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Ambulatory Emergency CareA Generalist’s View

Dr Simon Chapplesimon.chapple@shropdoc.nhs.

uk

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It’s The Little Things That Count

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The Elephant in the Rome Room

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Objectives

• By the end of this session you should be able to:– define Ambulatory Emergency Care (AEC)– describe what’s going on with AEC locally– understand your role in AEC better– describe the latest guidance for some

conditions

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Overview

• AEC Defined– Local initiatives

• Situation Awareness in Medicine• The Healthcare Continuum• ‘Phone a Friend’ or Informing

Uncertainty• Overview of some guidance:– CAP– PE

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AEC Defined1

‘Ambulatory care is clinical care which may includediagnosis, observation, treatment and

rehabilitation,not provided within the traditional hospital bed

baseor within the traditional outpatient services, and

that can be provided across the primary/secondary careinterface.’

1Royal College of Physicians (RCP) Acute Medicine Task Force, and endorsed by TheCollege of Emergency Medicine, 2012.

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A Specialist’s View of AEC2

http://tinyurl.com/o6kkpq5

2 RCP Acute care toolkit 10; Oct 2014

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AEC Locally

• Breaking The Cycle Week• AEC Steering Group• Site-specific AEC Project Groups• T&W Pathways Committee• Website• Pan-health economy group

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Situation Awareness

• Situational awareness (SA) is defined3 as a person’s perception of the elements in the environment within a volume of space and time, the comprehension of their meaning, and the projection of their status in the near future (PCP), or

• When perception matches reality4

3 Dr Mica Endsley (1995)4 Dr Simon Chapple (Just Now)

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70% of error in medicine is due to a level 1 SA failure

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The Healthcare Continuum

WMAS

ED

HomeHospital

Community Hospital

Hospiceat

HomeOutpatients

CMHT

Social Services

OOHDNs

Respite Care

GP Surgery

Int’ Care

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A Word From Our ‘Sponsors’

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Informing Uncertainty – Sharing The Plan

• Referral Letters• SBAR• Fitness to Sit• AMB score and EWS

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Referral Letters

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SBAR

• Situation• Background• Assessment• Recommendation

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AMB Score

• Sex:– Female 0– Male -0.5

• Age– <80 years 0– >80 years -0.5

• Access to transport– Yes 2– No 0

• Will likely need IV Rx– Yes 0– No 2

• Acutely confused– Yes 0– No 2

• NEWS– NEWS=0 1– NEWS >1 0

• Discharged last 30 days– Yes 0– No 1

• If score is ≥5 consider ambulatory care

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(N)EWS

• Heart/pulse rate• Breathing rate• Blood pressure• Temperature• Conscious level• Oxygen saturation (SpO2)• Inspired gas (air or oxygen?)

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Community Acquired Pneumonia6,7

• NICE released guidance on CAP in 2014• BTS reviewed their guidance in light of the above• Thorax article7 summarises the recommendations• Both guidelines recommend the use of:

– clinical judgement in conjunction with the CURB-65 score (CRB65 score for primary care) to assess illness severity,

– a single antibiotic as initial empirical therapy in patients with low severity CAP,

– dual combination antibiotics comprising amoxicillin and a macrolide for patients with moderate severity CAP, and

– dual combination antibiotics comprising a β-lactamase stable β-lactam (such as co-amoxiclav) and a macrolide for patients with high severity CAP.

• In addition, both guidelines recommend that processes are be put in place to allow the radiological diagnosis and treatment of patients with CAP within 4 h of presentation to hospital.

6https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/community-acquired-pneumonia-in-adults-guideline/7http://thorax.bmj.com/content/early/2015/05/13/thoraxjnl-2015-206881.full

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CRB-65

• CRB65 score is calculated by giving 1 point for each of the following prognostic features:– confusion (abbreviated Mental Test score 8 or less, or new

disorientation in person, place or time)– raised respiratory rate (30 breaths per minute or more)– low blood pressure (diastolic 60 mmHg or less, or systolic

less than 90 mmHg)– age 65 years or more.

• Use clinical judgement in conjunction with the CRB65 score to inform decisions about whether patients need hospital assessment as follows:– consider home‑based care for patients with a CRB65 score

of 0– consider hospital assessment for all other patients,

particularly those with a CRB65 score of 2 or more.

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CURB-65

• The above plus:– raised blood urea nitrogen (over

7 mmol/litre)

• Consider home based care if score is 0 or 1

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Community Acquired Pneumonia6,7

• If a diagnosis of pneumonia has not been made after clinical assessment and it is unclear whether antibiotics should be prescribed, GPs should consider a CRP test

• NICE recommends:– if the CRP > 100 mg/litre antibiotics should be

prescribed– if the CRP is between 20 mg/litre and 100

mg/litre a delayed prescription should be considered

– if the CRP concentration is less than 20 mg/litre antibiotics should not be offered routinely

6https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/community-acquired-pneumonia-in-adults-guideline/7http://thorax.bmj.com/content/early/2015/05/13/thoraxjnl-2015-206881.full

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VTE8

• Dichotomised Well’s Score For PE– Clinical signs and symptoms of DVT (minimum of leg

swelling and pain with palpation of the deep veins) 3– An alternative diagnosis is less likely than PE 3– Heart rate > 100 beats per minute 1.5– Immobilisation for more than 3 days or surgery in the

previous 4 weeks 1.5– Previous DVT/PE 1.5– Haemoptysis 1– Malignancy (on treatment, treated in the last 6 months, or

palliative) 1

• Clinical probability simplified scores: – PE likely - more than 4 points – PE unlikely - 4 points or less

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ttp://www.nice.org.uk/guidance/cg144/chapter/1-recommendations

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Summary

• AEC Defined– Local initiatives

• Situation Awareness in Medicine• The Healthcare Continuum• ‘Phone a Friend’ or Informing

Uncertainty• Overview of some guidance:– CAP– PE

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For The Appraisal Folder

• What 3 things would you like to change?

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Options For Change

SBARWells’Criteria

EWSPhone a Friend

CURB-65

Working Diagnosis

Web Resources

Anticipatory Care Plan