Process of care and activity in a clinically inclusive ambulatory emergency care unit: progressive effect over time on clinical outcomes and acute medical admissions

Abstract

Clinically relevant outcomes for same-day emergency care provided by ambulatory emergency care units (AECs) are largely unknown. We report the activity and outcomes for a large UK adult AEC operating an ambulatory-care-by-default model without specific exclusion criteria. The AEC consultant triaged all acute medical referrals to either the AEC or the standard non-ambulatory 'take' pathway during AEC opening hours. The proportion of acute medical referrals seen in the AEC increased to 42% (mean 700 referrals seen per month) in the last 6 months of the study and numbers seen in the nonambulatory pathway fell. The most common diagnoses were for chest pain, pneumonia, cellulitis, heart failure and urinary system disorders. Seventy-four point eight per cent of patients completed their care in a single visit. In the last calendar year, the conversion rate from AEC to inpatient admission was 12%, and the 30-day readmission rate was 6.9% and 18% for the AEC and non-ambulatory pathways, respectively. Across the whole study period, the 30-day mortality was 1.6% and 6.9% for the AEC and non-ambulatory pathway, respectively. This ambulatory approach is safe and effective.

Impact of the COVID-19 pandemic on emergency department attendances and acute medical admissions

“…In the UK, acute hospital care is provided by direct presentation of patients to the emergency department (ED) or referral of patients by their primary care general practitioner or paramedics to the hospital [ 11 ]. We sought to understand both the COVID-19 and non-COVID-19 activity in the ED and the acute medicine department and how this changed across the course of the pandemic.…”

“Virtual ward” community outreach support for COVID‐19‐positive hemodialysis patients may delay but not prevent subsequent admission to hospital: A single‐center retrospective case–control pilot study

“…Appropriate case selection and ambulant emergency management are associated with reduced length of stay, 30-day readmission rate, and functional decline in other settings and is increasingly the preferred option for acute care in the United Kingdom. 3,4,7 We are the first to report the outcomes for such a pathway for COVID-19-positive patients receiving HD and our findings have implications not only for the current COVID pandemic, but also for seasonal respiratory viruses such as influenza where cohorts with advanced renal impairment demonstrate excess mortality. 8 As this is a pilot, our study cohort is small, although we attempted to mitigate this by matching to multiple controls.…”

“…1,2 "Virtual ward" community management of acute illness decreases admission rates and length, lessening pressure on inpatient beds, and reduces mortality and the risk of deconditioning. 3,4 HD cohorts are particularly at risk of the latter due to comorbidities including sarcopenia, diabetes, and cardiovascular disease. 5 Specific interventions to prevent subsequent deterioration and admission in COVID-19-positive HD cohorts are lacking.…”

“…Cumulative time on HD therapy and past medical history of diabetes mellitus, lung disease, and recent (within 30 days of positive swab) immunosuppression did not significantly differ between groups; however, a history of cardiovascular disease was more common in controls (Table 1). There was no difference seen in the overall admission rate (Figure 1a), but there was a significant delay in admission in cases compared to controls (8 [7][8][9][10][11][12][13][14][15][16][17][18] vs. 4 [2][3][4][5][6][7] days after positive swab, p = 0.03). Management through the pathway was not associated with a shorter length of hospital stay in those admitted (cases: 8 [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] days, controls: 8 [6-10], p = 0.81).…”

How do we identify acute medical admissions that are suitable for same day emergency care?

“…Indeed, much of the evidence guiding SDEC relies on case studies of service development. [20][21][22] No studies have compared different SDEC service models, or SDEC to usual care (hospital admission), the number of patients that may benefit from SDEC services remains unknown, and there are no health economics studies evaluating the cost effectiveness of SDEC. Despite this lack of evidence, SDEC pathway development for several conditions has been widely encouraged.…”