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
0%
10%
20%
30%
40%
50%60%
70%
80%
90%
100%
0000-0400 0400-0800 0800-1200 1200-1600 1600-2000 2000-0000
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
-3000
-2000
-1000
0
1000
2000
3000
4000
5000
6000
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Difference Attendances Discharge
Lengths of Stay for AMU discharges
0%
10%
20%
30%
40%
50%60%
70%
80%
90%
100%
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