Acute Medicine - Organisation of Urgent Care

Dr Kevin Jones FRCP MD

Royal Bolton Hospital

Urgent Care

“The number one issue facing the NHS in England is reversing the ‘unsustainable’ rise in emergency hospital admissions .... There has been an almost 12 per cent rise in admissions over the last five years”

Nuffield Trust, 2010

Acute Medical Unit

Assessment and Short Stay Beds D1 Ward - female (26 beds) D2 Ward - male (22 beds ) GP Assessment Unit (GPAU) Clinical Decisions Unit (CDU) Emergency Department Bolton Community Unit (BCU) DVT Clinic

GP Assessment Unit

In Main Outpatients (Blue Bay) Same area as SARC Clinic Purpose Built Ambulatory Area Next to Emergency Department Next to CDU ( Red Area ) Acute Medicine Consultant 0800-1600 Closed weekends and bank-holidays In January 2013 – average 8 patients/day

Clinical Decisions Unit (CDU)

Purpose built in Red Area of Outpatients Not strictly speaking a CDU Only 14 beds Used as an ultra-short stay unit (12 hrs ideal) Telemetry and monitoring Cardiac chest pains awaiting Troponin-I Acute Medicine Consultant 0800-1600 hrs

Clinical Decisions Unit (CDU)

February 2013

254 admissions ( 9/day ) 82% discharged home Only 35% with length of stay < 12 hours 33% staying longer than 24 hours

Clinical Decisions UnitRing fencing

June 2013

In last 2 weeks – 186 admissions 13 per day 88% discharged home

Admissions(January 2013)

D1 448 D2 442 CDU 254 GPAU 173

Mean 42 per day 45% discharged directly home from AMU

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Time of Admission to AMU

Do our rotas reflect our demand and support senior review?

Approximately 24% total

admissions come direct from GPs

Discharge Flow does not mirror ‘input’ flow, and lags behind

A&E Total Attendances v Discharges

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Difference Attendances Discharge

Lengths of Stay for AMU discharges

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2hrs 4hrs 6hrs 12hrs 24hrs 24+ hrs

D1

D2

75% of patients kept on Acute Medical Unit

are discharged within 24 hours

45% discharged home

55% admitted to specialist ward

How to ReducePressure on Beds

Maintain 85% bed occupancy Reduce Lengths of Stay Consultant-held Triage Bleep Early senior decision maker review Capacity for Short Stay in AMU Ambulatory Care

Consultant held Triage Bleep for GP Direct Results Mean number of calls dealt with per day between

0800 and 1600: 13 (range 8 – 23) On average the consultant is able to divert or

deflect 4 – 6 admissions per day. Giving advice to the GP Advising referral to a specialist clinic Giving the patient an appointment in GPAU Asking the hospital Referral and Assessment Team

to assess patients with social problems.

Triage Bleep - Advice

Subarachnoid haemorrhage Temporal arteritis Transient ischaemic attack Bell’s Palsy Pneumonia Atrial Fibrillation Hyperkalaemia Severe Hypertension Iron Deficiency Anaemia

GP Assessment UnitMain Referrals

Headaches

Chest pain

Shortness of breath

Blackouts and collapses

Generally unwell

Admissions from ED

Emergency Admissions Length of Stay

Greater Manchester (12 Trusts)

Range 1.8 to 3.8 days Mean 2.6 days Bolton 2.4 days

95% Emergency Dept Target

>95% for every month April to Dec 2012 Below 95% for January 2013 Above 95% for February 2013 95.6% for March 2013 95.5% for Quarter 4 96.9% Year to Date

Clinical Quality Indicators for Acute Medical Units

1. All patients admitted to the AMU should have an early warning score measured upon arrival on the AMU.

2. All patients should be seen by a competent clinical decision maker within 4 hours* of arrival on the AMU who will perform a full assessment and instigate an appropriate management plan.

3. All patients should be reviewed by the admitting consultant physician or an appropriate speciality consultant physician within 14 hours of arrival on the AMU**.

Clinical Quality Indicators for Acute Medical Units

Consultant held Triage Bleep GP Assessment UnitClinical Decisions Unit

Any Questions ?

Ambulatory Emergency Care

Ambulatory Emergency Care

Ambulatory Emergency Care

Acute Admissions from Care Homes Acute Admissions from non-acute NHS beds End of Life Care

Percutaneous Endoscopic Gastrostomy Does Not Prolong Survival in Patients With Dementia

Lynne M. Murphy, MSN, RN, CNSN; Timothy O. Lipman, MD Arch Intern Med. 2003;163(11):1351-1353.

Improving end of life care for nursing home residents: an analysis of hospital mortality and readmission rates.

. Ahearn DJ,Jackson TB, McIlmoyle J,

Weatherburn AJ. Postgrad Med J. 2010 Mar;86(1013):131-5

Ahearn DJ et al, 2010

Analysis of all admissions to the acute medical unit of a busy district general hospital over a 94 day period, comparing nursing home residents with all admitted patients aged over 70 years.

Ahearn DJ et al, 2010 Nursing home residents were significantly less likely

to survive the admission than elderly people living in the community.

33.9% of nursing home residents did not survive the admission

51.6% died within 6 weeks of admission. Of those discharged alive, 41.5% were readmitted

or died within 6 weeks. Patients with a higher level of comorbidity were less

likely to survive the admission or live to 6 weeks.

Ahearn DJ et al, 2010

Many nursing home residents find acute admission distressing,

Many hospital admissions are ‘inappropriate’. Advance care planning can improve patients’ end

of life care. Nursing home residents were significantly less

likely to survive acute medical admission than elderly people living in the community.

Ahearn DJ et al, 2010

Patients with a higher level of comorbidity are less likely to survive the admission or to 6 weeks than those with lower levels.

Advance care planning should be considered in all nursing home residents, especially those with the greatest level of comorbidity.

Postgrad Med J 2010;86:131-135.

Transient Ischaemic Attack

Is it a TIA or not?

Are the neurological symptoms focal rather than non focal?

Are the neurological symptoms negative rather than positive?

Was the onset of the focal neurological symptoms sudden?

Were the focal symptoms maximal at onset? Syncope does not occur with TIA

TIA – ABCD2 Score

Age > 60 yrs 1 BP > 140/90 1 Clinical Weakness 2 Speech 1 Duration < 1 hour 1 > 1 hour 2 Diabetes 1

TIA – ABCD2 Score

Start aspirin 300mg Score 4 or more – clinic within 24 hours Score less than 4 – clinic within 1 week

Hypertension

Hypertensive Urgency

Systolic > 200 mmHg

Diastolic > 120 mmHg

No symptoms ( headache )

No end-organ damage

Usually poorly compliant

Headache

Subarachnoid haemorrhage

Suddeness of onset more important than severity

Comes on to maximum intensity within a minute

Lasts for at least an hour

Haematemesis

Stanley et al, Lancet, 373, Jan 3rd 2009. Glasgow-Blatchford

Pneumonia – BTS Guidelines

Can be a clinical diagnosis Chest X-ray not essential CRB-65 score of 0-1 may be treated in the

community

Pneumonia – CURB 65 score

Confusion – new onset Urea > 7.0 mmol/l Respiratory rate > 30 / min BP - < 90 syst or < 60 diast Age > 65 yrs

Bell’s Palsy

Diagnose lower motor neurone palsy Imaging not required unless atypical or not

recovering after 8 weeks Give prednisolone 60 mg for 1 week Protect the eye Primary care – not acute medicine

Temporal Arteritis

Usually aged above 50 years ESR usually above 80 mm/hr Start prednisolone 60 mg daily Temporal artery biopsy within a week

Discussion