COVER STORY


Establishing an acute ambulatory care service


Adoption of the ambulatory model, along with integration of point of care testing (POCT) and evidence-based lean service redesign, has allowed the James Paget University Hospital to provide emergency medical patients with efficient, high- quality care. There is increasing evidence that


ambulatory emergency care (AEC) services can play an instrumental role in reducing the inpatient burden; improving patient management and enhancing patient experience.1,2 The ethos of AEC is the identification and management of patients with acute medical conditions that should not require overnight admission.3,4 The James Paget University Hospital


previously utilised a small assessment bay within the acute medical unit to provide limited AEC services, in conjunction with a nurse-led DVT clinic. The existing set- up was not capable of meeting service demand or providing operational benefits. This presented an opportunity to redesign and implement fundamental work process changes to existing patient management streams, resulting in the establishment of an ambulatory care unit (AmbU) with the specific intention of improving patient experience, outcomes and flow.


Reducing LoS When beginning the process of redesigning ambulatory care pathways, it was evident that utilising POCT diagnostics could hold the key to significantly reducing the overall patient length of stay (LoS). It is now widely accepted that the reduced specimen


turnaround times provided by POCT can potentially help to reduce the time in which patient clinical review is undertaken; in turn offering: improved patient outcomes, increased patient satisfaction and, importantly, a possible reduction in costs.5 However, when POCT is provided as a stand-alone solution, it is often unable to generate desired improvements unless accompanied by system process changes, as laboratory test turnaround times may not be the rate-limiting step in a patient management process.6 By changing the processes and overall


system in which POCT is utilised, new approaches to patient management can be engineered; particularly those focussing on patient-centred care, as integrated POCT devices, such as the i-STAT® system (providing multiple, traditionally laboratory-associated, tests on a single platform), are well suited to increasing patient involvement in the decision- making process and reducing the patient’s perceived sense of waiting.7,8 Additionally, the majority of current health systems are based upon pathology testing within a centralised laboratory and are not configured to utilise POCT effectively; for this reason, process change and innovation is required to decentralise traditional testing methodologies – aligning service delivery and work-flow to ensure real-time availability of results to affect patient management.9 Consequently, James Paget University Hospital formed a working agreement with Abbott Point of Care to provide the


i-STAT platform and Emerald CEL-DYN full blood count analyser for an initial three-month pilot; coupled with service redesign expertise provided by the Lean Enterprise Academy (LEA). The LEA assisted the Trust-based


project team in exercises including extensive project planning, stakeholder salience analysis and ‘process activity mapping’ (PAM) to understand how the current system actually worked; in turn identifying an evidence-based ideal future-state, capable of fulfilling demand and leverage points on which to focus (such as POCT) to catalyse change.10 Additionally, the team used ‘failure mode and effect analysis’ (FMEA) to provide evolving process governance; obtaining multiple stakeholder input to identify, quantify, prioritise and resolve potential issues.11 By undertaking the redesign of AEC


Fig 1. AmbU service delivery at James Paget University Hospital 6 THE CLINICAL SERVICES JOURNAL


services in this manner, the team was able to define ‘value’ within the process (reducing LoS) and focus upon what really mattered to achieve this.11 This meant that process optimisation required close inter- departmental collaboration with the Emergency Department, a conscious breakdown of the traditional emergency floor NHS silo and integration of AEC services into the existing emergency care set-up (A&E and Acute Medical Unit); and so complying with national best practice guidance.3 Furthermore, this will provide a foundation to meet improvement objectives defined by the Institute of Medicine, stating that all healthcare systems should provide


APRIL 2015


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