Improving the quality of referrals to ambulatory emergency care

Abstract

A re-audit was conducted 4 weeks after the new AMU opened, 88 patients were audited over a 1-week period. Following a grand round presentation and internal communications to the medical teams, there was significant reduction in the percentage of rejected referrals (18%), and onward referrals to other specialties (19%). Although the percentage of patients seen in AEC post discharge from medical ward had gone up to 32%; 75% of these patients were discharged from the acute medical wards, aiding in admission reduction and reduced length of stay. Unfortunately, there was an increase in the number of referrals to follow-up blood test results to 28%.

What is the existing evidence base for adult medical Same Day Emergency Care in UK NHS hospitals? A scoping review

“…capacity to see discharged patients within a few days. 43 Standardisation and education on the purpose of SDEC will ameliorate lack of understanding amongst professionals, and robust standard operating procedures will support clinicians in declining inappropriate referrals. Organisations should consider whether acute medicine hot clinics should be implemented to follow up post-discharge patients, or whether these patients should be seen in SDEC, given that the hospital contract requires trusts to review these patients rather than discharge them for general practice review within days.…”

“… Factors independently associated with hospital admission were severe illness (SIRS/point, OR = 1.46, 95% CI = 1.15–1.87, p = 0.002) and markers of frailty: delirium (OR = 11.28, 3.07–41.44, p < 0.0001), increased care needs (OR = 3.08, 1.55–6.12, p = 0.001), transport requirement (OR = 1.92, 1.13–3.27), and poor nutrition (OR = 1.13–3.79, p = 0.02). Even with MDT approach, rates of hospital admission in those with severe illness and frailty were high 40 Service review – retrospective medical notes audit Pre and post SDEC (July 2013/July 2014) Two acute sites, one trust 191 patients pre-SDEC 344 SDEC SDEC patients had fewer diagnostic tests All SDEC patients discharged opposed to 2/3 discharged the same day pre-SDEC Improved admission avoidance Reduced diagnostics (more targeted) Increased efficiency 39 Report on direct streaming from ED to SDEC, with four pathways 4-day period in September 2019 33 patients, only two admitted, so 93.93% discharged Average waiting time for ED 5 h 44 min, compared to 49 min in SDEC Factor leading to unnecessary admissions was traditional referral process between ED and medicine 43 Audit of referrals to SDEC within an acute medical unit, 1 week period in 2018, prior to new medical unit opening, and re-audit afterwards in 2019 Education provided to medical team in between Pre-SDEC 118 referrals SDEC 88 referrals Pre-SDEC: 36% from acute medical team, 28% ED, 24% GPs, 12% inpatient wards for post-discharge review 31% of referrals rejected by consultant (majority from GPs, but 28% from medical on-call team) 30% referred onto other specialties/clinics Post-SDEC rejected referrals 18%, onward referral 19%, increase in post-discharge referrals to 32%, increase in referrals to follow up blood tests to 28% Large number of inappropriate referrals Medical hot clinics would reduce inappropriate referrals Consultants should follow up own inpatient results, not refer to SDEC 30 Review article Patient selection key Early senior decision making 30% of patients can be managed in SDEC Improved patient experience Need clear pathways and processes 11 Review article Process driven, rather than condition specific pathways Ambulatory by default recommended Acute generalists, including advanced nurse practitioners, acute medicine, ED, or GP clinicians Rapid access to diagnostics key Risk inherent – identifying safe discharges Outcome & experience metrics are needed 44 ...…”