COVER STORY


patient-centred, timely and efficient care in a safe, effective and equitable manner.12 Redesigned AEC pathways within the


Trust supported the attainment of these objectives through: the use of national guidance to enable early identification of suitable patients, such as those with chest pain, cellulitis or suspected pulmonary emboli,13 expedited investigations, and appropriate treatment/discharge planning; controlled and defined by condition- specific patient management algorithms and the involvement of senior decision makers (consultant, registrar or nurse practitioner) at the first point of patient clinical contact.1,14 Work processes have been specifically designed to integrate the role of nurse practitioners as the key staff group within the unit to provide strong leadership and accurate, early patient assessments.15


New AmbU model The new AmbU model (currently operational on weekdays only between 08:00 and 18:30, due to staffing constraints) has shown dramatic improvements in patient flow through the AMU, despite an overall 7.61% year-on- year increase in medical admission activity. The process change has reduced the LoS from 1.04 to 0.8 bed days within the AMU, despite only 26.06% of patients (425 of 1631) being managed through AmbU. Mean LoS for this patient cohort has reduced by 40.8% from an established baseline of 250 minutes; with an overall median LoS of 110 minutes. As expected, there has been an 8.22% increase (188 patients) in the number of same-day discharges (zero LoS admissions) in AMU; with an associated decrease of 8.93% in 1, 2 and 3 day LoS patient admissions – equating to 59 saved bed days during the pilot period. Table 1 shows the patient admission data for the three-month pilot period of the project. As the patients seen in AmbU were previously assimilated into the AMU take, there are no baseline comparable data for these patients. However, over the pilot period, there has been an increase in patients through the unit. This has therefore lead to a slight decrease in the overall same-day discharge rate, thought to be, in part, a result of accepting more patients and those with more complex issues. Regardless of this, the median and mean LoS has plateaued, despite the increase in numbers through the unit. Following the success of the pilot, the project team is now looking at further evidence-based expansion and development of services through a permanent, dedicated AmbU area designed to structurally enhance the current process pathway, in partnership with enhanced staffing levels and extended working hours (including


APRIL 2015


Table 1: James Paget University Hospital AmbU performance data Month 1


Total patients


Average patients per day Mean LoS (minutes) Median LoS (minutes) Same-day discharge rate


7-day working and weekday opening until 21:30) – the latter of which has been evidenced to potentially avoid an additional 40 overnight stays per month.


Conclusions


The overall changes to process and adoption of the ambulatory model,2 along with integration of POCT and evidence- based lean service redesign, has allowed the James Paget University Hospital to provide emergency medical patients with efficient, high quality care. By increasing both staff and patient engagement, improved operational performance and clinical outcomes are expected.16 In turn, this will maximise operational benefits and successfully reduce the LoS for this patient cohort, when combined with safe discharge and appropriate follow-up; underpinned by rapid assessment through senior decision makers at the first point of clinical contact and timely diagnostic results. ✚


Authors


Dominic Giles, Philip Weihser, Josip Stosic, Karen Foden, Richard Hall, James Paget University Hospitals Foundation Trust, Norfolk, UK.


References 1 Ambulatory Delivery Network. Directory of ambulatory emergency care. 3rd Edition. 2012. www.institute.nhs.uk/ambulatory _emergency_care/public_view_of_ambulator y_emergency_care/ambulatory_emergency_ care_homepage.html (accessed 18 November 2014).


2 Bardsley M et al. Is secondary preventive care improving? Observational study of 10-year trends in emergency admissions for conditions amenable to ambulatory care. BMJ Open 2013;3:e002007.


3 McCallum L et al. National ambulatory care survey: current level of adoption and considerations for the future. Clin Med 2010;10(6):555–9.


4 Ambulatory Emergency Care Network. Ambulatory Emergency Care: a solution to manage emergency demand, improve outcomes and reduce waits. 2012. www.institute.nhs.uk/ambulatory_emergency _care/public_view_of_ambulatory_emergency _care/ambulatory_emergency_care_homepage .html (accessed 19 November 2014).


5 Luppa PB et al. Point-of-care testing (POCT): Current techniques and future


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101 5.05 127 70


88.12%


161 120


Month 2 Month 3 143 6.5


181 9.05 150 120


85.31% 81.77%


perspectives. Trends Analytical Chem 2011;30(6):887–98.


6 Pearson J. Review: Point-of-care testing and clinical governance. Clin Chem Lab Med 2006;44(6):765–7.


7 DuBois JA. Clinical issues: The role of POCT and rapid testing. Med Lab Observer 2013;45(9):18–22.


8 Marshall A, Kitson A, Zeitz K. Patients’ views of patient-centred care: A phenomenological case study in one surgical unit. J Adv Nurs 2012; 68(12):2664–73.


9 Jani IV, Peter TF. How point-of-care testing could drive innovation in global health. N Engl J Med 2013;368(24):2319–24.


10 Baker M, Taylor I, Jones DT. The NHS Bermuda Triangle (and how to escape it). The Lean Enterprise Academy;2010.


11 de Sousa RVB, Carpinetti LCR. A FMEA- based approach to prioritise waste reduction in lean implementation. IJQRM 2014;31(4):346–66.


12 Institute of Medicine. Shaping the Future for Health. Crossing the Quality Chasm: a new health system for the 21st century. National Academy Press. 2001. Washington DC.


13 Ala L et al. Selecting ambulatory emergency care patients from the medical emergency in-take: the derivation and validation of the Amb score. Clin Med 2012;12(5):420–6.


14 Royal College of Physicians. Acute Medical Care – the right person, in the right setting – first time. Report of the Acute Medicine Task Force 2007. London. www.rcplondon.ac.uk/ sites/default/files/documents/acute_medical _care_final_for_web.pdf (accessed 24 November 2014).


15 Carter A. The Ambulatory Care Unit at Derriford Hospital. Clin Med 2014;14(3):250–4.


16 The King’s Fund. Leadership and engagement for improvement in the NHS. 2012. www.kingsfund.org.uk/publications/ leadership-engagement-for-improvement- nhs (accessed 20 November 2014).


For more information, contact: Abbott Point of Care Abbott House, Vanwall Business Park Vanwall Road, Maidenhead, Berkshire SL6 4XF Office: +44(0) 1628 589971 Email: marketing@apoc.abbott.com


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