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Thinking Out of the Box Ambulatory Service in
Hospital Authority
Dr. Woon-Leung NG
Department of Medicine & Geriatrics
United Christian Hospital
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Conventional • Ask for more IP beds
• Ask for more manpower
• Ask for more resources
• Ask colleagues to work harder
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Conventional • Ask for more IP beds
• Ask for more manpower
• Ask for more resources
• Ask colleagues to work harder
Counter-intuitive • Cut IP beds
• Convert to Ambulatory
• Cut wastages
• Challenge colleagues to work smarter
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Reforms
• Reduce In-patient Beds
• Redesign an ambulatory care centre (UACC)
• Recruit a dedicated ambulatory care team
• Reconfigure our service model
• Reducing Avoidable Hospitalization
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Average no. of IP beds per day (MED 1994 – 2014) UCH vs Average of the other 6 Major HA Hospitals
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Graph 1 – AE Adm Graph 2 – IP Beds
Graph 3 – Occupancy Rate Graph 4 – Total IP Bed Days
"A statistic should tell a story." -- Margaret Thatcher
Think Substitution - IP Bed is not the only Option
• IP bed is expensive
• IP bed cannot be expanded indefinitely
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Nurse-Led Service •Drug infusion / injection
•Transfusion / Chemo Rx
•Catheter Care
•Special dynamic tests
• Insulin tolerance test
• Autonomic function test
Medical Procedures Endoscopies
Bone marrow
Lumbar Puncture
Biopsies
Abdominal &
Pleural tap / Bx
(USG-guided)
Day Cardiac Procedures •Cardiac cath / Change of pacemaker
•Pre-procedure education and consent
Rheumatology •Biologic Rx
•Joint Injections
•Musculoskeletal
Ultrasound
Medical Consultation
For Complex Care •Supported Discharge
•Drug titration
•Conjoint programme with AED
Multi-disciplinary Service •TIA clinic
•Cognitive clinic
•Autologous BMT workup
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Alternatives
Life or organ threatening illness
Access to Specialist Services
Ambulatory Care To Reduce
Avoidable Hospitalization
Fast-tracked Ambulatory Procedures
Early Discharge
Prolonged
IP Rx AED Admission For Mx of
Wax and Wane Medical Conditions
Ambulatory
& Community
Intervention
to prevent
Admissions In-Patient
Procedures
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Think Substitution – Alternative Pathways
• Create timely and organized service to address patient needs
• Standardized and Protocol-Driven
• Tailored to individuals
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Workup of a Lung Mass
Traditional IP Pathway
• Admitted to MED through AED
• Initial Workup in ward, review results,
• Consult Respiratory team
• Further arrangement for workup
Workup of a Lung Mass
Traditional IP Pathway
• Admitted to MED through AED
• Initial Workup in ward, review results
• Consult Respiratory team
• Further arrangement for workup
Ambulatory Pathway
• Arranged to be directly assessed by Respiratory team specialist at Ambulatory Care Centre
• Preliminary workup initiated at AED
• One-stop counseling, workup, ± procedure
• Eliminate everything that is not value-added to patient care or that can be replaced
• Hotel Service
• Waiting (in hospital)
• Non-value added processes that consume the time and expertise of professional staff (Bottleneck)
“I just remove everything that isn’t part of the Statue.”
Think Substitution – Elimination
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http://www.institute.nhs.uk/ambulatory_emergency_care/public_view_of_ambulatory_emergency_care/ambulatory_emergency_care_homepage.html
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Think Ambulatory 1st
• Every emergency admissions would be considered as having ambulatory care potential unless there was clear evidence to the contrary
• For those where existing services cannot adequately provide the ambulatory alternative, there can be further exploration
Collaborations • Rapid access to Diagnostics: Imaging, Pathology
• Other supporting services: nursing, allied health, community healthcare support, transport
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Think “Back”
So we fix our eyes not on what is seen, but on what is unseen, since what is seen is temporary, but what is unseen is eternal.
2 Corinthians 4:18 , Bible
Deal with issues at the back