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By Dr Dominic Giles MBBS MRCP (Edin) and Philip Weihser BSc, PGCert. MSc, James Paget University Hospital, United Kingdom
In recent years, the NHS in the United Kingdom has seen a dramatic rise in the number of inpatients and subsequent bed occupancy levels. This has resulted in an unprecedented operational challenge to hospitals, especially when combined with the current need for streamlining and generating cost/efficiency savings across all aspects of healthcare; resulting in increased staffing pressures and negatively impacting upon patient experience. In response to these pressures, 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 the overall patient experience.
The ethos of AEC is the identification and management of patients with acute medical conditions that should not require overnight admission. Estimates demonstrate that ambulatory treatable conditions managed through conventional admission streams account for up to £1.42 billion of the national NHS budget per year. A predicted 50 per cent reduction in patient length of stay (LoS) could save the NHS an additional £683.8 million.
At the James Paget University Hospital, we previously utilised a small assessment u bay within the Acute Medical Unit (AMU) 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 re-design 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.
When beginning the process of redesigning ambulatory care pathways, it was evident at an early stage that utilising POCT diagnostics could hold the key to significantly reducing the overall patient LoS. It is now widely accepted that the reduced specimen turn-around-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.
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 turn-around times may not be the rate limiting step in a patient management process. By changing the processes and overall system in which POCT is utilised, new approaches to patient management can be engineered; particularly those focusing on patient-centred care, as integrated, multi-analyte POCT devices are well suited to increasing patient involvement in the decision-making process and reducing the patient’s perceived sense of waiting.
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.
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 3-month pilot; coupled with service redesign expertise provided by Operasea Limited – experts in Six Sigma improvement methodology.
Operasea 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 to catalyse change. Additionally, we utilised ‘failure mode and effect analysis’ (FMEA); obtaining multiple stakeholder inputs to identify, quantify, prioritise and resolve potential issues in terms of severity, occurrence and detection – adding additional items as and when identified to provide on-going project governance.
By undertaking the redesign of AEC services in this manner, we were able to define ‘value’ within the system (reducing LoS) and focus upon what really mattered to achieve this. This meant that process optimisation required close interdepartmental collaboration with the Emergency Department, a conscious breakdown of the traditional emergency floor NHS silo and integration of our AEC services into the existing emergency care set-up (A&E and Acute Medical Unit); and so complying with national best practice guidance. Furthermore, this will provide a foundation to meet improvement objectives defined by the Institute of Medicine, stating that all healthcare systems should provide patient-centred, timely and efficient care in a safe, effective and equitable manner.
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; expedited investigations; and appropriate treatment/discharge planning. The pathways were 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. 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.
During the pilot, the newly developed AmbU model (operational on weekdays only between 08:00 and 18:30) demonstrated dramatic improvements in patient flow through the AMU, despite an overall 7.61% year-on-year increase in Trust medical admission activity. The process change reduced the length of stay (LoS) from 1.04 to 0.8 bed days within the AMU, despite only 26.06% of patients being managed through AmbU. Mean LoS for this patient cohort has reduced by 40.80% from an established baseline of 250 minutes. As expected, we have seen an 8.22% increase 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.
Following the success of the pilot study, the project team has delivered further evidence-based expansion and development of services through a permanent, dedicated AmbU area designed to structurally enhance the processes and pathways. A ‘business as usual’ state was achieved through a business case demonstrating clinical, operational and financial benefits – the latter equating to £1.098 million per annum. This was enabled through enhanced staffing levels, extended 7-day working hours, and an enhanced POCT test cluster including the Abbott i-Stat (electrolytes and blood gasses), Sysmex XN-450 (full blood count), and Radiometer AQT 90 Flex (D-dimer).
The overall changes to process and adoption of the ambulatory model, along with integration of POCT and evidence-based Six Sigma service redesign, has allowed the James Paget University Hospital to provide emergency medical patients with a standardised and sustainable model of efficient, high quality care delivery. By increasing both staff and patient engagement, we have delivered improved operational performance and clinical outcomes. In turn, this has maximised operational benefits and successfully reduced the LoS for this patient cohort, whilst supporting safe discharge and appropriate follow-up; underpinned by rapid assessment through senior decision makers and timely diagnostic results.