Same Day Emergency Care

NotSDEC chairs ( not to be confused with the Titanic )

NotAmbulatory Emergency Care

Dr Vincent ConnollyExecutive Medical DirectorNorth Cumbria IHCS

NHS definition of quality

Patients can be referred to SDEC treatment through a number of different ways, including:

• triage in emergency departments (EDs)• direct referral from GPs• direct transfer from ambulance • direct referral from NHS111

Types of SDEC treatment include:

• acute medical SDEC • surgical SDEC• acute frailty

NHS Long Term Plan

All hospitals with a 24 hour ED (type 1) will provide:

• the provision of SDEC at least 12 hours a day, 7 days a week by September 2019 and by March 2020 for surgical SDEC

• an acute frailty service at least 70 hours a week by December 2019, with the aim to complete a clinical frailty assessment within 30 minutes of arrival in the ED/SDEC unit

• record all patient activity in EDs, urgent treatment centres and SDECs using same day emergency care data sets in April 2020.

https://improvement.nhs.uk/resources/same-day-emergency-care

What is the ambition for SDEC?

The headline for SDEC

This will increasethe proportion of acute admissions discharged on the day of attendance from a fifth to a third

Clinical Effectiveness

The beginning ………………..

Cohort One

• Calderdale & Huddersfield• Harrogate• Hull• Leeds• Liverpool• Nottingham• Plymouth• Tyne & Wear• Weston Super Mare• Whittington

Cohort Two

• Bath• Bristol• Gloucester• Imperial• Milton Keynes• North Cumbria• North Lincs• Pennine• Pilgrim• Stockport• Warrington

Cohort Three• Addenbrookes• Ashford CCG• Chester• Dudley• East Sussex• Heart of England• Kettering• Kings College• Peterborough• Sandwell & West Birmingham• St Helens and & Knowsley• Worcester

Cohort Four

• Barnsley• Basildon• Croydon• Epsom• Heatherwood & Wexham• Herts Valleys CCG• Ipswich • Kingston• Mid Staffs• Northampton• Northwick Park• St Heliers• St Georges• Southport & Ormskirk• UCLH

Cohort Five

• Bournemouth • Bradford • Coventry and Warwickshire • East Cheshire • Guys & St Thomas• Lewisham• Lister – East & North Herts• Portsmouth • PRU Kings College • Southend • South Manchester • Tameside • West Sussex• Wye Valley• Yeovil

Cohort Six

• Aintree• Burton• Central Manchester• Gateshead• Leicester• Mid Essex• North Staffs• Royal Cornwall• Royal Free – inc. Barnet• Shrewsbury & Telford• Swindon• Walsall• West Middlesex

Cohort Seven

• Buckinghamshire• Colchester• Medway• Morriston, Swansea• Neath Port Talbot• North Bristol• North Middlesex• Oxford• Princess of Wales, Bridgend• Singleton, Swansea• Sunderland• West Suffolk

Cohort Eight

• Ashford & St Peters• Barking, Havering & Redbridge• Blackpool• Heart of England• Homerton• Llandough• Maidstone & Tunbridge• Rotherham• Sherwood Forest• University Hospital Wales

Cohort Nine

• Barts Health• Bedford• Brighton & Sussex• Dorset• Frimley Park• Huddersfield & Calderdale SRG• Hull & East Yorkshire• Mid Cheshire• Mid Yorkshire• North Cumbria• Poole• United Lincolnshire• Warrington CCG• Wirral

Cohort Ten

• Airedale• East Lancashire• Hampshire• Lancashire• Pennine• Princess Alexandra Hospital, Harlow• Royal Devon & Exeter• Southampton

Ambulatoryemergencycare.org.uk

Gumption Traps

Default to Day Surgery

Suitability for day surgery Pathway

Clearly suitable

Unsure

Clearly unsuitable

Day surgeryHome if ok

Inpatient care? Home if ok

Inpatient careHospital stay

20–30%

5–20%

40–65%

Have a Clinical Conversation

Clinical Scenario

• 17y old woman

• Type 1 diabetes

• Symptomatic

• Blood glucose 27mmol/l

• Blood ketones 2.5

• SDEC?

Diagnostic criteria for DKA

Ketonaemia > 3.0mmol/L or significant ketonuria (more than 2+ on standard urine sticks)

Blood Glucose > 11 mmol/l or know diabetes

Bicarbonate < 15 mol/l and/or venous pH < 7.3

Clinical scenario

• 55y old male

• Several weeks of intermittent severe headache, left eye pain

• Holding head

• Bloodshot eye

• SDEC?

Management of cluster headache

Discuss the need for neuroimaging for people with a first

bout of cluster headache

Offer oxygen and/or a subcutaneous or nasal triptan for the

acute treatment of cluster headache. 100% flow at least 12 l

per minute, consider home oxygen

Do not offer paracetamol, NSAIDs, opioids, ergots or oral

triptans for the acute treatment of cluster headache.

Clinical Scenario

• 55 y old man

• Drinking

• After several vomits, small amount of haematemesis

• HR 90 bpm BP 128/76

• SDEC?

Glasgow Blatchford score

Admission risk marker Score component value

Blood Urea (mmol/L)[5]

6.5-8.0 2

8.0-10.0 3

10.0-25 4

>25 6

Haemoglobin (g/dL) for men

12.0-12.9 1

10.0-11.9 3

<10.0 6

Haemoglobin (g/dL) for women

10.0-11.9 1

<10.0 6

Systolic blood pressure (mm Hg)

100–109 1

90–99 2

<90 3

Other markers

Pulse ≥100 (per min) 1

Presentation with melaena 1

Presentation with syncope 2

Hepatic disease 2

Cardiac failure 2

Clinical scenario

• 55y old man

• In ED

• Drinks 1 l of vodka per day

• Distressed

• Unkempt wants emergency detox

• SDEC?

Community detoxpathway

Clinical Scenario

• 55y male in ED

• Faint lightheaded at the toilet

• Brief LoC

• Previous admission with abdominal pain

• Admit to SDEC ?

San Fransisco Syncope Rules

C - History of congestive heart failure

• H - Hematocrit < 30%

• E - Abnormal ECG

• S - Shortness of breath

• S - Triage systolic blood pressure < 90

Clinical Scenario

• 55 y old man

• Breathlessness, PND, ankle oedema

• HR 120bpm BP 110/70

• ECG tachycardia, non-specific t-wave changes

• Cardiomegaly

• SDEC?

A new patient

pathway –

a new

compact

Define who can

go home

Define who

needs

specialist care

0

10

20

30

40

01/10/201101/12/201131/01/201201/04/201201/06/201201/08/201201/10/201201/12/201231/01/201302/04/201302/06/201302/08/2013

Address this with anonymised data, constructive individualised feedback, joint rounds, coaching, developing pathways for high volume scenarios

Huge variation in clinical practice

Going for lunch8.00 8.30 9.00 9.30 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00 15.30 16.00 16.30 17.00

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

Measure the backlog

Increased admission rate8.00 8.30 9.00 9.30 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

Going for lunch & increased admissions & handover8.00 8.30 9.00 9.30 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00 15.30 16.00 16.30 17.00 17.30 18.00 18.30 19.00 19.30 20.00 20.30 21.00 21.30 22.00 22.30 23.00 23.30

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 2

SHO 1

SHO 1

SHO 1

SHO 1

SHO 1

SHO 1

At 5pm7 patients waiting to be seenMax wait 5.5 hours

SDEC Quality ImprovementCasefile analysis

Managed in AEC Not managed in AEC

Conversion

Appropriate for AEC Group 1: Success(expect about 10% conversion rate)

Group 3: Missed opportunity

Not appropriate for AEC

Group 4a: Waste(patient could be managed in another outpatient service)

Group 2: Success(appropriate inpatient care)

Group 4b: Risk(patient too sick/complex at time of selection)

Programme Sustainability Score

Top 3 areas for action are:

1. Senior Leadership Engagement

2. Infrastructure for Sustainability

3. Clinical Leadership Engagement

Gap between average score and maximum

ranked by decreasing gap

Elements of quality in designPatient Experience

The components of good design

Berkun, 2004 adapted by Bate

Performance

How well it does the

job /is fit for

the purpose

Functionality

Engineering

How safe, well

engineered and

reliable it is

Safety

The aesthetics

of experience

How the whole

interaction with the

product/service

‘feels’/is experienced

Usability

Patient experience audit - NCUH

What would a 10% increase in AEC mean in your Trust?

60 admissions per day

6 more admissions avoided

An empty bay on AMU

Thank you