients to ambulatory care.

Through this model, Pennine has increased the proportion of its emergency visits managed in ambulatory care from 9% to 25%.

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