Associate Professor Ian Scott Director Internal Medicine & Clinical Epidemiology; Associate Professor of Medicine Princess Alexandra Hospital; University of Queensland

1. Impact of an acute ambulatory
care program on ED access and
patient flows
Ian Scott MBBS, FRACP, MHA
Director of Internal Medicine and Clinical Epidemiology, Princess Alexandra
Hospital
Co-chair, Statewide General Medicine Clinical Network
Associate Professor of Medicine, University of Queensland
Emergency Department Management Conference
Sydney
31/7/17

2. Challenges in Metro South HHS
• Ageing population
– 12% over 65 which will increase to 16% by 2026 with
high co-morbidity burden
• Increasing ED presentations
– ~5% increase per year to 2016
• Growth in acute inpatient admissions
outstripping population growth by > 5:1
• Almost half acute medical admissions spend
less than 48 hours in hospital
• Sub-optimal QEAT compliance rates (average
65% versus state target of 80%)
• Exit block with hospital occupancy rates >90%
– 1 in 14 hospital beds occupied by non-acute patients
• Unplanned readmissions (~ 20%)
• Bed demand increasing due to population
growth
– Population bed shortage >400, to 1200 by 2026

3. Maximising whole system flow
Reduce attendances
• Hospital avoidance
• Substitutive care
Reduce admissions
• Ambulatory care units
• MAPUs
• HITH
Streamline care
• Care and disposition
protocols
• Co-management
• Single point referrals
• Pull strategies
Reducing exit block
• Discharge
planning
• Stranded patient
programs
• Push strategies
Patient journey
Readmission reduction programs

4. Maximising whole system flow

5. Avoiding ED presentations
• Direct call line which provides GPs direct access to a general
physician on call who can provide expert opinion on patients
presenting to GPs with acute clinical syndromes
• Rapid Access to Consultative Expertise (RACE) consultant can advise
the GP whether to refer the patient to ED, AACU, Rapid Access
Clinics, HITH or Palliative Care
• Aim of the RACE call-line is to redirect patient referrals away from
ED if appropriate care can be delivered in alternative settings
• Up to 30% of GP referrals to ED can be managed via alternative
pathways
Dale et al. Emerg Med J 2003;20:178–83.

6. Avoiding ED presentations
• RACF outreach – CARE-PACT
Burkett, Scott Aust Fam Phys 2015

7. Expediting patient flow following ED
presentation
– The streams ‘overlap’ – very many can have reduced LOS
– Allocate early (Day 0) to teams skilled in that stream
0
50
100
150
200
250
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59
Length of stay (days)
Numberofpatients
Specialty - Clarity of specialty criteria
Early management plan
Minimal process delays
Short stay – manage to the hour
Maximise ambulatory care
Stranded patients
Identify and address causes of delay
Older, frail, multi-morbid
Early CGA
Minimise moves
Minimise deconditioning
Early assertive management
Minimally intrusive care

8. Expediting patient flow
30%
50% of demand –
Avoid downstream
longer than necessary stays
19%
1% of demand
Specialty cases
Single organ isease
Trauma
Mental health
0
100%
Cumulative ED demand
LOS
Sick frail, multi-
morbid patients
Short stay patients
< 48 hours
Very complex patients

9. Expediting decision-making and
patient flow within ED
• Real-time monitoring of ED caseload
– Identifying probable medical admissions
• Frequent ED rounding with general physicians
– Expediting care and disposition decisions
– Single patient vs batch processing
– Parallel vs linear processing
• Rapid response to requests for review/advice/admission
– Path of least resistance
– Navigates and negotiates the downstream path
• Assistance with undifferentiated clinical presentations
• Collaboration in developing standardised care protocols for common presentations
that minimise low value care which wastes time and resources
– 4Fs project (fits, feints, funny turns, falls)
– acute geriatric syndromes
PULL
strategies
Sullivan et al Aust Health Rev 2015

10. Expediting decision-making and
patient flow within ED

11. Expediting patient flow across the
ED-inpatient interface (EDII)
• Single point referral contact for requests for
advice/review/admission
• MASPER/CASPER
• ‘Take it and own it – the clock’s running’
• On-floor consultant for rapid review and decision-making for
admissions to non-critical care wards
• Physician supervised clinical decision units or transition units
• Redirect and fast track high-risk older, frail patients to purpose-
designed older patient care areas
– Acute frailty units; acute care of elderly (ACE) units
• Direct to ward admission pathways co-ordinated by general
medicine flow nurses

12. Avoiding in-patient admissions
• Redirect and fast track patients presenting to
ED into alternate non-inpatient services where
appropriate
– Acute ambulatory care units
– MAPU
– HITH
– Rapid access clinics
– Hospice care, interim care
– Targets all patients who ED would have admitted
as overnight stays but who are likely to have LOS
<48 hours

13. Acute ambulatory care units (AACU)
• Short stay medical unit (8am-8pm) that provides urgent assessment,
investigation, and management for patients with acute medical problems
who are not so ill or unstable that they require evaluation and stabilisation
in ED
• Aim to discharge eligible patients the same day with ongoing clinical
follow-up as required
– Minority that exceed 8pm admitted to MAPU
• Unit comprises chairs (not beds) so patients must be ‘fit to sit’
• Staffed by general physicians and multidisciplinary team with rapid access
to medical diagnostics and procedures
• Patients can be referred from a medical doctor (GP, ED physician, other
specialist), nurse practitioner, or trained paramedic
Ambulatory Emergency Care NHS. Ambulatory Emergency Care – ‘Best Practice’ Case Studies: www.ambulatoryemergencycare.org.uk
Royal College of Physicians. Acute care toolkit 10. Ambulatory Emergency Care. www.ambulatoryemergencycare.org.uk
Directory of Ambulatory Emergency Care for Adults. Version 5, August 2016. NHS Elect 2016
Strang G. The concept, delivery and future of medical ambulatory care. Clin Med 2008; 8: 276-9.
Connolly V, Hamad M. The acute medical take: an outpatient specialty. Clin Med 2008; 8: 21-24.
McCallum L et al National ambulatory emergency care survey:Clin Med 2010;10:555-9.

14. Acute Ambulatory Care Unit (AACU)

15. Acute Ambulatory Care Unit (AACU)

16. Who’s eligible for AACU?
• List of all emergency medical admissions to PAH between July 1st 2015 and June 30th 2016 with
length of stay <48 hours and which did not involve a stay in SSW.
• 4581 acute medical admissions
– mean (SD) LOS 25.4 (12.6) hours
– 30% of all ~15000 emergency medical admissions
• 2069 (45%) considered potentially eligible for admission to AACU:
– Chest pain – 888 comprising unspecified chest pain (587), other chest pain (212), angina (89)
– Respiratory syndromes – 242 comprising asthma, COPD exacerbation, LRTIs
– Arrhythmias – 221 mostly AF or SVT
– Syncope and collapse – 172
– Congestive cardiac failure – 83
– Dizzy turns – 77
– Orthostatic hypotension – 71
– Minor GI syndromes - 69 comprising GORD, ascites and mild upper GI bleed
– Urinary tract infection – 68
– Transient ischaemic attack – 56
– Cellulitis – 52
– Iron deficiency anaemia – 22
– Anxiety and adjustment disorder – 21
– Transient global amnesia – 17
• Average of 6 patients per day – estimated saving of 4 in-patient beds

17. Impact of AACU
400
400
380
40
Acute Ambulatory
Care Unit (LOS=0 )
MAPU patients
(LOS < 2 days)
1000
400
350
310
50
40
Patients to Inpatient Wards
ED medical attendances
per week
Admitted patients minus
MAPU patients
Admitted patients to
home wards
Admitted patients
1000
Potential for 70 fewer patients/ week moving to in-patient wards
through optimising AACU/MAPU
600 600
Not admitted
Current State Future State
Beware
supply
side
drivers –
AACUs
should
only do
AACU
work

18. Impact of AACU

19. Medical assessment and
planning units
• Cohorting patients with defined conditions
• 17 studies of 12 AMUs across five countries
• Reduction in-hospital length of stay (LOS) in all
analyses ranging from 0.3 to 2.6 days
• Reduction in mortality in 12 of the 14 analyses
ranging – up to 8.8%
• Evidence relating to readmissions and patient/staff
satisfaction less conclusive
• Variation admission criteria, entry sources, functions
and consultant work patterns
Reid et al Int J Qual Health Care 2016; Scott et al Int J Qual Health care 2009

20. Focus on older patients
• Early assessment within ED by CGA-trained ED nurses using validated
screening tools to identify and assess older patients who need:
– more support if discharged OR
– rapid transfer to older patient-friendly area for further evaluation and
management
• particular focus on certain patient types: frailty, cognitive impairment,
anxiety/depression, acute delirium or risk of delirium, risk of rapid deconditioning
• emphasis on minimally invasive care and advance care planning
Benefits
• Systematic review confirmed avoidance of hospital admissions and decreased LOS
for those who are admitted (Graf et al 2011)
• Lower admission rates (44% vs 60%), no increased ED revisits (Aldeen et al 2014)
• Reduced admission rates by 12%, and reduced readmissions in people aged 85
years or older discharged from ED by 15% (Conroy et al 2014)
• 33% of older patients presenting to ED discharged same day and LOS for overnight
admitted patients decreased by 18% (Wright et al 2013)

21. Focus on older patients
• Areas within ED or MAPUs that provides older patient-friendly physical
environment and rapid comprehensive geriatric assessment (CGA) and
management
• Physical design and environment more older patient friendly
• Staffed by nurses and AHPs highly skilled in CGA and cognition/delirium management
• Liaison with geriatricians in optimising care and identifying patients who may benefit
from rehabilitation, rapid access to TCP, interim care
• Strong evidence that such areas meet specialised needs of older patients
at risk of delirium, falls and other geriatric syndromes
• Fewer adverse events and reduced mortality
• Less likely to be institutionalised or become more dependent
• Have fewer readmissions to hospital and fewer days in hospital
– Baztan et al 2009; Fox et al 2012; Ekerstad et al 2017
• In the NHS, acute frailty units (AFUs) associated with more rapid exit of at-
risk older patients from ED, with reduction in LOS in ED and improved 4-
hour rule compliance
– Silvester et al 2014; more case studies available at: www.acutefrailtynetwork.org.uk

22. Improving patient flow by
reducing exit block from ED
• Discharge planning from day 0
– Gonçalves-Bradley et al Cochrane Database Syst Rev
2016;(1):CD000313.
• Daily interdisciplinary meetings (huddles)
– Mudge et al Intern Med J 2006;36(9):558-563.
• Daily consultant review
– Bell et al PLoS One 2013; 8(4):e61476
• Expected date of discharge
– Ou et al Aust Health Rev 2011; 35(3): 357-63.
• Flow processes
– Patient flow nurses, nurse navigators
• Review of all long stay patients
– Twice weekly case conferencing
– Prioritised specialty referrals
– Salonga-Reyes, Scott Aust Heath Rev 2017; 41: 54-62.

23. Improving patient flow
Stranded patients
WOW
RACF
Wait
Builder

24. Improving patient flow
Stranded patients

25. Improving patient flow
Stranded patients

26. Improving patient flow
Stranded patients

27. Improving patient flow
Stranded patients

28. Improving patient flow
Stranded patients

29. Improving patient flow
Stranded patients

30. Improving patient flow by removing
delays in acute care
Delays in discharge
when acute care no
longer required
Delays in discharge
when acute care
interrupted by
clinically
inappropriate delays

31. Reducing unplanned
re-presentations to ED
• Discharge nurse co-ordinators and peri-discharge
programs
• Reduce readmissions by up to 20%
» Leppin et al. JAMA Intern Med 2014; 174(7):1095-107; Scott Aust Health Rev 2010; 34: 445-451.
• Prompt discharge summaries
» van Walraven et al. J Gen Intern Med 2002;17(3):186-92.
• Early follow-up and rapid review clinics (<2/52)
» Tung et al. PLoS One 2017;12(1):e0170061
• Chronic disease management
» Scott Intern Med J 2010; 38: 427–437
• Advance care planning
» Scott et al Med J Aust 2013; 199: 662-666; Houben et al J Am Med Dir Assoc 2014; 15: 477–89
• Reduction in inappropriate polypharmacy
» Scott et al JAMA Intern Med 2015; 175: 827-834.

32. Goal-driven care (not targets)

33. Processes within ED
• Rapid streaming and
disposition
• Pull systems and
dynamic floor
management
• Escalation for flow
blockages
33
Improving inpatient flow
• SAFER Flow Bundle
• Overcoming waits
• Interdisciplinary teamwork
Discharge Planning
• Discharge plan from
day 0
• Peri-discharge care
• Stranded patient
policies
Primary care
• Rapid access to consultative
expertise (call lines)
• Rapid access clinics
RACFs
• ED outreach (CARE-PACT)
Mental health
• Rapid response teams
Acute Care
Alternatives to inpatient admission
• Acute ambulatory care unit
• MAPU
• HITH
Inpatient admissions
• Single point referral/acceptance
• Explicit referral criteria
• Rapid admission processes
• Standardised care plans
• Consultant to consultant liaison
• Activation/clinical desk
• Treat and leave
• Ambulance handover
• Avoiding ramping
• Streaming – ‘fast track
ambulatory care’
• Alternative care pathways
Acute Older Patient Care
• Targeting at-risk groups
• Early CGA
• Assertive mobilisation
• Discharge priority
Emergency Care Improvement
Maximising whole of system patient flow

34. Preventative/
predictive care
Chronic disease
management
Alternatives to
admission to
in-patient
wards
Alternative
access for
diagnosis
Alternative
settings for
therapy
Peri-
discharge
care
programs for
reducing
readmission
Health
promotion
General
practice Community
Support
Ambulance
Service ED
SSW
MAPU
AACU
HITH
Focus on CDM and more effective responses to urgent care needs
Clear operational performance framework integrated into primary care
Improved integration with primary care responders
Front load senior decision process
Redesign
to left shift
LOS
Inpatient
wards
Optimise acute
ambulatory care
Information flow converting unheralded ED presentations to heralded presentations
Discharge Process
Maximising whole of system patient flow