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Directory of Ambulatory Emergency Care for Adults

This third edition published in November 2012

Previous version October 2010

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NHS Institute of Innovation and Improvement i-House University of Warwick Science Park Milburn Hill Road COVENTRY CV4 7HS

This third edition published in November 2012

© Copyright NHS Institute for Innovation and Improvement 2012

Directory of Ambulatory Emergency Care for Adults is published by the NHS Institute for Innovation and Improvement, Coventry House, University of Warwick Campus, Coventry, CV4 7AL. Directory of Ambulatory Emergency Care for Adults, belongs to the NHS Institute for Innovation and Improvement. Any third party concepts and trademarked devices have been reproduced in this document with the permission of the respective copyright / IP owners. All rights reserved.

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04 Foreword by Professor Matthew Cooke

Section 1: An introduction to ambulatory emergency care (AEC)

08 Who is the Directory of Ambulatory Emergency Care for Adults written for?

08 Context and background 09 What is ambulatory emergency care (AEC)? 12 How does AEC fit into the bigger picture? 13 The economics of AEC 14 Which patients are suitable for AEC? 15 Models of delivery 19 The quality agenda framework for AEC 20 Developing AEC services 25 Principles for success

Section 2: Directory of clinical conditions

28 Using the Directory 28 Description of conditions 28 Codes: some clarification 29 Clinical evidence and best practice 29 Clinical coding 29 Examples of good and poor documentation 30 General Medicine 54 Trauma and Orthopaedics 60 General Surgery 64 Urology 68 Obstetrics and Gynaecology

Section 3

72 Further information and support for

implementing Ambulatory Emergency Care

74 Acknowledgements

Contents

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Foreword

For many years the care of many emergency conditions has followed a model of care based on inpatient management. There is increasing evidence that we can safely and effectively manage a significant number of patients who present to urgent and emergency care services on the same day with increased patient satisfaction.

There are increasing examples of ambulatory care services developing around the country, but the uptake is still patchy.

To help understand the potential of the Directory of Ambulatory Emergency Care for Adults, we can draw on an analogy with elective care; ambulatory emergency care as a concept parallels the innovation that day case surgery has brought

to elective surgery. Day case surgery for many procedures is now the norm and utilised for cases thought impossible in the recent past; we now need to focus on how we can safely and effectively increase the spread and adoption of ambulatory emergency care in the same way.

Since the production of the first version of the Directory, there has been considerable interest in its implementation, and there are a number of organisations across the country that have ambulatory emergency care programmes. The most successful emergency ambulatory care systems have been developed by enthusiastic nursing and medical clinical leaders working closely with primary care and with their community care colleagues. In the last twelve months, the NHS Institute has run

a support programme, The AEC Delivery Network, which has helped organisations to accelerate their implementation.

The Directory of Ambulatory Emergency Care for Adults from the NHS Institute for Innovation and Improvement provides learning and principles which could help teams all over the country to start on their journey to transform care delivery for a substantial number of patients who are currently admitted to a hospital bed.

The extent to which this can be delivered is dependent on improved integrated working across the whole system and the potential could be extended by innovations such as remote monitoring and other technological advances.

Foreword

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Foreword

Implementation of AEC will require examination of new ways of working across the traditional health and social care structures within a joint governance framework, changing the mind set of how we deliver a significant proportion of emergency care. This can only be achieved if there is effective integration focussed on the patient’s journey as opposed to the current professional/organisational structures. The new pathways will need to support real time exchange of information to facilitate effective and timely clinical assessment, diagnostics and therapeutic intervention.

By using the tools and learning within this directory it will be possible for teams to achieve improved quality, timeliness and cost effectiveness of care in addition to creating a pathway that is better for

patients, better for staff and better for the NHS. I look forward to seeing the widespread adoption of the guidance in this Directory to achieve improvements for patients.

Professor Matthew Cooke

National Clinical Director for Urgent and Emergency Care, Department of Health

The views of Professor Cooke are given in a clinical capacity and as a national expert in the field. They do not in themselves impose any mandatory requirements on NHS organisations although commissioners are expected to take them into account.

Introduction

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1. An introduction to Ambulatory Emergency Care (AEC)

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An introduction to Ambulatory Emergency Care

An introduction to Ambulatory Emergency Care (AEC)

Who is the Directory of Ambulatory Emergency Care written for?

The short answer is anyone who is involved in developing or running same day emergency care services. You will find it useful if you are a clinician, manager, clinical commissioner, information specialist or community services provider.

If you would like to find out more information about AEC, visit the NHS Institute’s AEC webpage: www.institute.nhs.uk/aec

Context and background

“The number one issue facing the NHS in England is reversing the ‘unsustainable’ rise in emergency hospital admissions .... There has been an almost 12 per cent rise in admissions over the last five years” Nuffield Trust, 2010 1

This rise means that healthcare communities are under a great deal of pressure to manage the increasing demand for emergency care within a reducing resource of inpatient beds and constrained financial resource.

The underlying principle of ambulatory emergency care (AEC) is that a significant proportion of adult patients requiring emergency care can be managed safely and appropriately on the same day either without admission to a hospital bed, at all, or through admission for only a few hours. This is achieved by reorganising the working patterns of emergency care to be able to provide early decision making and rapid access to diagnostics. There is also a need for immediate access to support services in the community to provide robust ‘safety net’ systems and optimise integrated care. This is particularly important for managing frail elderly patients on an AEC pathway.

1 Blunt I, Bardsley M & Dixon J: 5th July, 2012, Trends in emergency admissions in England: 2004-2009: is greater efficiency breeding inefficiency?, Nuffield Trust.,

Action is needed to:

– reduce the number of unnecessary emergency admissions

– ensure only patients who actually require admission are admitted

– provide ambulatory or ‘same day’ emergency care as an alternative to admission.

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The avoidance of unnecessary overnight stays for emergency patients not only improves the quality of patient care and experience but also reduces occupied bed days in hospitals.

Where AEC has been successfully implemented, Acute hospitals have been able to effectively and safely close beds – a real cost saving to the healthcare system.

What is ambulatory emergency care?Ambulatory Emergency Care (AEC), or ‘same day emergency care’ is a whole system approach that includes both primary and secondary care to ensure that, patients who are assessed as appropriate for AEC, are diagnosed and treated on the same day and then sent home with ongoing clinical follow up as required.

“Ambulatory care is clinical care which may include diagnosis, observation, treatment, and rehabilitation, not provided within the traditional hospital bed base or within the traditional out-patient services that can be provided across the primary/secondary care interface”.

The Royal College of Physicians – Acute Medicine Task Force & endorsed by the College of Emergency Medicine, 2012


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Where AEC has been successfully implemented it has led to a change in mindset, which means AEC becoming the default position for emergency patients unless admission is clinically indicated. This change in mindset has been likened to the changes that happened as the concept of day surgery developed and became more widespread to the point where it is now the norm for many elective surgical procedures.

Pioneers of AEC are achieving good results and demonstrating improved patient experience. Some trusts have been able to reduce the number of in-patient beds as a result of AEC services, resulting in significant cost-savings for local healthcare systems.

“Ambulatory emergency care

shares many parallels with day

surgery, which has experienced

enormous growth, achieved

predominantly by changes in

mindset and simple alterations to

the patient pathway, resulting in

safer, higher-quality care”.

Ian Smith President of the British Association of Day Surgery, (AEC Delivery network conference 2012)


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“AEC has the potential to significantly change how we provide emergency care. Judging by some of the work going on at the moment, I think we are looking at a future state where people might wonder how they ever coped with what went before.

Major changes like the introduction of AEC or day surgery can seem radical, almost unthinkable at the time. However, as organisations begin to tackle the issue and overcome the challenges, a radical change becomes the norm, and its introduction helps to transform the experience of patients and staff. I believe this is what we will see with the further development of ambulatory emergency care.” (2012)

Deborah Thompson Associate Director at Weston Area Health NHS Trust

If you would like to find out more about Weston’s AEC services, read the full case study on the NHS Institute’s AEC website: www.institute.nhs.uk/AEC


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How does AEC fit into the bigger picture?

Patients want services which are easy to access, that can deliver quick and effective care. AEC is designed to achieve this, in line with the NHS Operating framework 2012/13, which states that “‘The NHS will have to make bold, long term measures to secure sustainable change,’ meeting the three national measures of quality, resources and reform.” Development of AEC services contributes to the NHS achieving four of the five key domains within the NHS Outcomes Framework 2012/13 2, namely:

2(NHS Outcomes framework 2012/13, pg 5, http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131723.pdf)


1. ‘Enhancing quality of life for people with long term conditions.’

2. ‘Helping people to recover from episodes of ill health or following an injury’ specifically:

– Emergency admissions for acute conditions that should not usually require hospital admission.

– Emergency readmissions within 30 days of discharge from hospital.

3. ‘Ensuring people have a positive experience of care.’

4. ‘Reducing the incident of avoidable harm.’

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The economics of ambulatory emergency care Commissioners of healthcare are required to fund pathways that will be safe, effective, efficient and patient centred. AEC fulfils all of these criteria and should be specifically recognised within the NHS economic framework.

In April 2012 the Department of Health introduced best practice tariffs for 12 emergency clinical scenarios (see fig 1) following work with the NHS Institute for Innovation and Improvement and the College of Emergency Medicine. (AEC is referred to as Same Day Emergency Care (SDEC) in Best Practice Tariff (BPT) guidance). The aim of BPT is to promote the management of some emergency conditions on a same-day basis using an ambulatory emergency care model, converting a significant volume of emergency patients from admission into a hospital bed to same day care.

Further work on coding systems is required to realise the potential advantages for SDEC which would significantly enhance the efficient use of emergency care resources in the future.

The intention is that this list of codes will be revised and expanded on an annual basis, and that process is currently underway for 2012/13.

• Acute headache. • Appendicular fractures not requiring immediate fixation. • Asthma. • Cellulitis. • Chest pain. • Deep vein thrombosis (DVT).

• Deliberate self harm. • Epileptic seizure. • Falls including syncope and collapse. • Lower respiratory tract infections without chronic

obstructive pulmonary disease.• Pulmonary embolism. • Renal/ureteric stones.

Figure I: Best practice tariff: Same day emergency care clinical scenarios list (Year 1)


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Which patients are suitable for AEC?

There are essentially four groups of patients for whom ambulatory emergency care could be the norm:

1. Diagnostic Exclusion Group: This group of patients present with a variety of symptoms where a specific potentially life threatening condition needs to be excluded (eg acute coronary syndrome, pulmonary embolism or sub arachnoid haemorrhage).

2. Risk Stratification and observation Group: Patients presenting with a range of conditions where after appropriate risk stratification and observation they can be safely discharged back into the community. These include patients with syncope, minor head injury, self harm and elderly patients who require multidisciplinary assessment prior to safe discharge.

3. Short term therapy group: This third group benefit from a period of short term therapy and observation prior to discharge back for community follow up. They include patients with moderate asthma, cellulitis, pain control following soft tissue trauma and pneumothorax.

4. Specific Procedure Group: A fourth group requires a specific procedure / treatment which enables early discharge. These include patients with pleural effusions. Key to implementation is how ambulatory care for this group of patients can be delivered when they present out of hours.


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AEC models of delivery

Different models of AEC delivery have evolved in the United Kingdom over the past 10 years. A number of common factors recur in the most successful systems – strong leadership shared between medicine, nursing and management is the most important. A senior clinical presence ensures signposting of the patient towards AEC and system redesign to ensure that care is timely, efficient and effective. AEC may be delivered in many different locations and this can vary between local healthcare communities. Examples of where AEC may be provided include;

– dedicated Ambulatory Care units (some of which may be community based)

– assessment units

– urgent care outpatient (‘hot clinic’) settings

– emergency departments (and associated ward areas/clinical decision units)

Key to all of the models is an appreciation that AEC is a process rather than a place.

The key components are:

– the judgement of an appropriately skilled initial decision maker with the correct competencies to ensure that the patient is on the correct pathway

– access to timely, evidence based diagnostics

– a short period of observation and/or therapeutic intervention

– final re-assessment and management plan combined with appropriate ‘safety netting’ and discharge back into the community.

– communication of information to the patient, GP and other healthcare professionals or community services

– data capture and analysis by an engaged team to ensure quality improvement

Over the last decade, pioneers of AEC have succeeded in applying the approach to an ever increasing range of clinical conditions/scenarios in addition to those listed in this Directory and in earlier versions (2007 and 2010), moving beyond a pathway based approach towards an ‘exclusion’ approach in AEC.

By using senior clinical decision makers to identify which patients can be treated in an ambulatory way, rather than taking a specific individual pathway approach, a wider range of patients (particularly more complex patients with co-morbidities) can benefit from same day care.

This approach has been taken by James Cook University Hospital in South Tees. Their implementation of AEC has resulted in a rise from 6% to 50% in same day discharge over a three year period. Whilst this may not be solely attributable to AEC, this service it has played a very significant role in this improvement. Patient experience and satisfaction has also improved as a result of the AEC service. Patients appreciate early input from consultants, rapid diagnosis and a shorter stay that avoids having to stay in hospital overnight:


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There is not one ‘right’ model: local AEC services need to be designed to suit local circumstances based on the needs of local populations.

Their AEC unit deals with a wide range of emergencies, including Chronic obstructive pulmonary disease (COPD), cardiac failure, cellulitis, diabetes and low-risk gastro-intestinal bleeding. The unit also handles blood transfusions, low risk chest pain, suspected pulmonary embolism, headache, surgical patients and many other conditions. Consultants discuss referrals with GPs by telephone to ensure as many patients as possible are managed through the unit. This approach has helped to increase throughput by 50%. The Ambulatory Emergency Care service has grown from 1,808 patients per year in 2007 to 5,211 patients in 2011 and the unit now manages around 22% of all patients who would have previously been admitted as an emergency.

If you would like to find out more about the AEC service at James Cook University Hospital, read the full case study on the NHS Institute’s AEC webpage: www.institute.nhs.uk/aec

Figure II: James Cook University Hospital AEC Unit“Ambulatory emergency care offers a positiveexperience for patients whose emergencyepisode can be dealt with in a few hours. Itis positive for the Trust as it improves patientflow and efficiency, and it is positive for staffas providing such an improved service forpatients, increases job satisfaction.”

Dr Vincent Connolly James Cook University Hospital

“I feel as if I will get bet ter more quickly if I can sleep in my own bed and am with my husband...; I can relax in my own home” – Patient


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Hull and East Yorkshire Hospitals NHS Trust (a new AEC service): This AEC service is relatively new but has already had a significant impact. Between 2010 and 2011, the number of emergency admissions fell by 3.65% with an accompanying reduction in excess bed days of 15%

Leeds Teaching Hospitals - An Emergency Dept based CDU model :

In Leeds, ambulatory emergency care models have been developed and delivered using two emergency department (ED) based Clinical Decision Units open 24hrs a day (with a combination of beds and chairs) over the past 10 years. The Emergency Medicine clinicians use over 15 protocols for a range of common conditions that would otherwise have required admission into the traditional hospital bed base. Length of stay has been reduced from 2.5 days on average to 15 hours for approximately 85,000 patients in the past 10 years with only around 17% of patients going on to require admission to the hospital bed base.

“For the Emergency Medicine physician, it is vital to be able to safely discharge patients from ED and ‘gate keep’ an ever more scarce in-hospital bed base. Certain groups of patients can benefit hugely if appropriately managed on an ambulatory care pathway using a consistent evidence based approach. A certain proportion of ambulatory care work can occur in the Emergency Department (ED) itself with discharge back into an outpatient setting. In EDs with a Clinical Decision Unit (CDU), there is more time to access diagnostics, re-assess the patient in a timely fashion and admit only those patients with pathology that merits an in-hospital bed. For us in Leeds, this has significantly increased the safe discharge of patients. The College of Emergency Medicine believes that Emergency Departments themselves and also those with short stay units (like CDUs) have a vital role to play in AEC if resourced to do so and appropriately recognised for the activity. We see this activity as being a vital part of the emergency care process in the coming years.”

Dr Taj Hassan Consultant in EM, Leeds Teaching Hospitals & and Vice President, College of Emergency Medicine

Figure III: An example of a reclining treatment couch used in an AEC unit.


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There are also excellent examples of many other systems of AEC that are continuing to evolve or be refined. The following organisations took part in the first wave of the NHS Institute’s Ambulatory Emergency Care Delivery Network, along with their partner organisations e.g. commissioners, primary care, community services, and are all making excellent progress with their programmes:

– Calderdale & Huddersfield Foundation NHS Trust – Hull and East Yorkshire Hospitals NHS Trust – Leeds Teaching Hospitals NHS Trust – Nottingham University Hospitals NHS Trust – Royal Liverpool University Hospital NHS Trust – Plymouth Hospitals NHS Trust – South Tyneside NHS Foundation Trust – Weston Area Health NHS Trust – Whittington Health NHS Trust

For more details about the AEC Delivery network visit the NHS Institute’s AEC website: www.institute.nhs.uk/aec


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In developing this directory, the priority has been to focus on quality outcomes and improved patient safety. Delivery in any setting requires collaborative working between local health, social and voluntary services, with clear ownership and leadership at every stage of the pathway. The key components of a successful AEC system are described in Figure IV. Any ambulatory patient pathway must be underpinned by strong leadership and governance alongside continuous quality improvement systems, combined with a patient-centric culture. Joint clinical, managerial and financial risk assessment processes within an integrated clinical and managerial governance framework is essential. This guide contains information that will help teams to achieve this.

Figure IV: The framework required to deliver successful AEC services

The quality agenda and framework for AEC

Define safety netting systems

Embedded informatics and

quality improvement systems

Leadership and culture

Initial contact and assessment (GP or self present to ED)

Access to diagnostics and reporting

Management pathway and location. Reassessment by competent clinician appropriate setting (ED, CDU, ward, area outpatient setting,

or ambulatory care depending upon local system design.

Governance & safety

Condition X

Health economic QIPP framework


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Figure V: An example of a typical AEC pathway

Developing AEC services


GP/out of hours (OOH) assessment of need for emergency hospital attendance or ED attendance (may be telephone

discussion with AEC triage service)

Own transport or ambulance to AEC

centre

Clinical assessment in the ED / CDU,

Acute Medical Unit (AMU) or Ambulatory

Care Centre by a competent clinician with a focus on AEC

Diagnostic tests Clinical review Discharge with case management plan

It is important to integrate and develop the ‘streaming’ assessments currently utilised by primary care, ambulance, out-of-hours, mental health and social care services to provide consistent and safe ‘signposting’ to the appropriate urgent/emergency care process.

The initial assessment may occur either in the GP surgery or in an Emergency Department setting. In some settings, the patient may be managed on an ambulatory pathway at this point. The process to access ambulatory care must be clear, allowing the assessor to manage or stream appropriate patients to AEC, avoiding the potential for unnecessary hospital admission. Some AEC services have designed a telephone triage process to manage referrals from these routes.

If the patient does progress to secondary care, assessment can take place in a variety of settings, for example emergency departments, CDU, medical admissions unit or a dedicated ambulatory care area; different models are developing around the UK.

Good engagement with ambulance services is vital to minimise the wait to arrive at the AEC unit, thereby maximising the opportunities for the clinical team to make a diagnosis and develop a management plan.

An initial assessment of illness severity should be completed immediately on arrival using a validated score based on physiological variables e.g. NEWS (National early warning score, published by the Royal college of Physicians). This is to ensure patients who may have deteriorated can be promptly identified and moved to the most appropriate clinical environment.

In some centres after the initial assessment, the next stage of the pathway can take place in a ‘hot clinic’ environment, depending upon pathway complexity and the need for short term observation or therapy.

Diagnostics

Access to appropriately timed diagnostics is absolutely critical for a successful AEC, as diagnostics and reporting need to be delivered on the day of assessment or as part of the patient’s care pathway after the initial face to face assessment. It is vital to ensure that patients on AEC pathways have diagnostic access which is equivalent to patients on emergency pathways. This group of patients require an emergency approach rather than an out-patient approach. The engagement of colleagues in diagnostic services is important in developing the principles and pathways necessary for a high quality clinical service. There are different ways of approaching this, for example having dedicated diagnostic slots for the AEC service can be valuable. This can be achieved by matching demand and capacity (e.g. ultrasound slots for suspected DVT). Alternatively a radiologist with dedicated sessions supporting the emergency pathways including AEC, with clear standardised times for performing each test and reporting it if appropriate, can also be successful. Whatever the local solution, the key is to engage and involve diagnostic service colleagues at an early stage of your AEC design.

Assessment


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Staffing and Facilities

Clinical leadership to develop Ambulatory Emergency Care is crucial for its safe and effective design and delivery. Senior clinical personnel with expertise in illness severity, co-morbidity and functional assessment with the experience to make balanced risk decisions are required.

The NHS Institute led a Delivery network in 2011/12 for teams of NHS Organisations who were at varying stages of implementing AEC services. One of the key learning points from this was the importance of developing highly skilled, competent and cohesive multidisciplinary teams to deliver these services, to ensure that the quality and appropriateness of care is developed and maintained across departments and organisations.

AEC can be delivered in a range of locations and it is for each local health and care system to decide on the appropriate configuration of facilities to develop and continue to improve services. Many AEC pioneers started from very humble beginnings, including makeshift offices and even utilising cupboard space as a base for their services, but, as the case for service expansion became evident, they were able to progress to more appropriate facilities. However, as the benefits of AEC are becoming more widely recognised, many services are starting up with fit for purpose units that contribute to the success of the service.

Case Management Plans It will be the responsibility of the Senior Clinical team members to ensure that well documented, clear case management plans with transparent lines of clinical responsibility are developed. Managing these could include monitoring the patient’s condition by either telephone consultation, electronic communication, at home by the community healthcare team, attendance at primary care, a day treatment unit or an out patient clinic, depending on the clinical situation and local service configuration.

Specific pathways for high volume clinical presentations e.g. DVT can be helpful within a more generic document. Ideally a written plan should be developed which supports the patient’s care throughout the pathway and can be started wherever the patient presents and wherever they receive their on going care.

The case management plan should be communicated with all parties involved in managing the patient’s care and of course the patient. The case management plan should include:

– diagnosis – relevant diagnostic results – treatment plan – referrals made – actions required from other clinicians – contact in the event of clinical deterioration or

non-response to treatment– contact details for enquiries.


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Patient Information and experience

Patients should be provided with clear, concise, easy to read information explaining:

– what ambulatory care is;

– their condition;

– their case management plan;

– what to look out for that suggest any deterioration in patient condition;

– the monitoring process;

– a specific contact point if there is any concern.

This could be given at various points in the patient journey e.g. in primary care, emergency care, and in ambulatory care units.

Ideally this information should be developed with patients to ensure that it really meets their needs. Shared decision making, involving patients fully in their own care, with decisions made in partnership with clinicians should be the norm in AEC.

Please see the ‘Experience based design for AEC’ Guide on the NHS institute AEC Webpage, for ideas on how you can involve patients more meaningfully: www.institute.nhs.uk/aec

A copy of the relevant clinical documentation should be given to the patient before they leave AEC. Having a contact point is important to ensure that patients feel confident that they are being supported safely. Local implementation teams will need to consider how best to provide this contact 24 hours a day, 7 days a week.

Depending on the service delivery model this could be the Emergency Department or Acute Medical Unit. Other options to consider might be integration of this contact point with out of hours services, NHS 111, or with the Ambulance services.

Measuring the impact of your AEC service

Simply measuring the number of patients receiving same day emergency care will not provide sufficient evidence to demonstrate its impact. As the baseline for AEC is current emergency patient flow, this needs to be understood ahead of implementing AEC services. Organisations implementing AEC need to develop a tactical approach to measurement that reflects their model of implementation and using their existing systems of collecting patient information.

The key consideration is to have a balanced approach to measurement considering outcome, process and balancing measures (that reflect what may be happening elsewhere in the system as a result of the change). The three core questions are:

– who are the AEC patients?

– how effective is the service is in terms of decision making?

– how effective is the service is in terms of outcomes?


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As AEC activity can legitimately span inpatient, outpatient and ward attendance, it is important to have a tactical approach to coding this activity. The following steps will help you to ensure that you have the information you need to demonstrate impact for commissioners:

• Identify any AEC activity separately from other emergency activity locally so that providers and commissioners can see the impact on emergency patient flow.

• Define AEC activity based on the intention for same day emergency care irrespective of whether or not a bed is involved.

• Ideally there should be a local agreement with commissioners about tariff, using the Payment by Results Best Practice Tariff as a guide

• All AEC activity should have clinical coding performed so that major diagnostic groups can be identified and comparisons made with the pre-AEC position.

The tactical solutions work best where there is a clear agreement on the definition of AEC activity between commissioners and providers.

As length of stay in AEC needs to be measured in hours (as opposed to days), some organisations

have found that there can be challenges in terms of the capability of existing measurement systems to record this. It is therefore helpful to plan how to effectively capture the right data early on in planning for AEC.

Further detail on how to measure the impact of AEC services can be found in ‘Ambulatory emergency care: Guide to measurement for improvement’, available from the NHS institute AEC website: www.institute.nhs.uk/aec

5. Analyse & Present

1. Decide Aim

2. Choose Measures

3. Define Measures

4. Collect Data

6. Review Measures

Repeat steps 4-6

Figure VI: The seven steps in measurement for improvement


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– Senior medical, nursing and managerial leadership working on a shared quality agenda to achieve system level improvement in Emergency Care.

– Executive and strategic organisational support.

– Consultant led service (Emergency Medicine and/or Acute medicine) with a skilled and cohesive multi disciplinary team.

– Early engagement and involvement of clinicians and stakeholders including clinical commissioners.

– Effective whole system planning and delivery understanding and alignment of financial incentives and executive leadership in all participating organisations.

– Project management support and improvement expertise

– A high degree of involvement from patients and the public and good communication with clear information.

– Selection criteria for patients suitable for AEC.

– Self contained facilities are needed (close to ED if possible).

– Effective clinical triage at the point of referral.

– Regular team reviews of data, patient feedback and staff experience to effect further improvement.

Following discussions with pioneer organisations, national experts, and members of the AEC Delivery network, the NHS institute has compiled some principles which we think are important to the successful implementation of ambulatory emergency care services:

Principles for success


Directory of Clinical Conditions

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2. Directory of clinical conditions

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Directory of clinical conditions

The Directory should be used as an enabler to deliver new integrated systems of emergency care. It is not designed to be used as a demand management tool or a performance management tool, and this is not an exhaustive list of conditions that can be managed in an ambulatory way. For example it does not include all the potential codes for non-specific symptoms and signs or all of the potential outcomes for patients referred with a suspected diagnosis.

The table that follows has been provided to support local health communities to develop services that will enable them to manage emergency patients in an ambulatory manner. Table 1 overleaf provides information on the following components:

Description of conditions The specialities included in the following table are: general medicine, general surgery, urology, obstetrics and gynaecology, trauma and orthopaedics.

The Directory excludes children, but paediatric services could apply some of the processes described in this publication to deliver care to children with acute illness in an ambulatory manner.

The focus of the document is on high volume clinical presentations, and there are potentially many other clinical scenarios which could be managed through an AEC approach.

Codes: some clarification The Healthcare Resource Group (HRG) codes have been updated in line with 2011/12 Payment by results (PBR) information and changes, version 4.

The HRG codes in brackets are the same conditions, but where there are secondary codes that would result in a ‘with complications or co morbidities’ HRG being assigned.

HRGs described as with CC or with intermediate CC are included in brackets as the complications may not always exclude the possibility of ambulatory care. The groups described with major complications or co morbidities have been excluded.

ICD10 codes linked to the primary diagnosis with the potential for ambulatory care are identified. Additional ICD10 codes for the same episode will assist in identifying the complications or co-morbidities which may affect the likelihood of delivery of ambulatory care. Secondary asterisk diagnoses (*) require a dagger primary diagnosis. Please refer to the HRG Definition Documents (available at http://tinyurl.com/9d8r255) and the Clinical Coding Instruction Manual for ICD 10 (available at http://tinyurl.com/97fpovm) for further details.

Admission codes have been used for admissions from Care Homes and other non-acute NHS facilities. For the former there is the risk of missing episodes, as the code for these cases may be mistakenly identified as 19 (Usual place of residence) or 29 (Temporary place of residence when usually resident). For admissions from other non-acute NHS beds we have not included the code 51 – i.e. ‘transfer from.’

Using the Directory for Ambulatory Emergency Care for Adults

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Table I Examples of good and poor documentationClinical evidence and best practice Wherever possible, each section is supported by links to clinical evidence and best practice, which reference clinical guidelines produced by colleges, specialist societies or specific peer reviewed publications. Local health care communities need to review the grade of evidence within these referenced guidelines, to develop local solutions.

Clinical coding Clinical Coding has the function of creating accurate and timely clinically coded data which will provide a statistical analysis both at a local and national level, and, more importantly, to be utilised in order to secure the correct level of income to the acute hospital trust from commissioners...

Robust, accurate and timely clinically coded data can only be created if the clinical coding team have access to clear and legible clinical information that is an accurate reflection of the patients’ hospital encounter.

Vague, ambiguous and/or incomplete clinical statements may potentially result in the assignment of codes that cannot be considered a true representation of the actual episode of care. Likewise, it is equally the responsibility of the clinical coding team to follow the four step coding process associated with the ICD 10 and OPCS 4 Classifications at all times, applying the nationally mandated clinical coding standards, rules and conventions as and where necessary to ensure accurate code assignment.

In order to ensure this directory is used to its maximum potential, it is recommended that a dialogue is established between the clinical teams and clinical coding departments, so that both parties understand each others’ needs and requirements with regard to the level and detail of the clinical information that is required to support the coding of patients on the ambulatory pathway. Examples of good and poor documentation are shown in the table.

Poor Examples Good Examples

Head injury Laceration of scalp due to a falling out of bed at home

LRTI/ Chest infection Pneumonia/ Consolidation on chest x-ray

Catheter problem Blocked urethral/ suprapubic catheter; Pain due to catheter

Avoid the use of abbreviations as some have multiple meanings e.g. MS = multiple sclerosis or mitral stenosis. Be as specific as possible when documenting information.

It is good practice to record (in addition to the presenting complaint/condition) any relevant comorbidities from which the patient suffers.

Directory of clinical conditions

General Medicine

31

General Medicine

General Medicine

Deep vein thrombosis

EB11Z Deep vein thrombosis Very high – >90%

Thrombophilia or possible malignancy.

Procedures for the outpatient management of patients with deep venous throbosis http://tinyurl.com/c5usvcf

ICD-10 I801, I802/I822 I803, M796, M798

Pulmonary embolism DZ09C Pulmonary Embolus without CC High – 60–90%

Massive vs non-massive pulmonary embolism. Thrombophilia or possible malignancy. http://tinyurl.com/8afkufb

British Thoracic Society (BTS) guidelines for the management of suspected acute pulmonary embolism: http://tinyurl.com/c5usvcf

DZ09B Pulmonary Embolus with CC

ICD-10 I269, R071, R074

Pneumothorax DZ26B Pneumothorax without CC Low – 10–30%

Primary pneumothorax only. Clarity of success of aspiration.

BTS guidelines for the management of spontaneous pneumothorax: http://tinyurl.com/cy59s59

DZ26A Pneumothroax with CC

ICD-10 J93.0, J931, J938, J939

Condition/ scenario HRG Codes 11/12

HRG Codes 11/12 Detail

% potentialambulatory care(primary ICD-10 coded admissions)

Specific safety issues(not exhaustive)

Evidence

Blue shaded cells indicate where nurses have identified a pathway that has the potential to be nurse led; given advanced clinical skills and relevant training.

32

General Medicine

Pleural effusions DZ16C Pleural Effusion without CC High – 60–90%

Transudate vs exudate. Para-pneumonic effusions.

BTS guidelines for the investigation of a unilateral pleural effusion in adults: http://tinyurl.com/c6funey

DZ16B Pleural Effusion with CC

ICD-10 J90X, C782, J111

Asthma DZ15F Asthma without CC without Intubation

Low – 10–30%

Assessment of illness severity using BTS asthma guidelines and response to initial treatment.

British Guideline on the Management of Asthma: http://tinyurl.com/7n4ocyr A national clinical guideline (British Thoracic Society. Scottish Intercollegiate Guidelines Network)

DZ15E Asthma with CC without Intubation

ICD-10 J450, J451, J458, J459





Evidence

33

Chronic obstructive pulmonary disease (COPD)

DZ21A Chronic Obstructive Pulmonary Disease or Bronchitis with length of stay 1 day or less discharged home

Low – 10–30%

See Table 8 NICE COPD Guideline.

Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in adults in primary and secondary care: http://tinyurl.com/7q7s55a

DZ21K Chronic Obstructive Pulmonary Disease or Bronchitis without NIV without Intubation without CC

DZ21J Chronic Obstructive Pulmonary Disease or Bronchitis without NIV without Intubation with CC

ICD-10 J40X, J410, J42X, J440, J441, J448, J449, J43.9

Community-acquired pneumonia

DZ11C Lobar, Atypical or Viral Pneumonia without CC

Low – 10–30%

Clinical assessment and CURB-65 score – CURB-65 score of 0 or 1 suggests suitable for home treatment. BTS guidance suggests that a CURB-65 score of 2 be managed through short stay acute care or hospital supervised outpatient care. This decision is a matter for clinical judgement.

BTS guidelines for the management of community-acquired pneumonia in adults 2009 update http://tinyurl.com/75yf5h2

DZ11B Lobar, Atypical or Viral Pneumonia with CC

DZ23C Bronchopneumonia without CC

DZ23B Bronchopneumonia with CC





Evidence

General Medicine

34

ICD-10 J100, J110, J120, J121, J122, J128, J129, J13X, J14X, J153, J154, J157, J158, J159, J160, J168, J180, J181, J188, J189

Lower respiratory tract infections without COPD

DZ22C Unspecified Acute Lower Respiratory Infection without CC

Moderate – 30–60%

DZ22B Unspecified Acute Lower Respiratory Infection with CC

ICD-10 J200, J201, J202, J203, J204, J205, J206, J207, J208, J209, J22X,

Congestive cardiac failure

EB03I Heart Failure or Shock without CC Moderate – 30–60%

Reason for decompensation. Weight, renal and electrolyte monitoring.

Guidelines for the diagnosis and treatment of chronic heart failure - http://tinyurl.com/6f3flb9

EB03H Heart Failure or Shock with CC

ICD-10 I110, I130, I500, I501, I509

Supraventricular tachycardias & other unspecified tachycardias

EB07I Arrhythmia or Conduction Disorders without CC


Cardiac and non-cardiac aetiology. Electrolyte and thyroid function. Underlying LV function. Pre-arrest criteria. Rate and/or rhythm control achieved before discharge.

NICE Atrial fibrillation: http://tinyurl.com/955bn79 ACC/AHAS/ESC guidelines for the management of patients with supraventricular arrhythmias: http://tinyurl.com/9ra4f9r

EB07H Arrhythmia or Conduction Disorders with CC

ICD-10 I471, I479, I48X, I495, I498, I499, R000, R002, R008





Evidence

General Medicine

35

Low risk chest pain EB10Z Actual or Suspected Myocardial Infarction


Early risk stratification and streaming.

Task force on the management of chest pain: http://tinyurl.com/8obrfks EB01Z Non interventional acquired

cardiac conditions 19 years and over

ICD-10 I201, I208, I209, I248, I249, I256, R072, R073, R074, Z034, Z035

Transient ischaemic attack

AA29Z Transient Ischaemic Attack High – 60–90%

ABCD score ‘Crescendo TIAs’, ie more than one TIA in a week. Aetiology. 2° prophylaxis. Timeliness of access to Carotid Doppler and neurovascular service.

National clinical guidelines for stroke – second edition: http://tinyurl.com/8gx65t5 Primary care concise guidelines for stroke 2008: http://tinyurl.com/9t9kfjx

ICD-10 G450, G451, G453, G454, G458, G459





Evidence

General Medicine

36

General Medicine

Stroke AA22Z Non-Transient Stroke or Cerebrovascular Accident, Nervous system infections or Encephalopathy

Low – 10–30%

Outside ‘thrombolysis’ window. Stroke team assessment including CT. Lacunar strokes or minor partial anterior circulation. Aetiology. 2° prophylaxis. Timeliness of access to Carotid Doppler (OPCS 4.3 U11.7) and neurovascular service.

National clinical guidelines for stroke – third edition: http://tinyurl.com/cq2n267 Primary care concise guidelines for stroke 2008: http://tinyurl.com/95ejurt

ICD-10 I633, I634, I635, I636, I638, I639, I64X, I660, I661, I662, I668, I669, I672, I698, R470

First seizure AA26Z Muscular, Balance, Cranial or Peripheral Nerve disorders; Epilepsy; Head Injury

High – 60–90%

Full recovery and no atypical features. Screening tests (glucose, sodium, calcium) stable. Neuro-imaging for focal seizure. Appropriate specialty follow up. Driving advice.

The epilepsies – The diagnosis and management of the epilepsies in adults and children in primary and secondary care: http://tinyurl.com/9b2x7mz

ICD-10 R568





Evidence

37

Seizure in known epileptic

AA26Z Muscular, Balance, Cranial or Peripheral Nerve disorders; Epilepsy; Head Injury

High – 60–90%

Seizure pattern. Trigger factors. Drug review.

The epilepsies – The diagnosis and management of the epilepsies in adults and children in primary and secondary care: http://tinyurl.com/9b2x7mz

ICD-10 G253, G400, G401, G402, G403, G404, G405, G406, G407, G408, G409, R568

Acute headache AA31Z Headache or Migraine Medium – 30–60%

Glasgow Coma Scale and focal signs. If sub-arachnoid haemorrhage suspected CT (OPCS 4.3 U05.1) +/- lumbar puncture (OPCS 4.3 A55.9).

National Guidelines for Analysis of Cerebrospinal Fluid for Bilirubin in Suspected Subarachnoid Haemorrhage: http://tinyurl.com/8dz87pm Early Management of Suspected Bacterial Meningitis and Meningococcal Septicaemia in Immunocompetent Adults – Journal of Infection (2003) 46:75-77: http://tinyurl.com/99pldox

General Medicine





Evidence

38

General Medicine

ICD-10 G430, G431, G432, G433, G438, G440, G441, G443, G444, G448, G971, R51X

Upper gastro-intestinal haemorrhage

FZ38F Gastrointestinal Bleed with length of stay 0 days

Low – 10–30%

Haemodynamic assessment. Transfusion criteria. Risk assessment using the post-endoscopy Rockall Score or Blatchford Score.

Scottish Intercollegiate Guidelines Network Guidelines on Management of Acute Upper and Lower Gastrointestinal Bleeding in Adults http://tinyurl.com/9tv5f84

FZ38E Gastrointestinal Bleed with length of stay 1 day or more without Major CC

ICD-10 K920, K921, K922, K20X, K210, K219, K221, K226, K250, K254, K260, K264, K270, K274

Lower gastro-intestinal haemorrhage

FZ36F Intestinal Infectious Disorders with length of stay 0 days

High – 60–90%

Haemodynamic assessment. Transfusion criteria. Access to flexible sigmoidoscopy/ colonoscopy (OPCS 4.3 H28.1 H28.8 H28.9 H25.1 H25.8 H25.9 H22.1 H22.8 H22.9).

Management of colorectal cancer, Section 5: Primary care and referral http://tinyurl.com/9oxp3b5 Referral guidelines for suspected cancer in adults and children http://tinyurl.com/y9k5qox

FZ36E Intestinal Infectious Disorders with length of stay 1 day or more without Major CC

FZ36D Intestinal Infectious Disorders with length of stay 1 day or more with Major CC

ICD-10 K625, K922





Evidence

39

Gastroenteritis FZ36F Intestinal Infectious Disorders with length of stay 0 days

High – 60–90%

Haemodynamic, renal and electrolyte assessment. Consider the possibility of inflammatory bowel disease and pseudomembranous colitis. Consider use of ambulatory IV hydration.

Farthing M, Feldman R, Finch R et al. (1996). The management of infective gastroenteritis in adults. A consensus statement by an expert panel convened by the British Society for the Study of Infection. Journal of Infection 33(3), 143-152

FZ36E Intestinal Infectious Disorders with length of stay 1 day or more without Major CC

FZ36D Intestinal Infectious Disorders with length of stay 1 day or more with Major CC

ICD-10 A090, A099 A020, A040, A045, A04.6, A048, A049, A054, A058, A059, A080, A081, A082, A083, A084, A085, K520, K521, K522, K528, K529, T629

General Medicine





Evidence

40

General Medicine

Painless obstructive jaundice

GC12B Malignant Liver and Pancreatic Disorders with length of stay 1 day or less


Consider risk of ascending cholangitis. Coagulation status. Access to ultrasound/ CT scanning.

Guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas http://tinyurl.com/8dtlbtm UK guidelines for the management of acute pancreatitis http://tinyurl.com/8wbju6r

GC13B Liver Disorders Category 3 with Intermediate CC

GC13C Liver Disorders Category 3 without CC

GC13A Liver Disorders Category 3 with Major CC

GC14A Pancreatic and Biliary Disorders Category 3 with Major CC

GC14B Pancreatic and Biliary Disorders Category 3 with Intermediate CC

GC14C Pancreatic and Biliary Disorders Category 3 without CC

GC03A Liver and Pancreatic Disorders category 5 with CC

GC03B Liver and Pancreatic Disorders category 5 without CC

GC06A Liver and Pancreatic Disorders category 2 with Major CC





Evidence

41

GC06B Liver and Pancreatic Disorders category 2 with Intermediate CC

GC06C Liver and Pancreatic Disorders category 2 without CC





GC09B Pancreatic and Biliary Disorders Category 6 without Major CC




General Medicine





Evidence

42

GC12A Malignant Liver and Pancreatic Disorders with length of stay 2 days or more

ICD-10 K805, K831, K839, C250, C251, C253, C259, C23X, C240, C241, C248, C249, D015, D135, D376, R17.X

Abnormal Liver Function

GC12B Malignant Liver and Pancreatic Disorders with length of stay 1 day or less

Consider risk of ascending cholangitis. Coagulation status. Access to ultrasound/ CT scanning.

Guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas http://tinyurl.com/8dtlbtm UK guidelines for the management of acute pancreatitis http://tinyurl.com/8wbju6r

GC13B Liver Disorders Category 3 with Intermediate CC

GC13C Liver Disorders Category 3 without CC

GC13A Liver Disorders Category 3 with Major CC




GC03A Liver and Pancreatic Disorders category 5 with CC

General Medicine





Evidence

43

GC03B Liver and Pancreatic Disorders category 5 without CC


High - 65-75%







GC09B Pancreatic and Biliary Disorders Category 6 without Major CC


General Medicine





Evidence

44



GC12A Malignant Liver and Pancreatic Disorders with length of stay 2 days or more

ICD-10 K831, K839, C250, C251, C253, C259, C23X, C240, C241, C248, C249, D015, D135, D376, R94.5

Anaemia SA04F Iron Deficiency Anaemia without CC

High – 60–90%

Aetiology. Transfusion need is based on haemodynamic impact not on haemoglobin level.

Guidelines for the clinical use of red cell transfusions: http://tinyurl.com/9lgt8zx SA04E Iron Deficiency Anaemia

with Intermediate CC

SA05F Megaloblastic Anaemia without CC

SA05D Megaloblastic Anaemia with CC

SA06F Myelodysplastic Syndrome without CC

General Medicine



% potentialambulatory care(primary ICD-10 coded


Evidence

45

SA01F Aplastic Anaemia without CC

SA03F Haemolytic Anaemia without CC

SA03D Haemolytic Anaemia with CC

SA01F Aplastic Anaemia without CC

SA01E Aplastic Anaemia with Intermediate CC

ICD-10 D460, D461, D464, D500, D508,D509, D511, D512, D513, D518, D520, D521, D528, D529, D531, D571, D580, D581, D590, D591, D592, D599, D601, D608, D609, D610, D611, D640, D641, D642, D643, D644, D648, D649

Hypoglycaemia KB01A Diabetes with Hypoglycaemic Disorders 70 years and over

High – 60–90%

Applies only in patients with diabetes receiving hypoglycaemic agents. Review of cause and education of patient required. More caution with sulphonylurea associated/long-acting insulin induced hypoglycaemia.

NICE CG15 Diagnosis and management of type 1 diabetes in children, young people and adults http://tinyurl.com/8ld8ava NICE CG66 Type 2 diabetes: the management of type 2 diabetes (update) http://tinyurl.com/8mwqk3m

General Medicine





Evidence

46

KB01B Diabetes with Hypoglycaemic Disorders 69 years and under

ICD-10 E162

Diabetes KB01A Diabetes with Hypoglycaemic Disorders 70 years and over

High – 60–90%

Symptom severity assessment. Haemodynamic, renal and electrolyte status.

Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults http://tinyurl.com/9s6zy7x NICE CG66 Type 2 diabetes: the management of type 2 diabetes (update) http://tinyurl.com/8mwqk3m

KB01B Diabetes with Hypoglycaemic Disorders 69 years and under

KB02C Diabetes with Hyperglycaemic Disorders 70 years and over without CC

KB02F Diabetes with Hyperglycaemic Disorders 69 years and under without CC

KB02B Diabetes with Hyperglycaemic Disorders 70 years and over with Intermediate CC

KB02E Diabetes with Hyperglycaemic Disorders 69 years and under with Intermediate CC

General Medicine





Evidence

47

ICD-10 E100-9, E110-9, E120-9, E130-9, E140-9

Cellulitis of limb JD03C Intermediate Skin disorders category 2 without CC

High – 60–90%

Exclude necrotising fasciitis. Class III and IV require admission. Ambulatory IV antibiotic policy with review of IV access site (OPCS 4.3 X28.1).

Guidelines on the management of cellulitis in adults: http://www.cks.nhs.uk/celluli-tis_acute

JD04C Intermediate Skin disorders category 1 without CC

JD05C Minor Skin disorders category 2 without CC

JD03B Intermediate Skin disorders category 2 with Intermediate CC

JD04B Intermediate Skin disorders category 1 with Intermediate CC

JD05B Minor Skin disorders category 2 with Intermediate CC

ICD-10 L030, L031, L032, L033, L038, L039, I891, L088, L089

Known oesophageal stenosis (either stented or unstented)

FZ31F Disorders of the Oesophagus with length of stay 0 days

High – 60–90%

Aspiration pneumonia. Oesophageal rupture/ perforation.

Guidelines for the management of oesophageal and gastric cancer: http://tinyurl.com/8hpqhua Guidelines on the use of oesophageal dilatation in clinical practice: http://tinyurl.com/94lagsd

FZ31E Disorders of the Oesophagus with length of stay 1 day or more without Major CC

General Medicine





Evidence

48

ICD-10 K220, K222, R13X, T181, C150, C151, C152, C153, C154, C155, C158, C159

PEG related complications

FZ33E Small Intestinal Disorders (excluding Inflammatory Bowel Disease) with length of stay 0 days

Very high – >90%

Local PEG re-insertion policy. Maintenance of tract.

Nutrition support in adults – Oral nutrition support, enteral tube feeding and parenteral nutrition http://tinyurl.com/8adhtl3 FZ43B Non-Malignant Stomach or

Duodenum Disorders with length of stay 1 day or more without Major CC

FZ43C Non-Malignant Stomach or Duodenum Disorders with length of stay 0 days

ICD-10 Z431, T855, T858

General Medicine





Evidence

49

Acute admissions from care homes

No HRG codes Moderate – 30–60% from residential homes, high – 60–90% from nursing homes

Scenario planning (eg advanced care directives including resuscitation) and review. Rapid access to specialist multidisciplinary assessment. These include intermediate care beds, mental health beds and other community hospital beds. In these situations, the principle should be to take the ‘care to the patient and not the patient to the care’ unless absolutely necessary.

The Silver Book: QUALITY CARE FOR OLDER PEOPLE WITH URGENT & EMERGENCY CARE NEEDS http://tinyurl.com/cebaqz3

Acute admissions from non-acute NHS beds

No HRG codes

General Medicine





Evidence

50

Condition/ scenario

HRG Codes 11/12




Evidence

Self-harm & Accidental Overdose

WA11Y Poisoning, toxic, environmental and unspecified effects without CC

High – 60–90%

Suicide risk assessment. Rapid access mental health response (not just assessment) if physical risk from DSH does not require admission to an acute bed and significant suicide risk.

A national survey of the hospital services for the management of adult deliberate self-harm http://tinyurl.com/8dl8b62 A national survey of the hospital services for the management of adult deliberate self-harm http://tinyurl.com/8dl8b62 National Suicide Prevention Strategy for England http://tinyurl.com/lerv6 Bennewith O, Gunnell D, Peters T, Hawton K, House A – Variations in the hospital management of self-harm in adults in England: observational study, BMJ, 2004, 328: 1108–1109 (8 May), doi:10.1136/bmj.328.7448.1108 http://tinyurl.com/cw69vxj Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care http://tinyurl.com/9v95fma

WA11X Poisoning, toxic, environmental and unspeci-fied effects with Intermediate CC

General Medicine

51

WA11X Poisoning, toxic, environmental and unspecified effects with Intermediate CC

ICD-10 T361, T362, T363, T364, T365, T366, T367, T368, T369, T370, T371, T372, T373, T374, T375, T376, T377, T378, T379, T380, T381, T382, T383, T384, T385, T386, T387, T388, T389, T390, T391, T392, T393, T394, T398, T399, T400, T401, T402, T403, T404, T405, T406, T407, T408, T409, T410, T411, T412, T413, T414, T415, T416, T417, T418, T419, T420, T421, T422, T423, T424, T425, T426, T427, T428, T430, T431, T432, T433, T434, T435, T436, T437, T438, T439, T440, T441, T442, T443, T444, T445, T446, T447, T448, T449, T450, T451, T452, T453, T454, T455, T456, T457, T458, T459, T460, T461, T462, T463, T464, T465, T466, T467, T468, T469, T470, T471, T472, T473, T474, T475, T476, T477, T478, T479, T480, T481, T482, T483, T484, T485, T486, T487, T488, T489, T490, T491, T492, T493, T494, T495, T496, T497, T498, T499, T500, T501, T502, T503, T504, T505, T506, T507, T508, T509, T510 The listed codes are only considered to be self harm when associated with a secondary code from Categories X60 - X69 for intentional self harm.

End of life care No HRG codes Prior planning of potential scenarios including patient, family and multi-disciplinary team (ie advance care directives). Rapid access to specialist ambulatory multi-disciplinary care.

High – 60–90%

End of Life Care Programme: http://tinyurl.com/6falwmv

General Medicine





Evidence

52

No HRG codes

Falls including syncope or collapse

EB08H Syncope or Collapse with

High – 60–90%

Exclusion of significant cardiovascular risk – eg high-grade AV block or high risk dysrhythmia. Osteoporosis assessment. Access to specialist falls assessment. If new onset of falls, consider acute illness as precipitant.

Osteoporosis – secondary prevention. The clinical effectiveness and cost effectiveness of technologies for the secondary prevention of osteoporotic fractures in postmenopausal women: http://tinyurl.com/8uk2q87 Falls. The assessment and prevention of falls in older people: http://tinyurl.com/8aly3qx The Silver Book: QUALITY CARE FOR OLDER PEOPLE WITH URGENT & EMERGENCY CARE NEEDS http://tinyurl.com/cebaqz3 Osteoporosis – secondary prevention. The clinical effectiveness and cost effectiveness of technologies for the secondary prevention of osteoporotic fractures in postmenopausal women: http://tinyurl.com/8uk2q87 Osteoporosis. Clinical guidelines for prevention and treatment. Update on pharmacological interventions and an algorithm for management: http://tinyurl.com/9m4pnb7 Falls. The assessment and prevention of falls in older people: http://tinyurl.com/8aly3qx The Silver Book: QUALITY CARE FOR OLDER PEOPLE WITH URGENT & EMERGENCY CARE NEEDS http://tinyurl.com/cebaqz3

EB08I Syncope or Collapse with-

WA23Y Falls without specific cause

WA23X Falls without specific cause with Intermediate CC

General Medicine

Condition/ scenario

HRG Codes 11/12




Evidence

53

ICD-10 I951, R268, R54X, R55X

Urinary tract infections

LA04G Kidney or Urinary Tract Infections with length of stay less 1 day or less


Impaired renal function – renal imaging. Bladder outflow obstruction. Foreign body. Increasing prevalence of multiresistant organisms especially with indwelling urinary catheters. Consider use of ambulatory IV hydration if dehydrated (OPCS 4.3 X28.1). Pregnancy related UTI.

SIGN. Management of suspected bacterial urinary tract infection in adults. A national clinical guideline www.sign.ac.uk/pdf/sign88.pdf

LA04E Kidney or Urinary Tract Infections with length of stay 2 days or more with Intermediate CC

LA04F Kidney or Urinary Tract Infections with length of stay 2 days or more without CC

ICD-10 N300, N301, N302, N303, N304, N308, N309, N390

General Medicine





Evidence

Trauma and Orthopaedics

55

Acutely hot painful joint

HD23C Inflammatory Spine, Joint or Connective Tissue Disorders without CC


Exclusion of septic arthritis. Prosthetic joint sepsis.

BSR and BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults http://tinyurl.com/9r9xlpa

HD23B Inflammatory Spine, Joint or Connective Tissue Disorders with CC

HD26C Musculoskeletal Signs and Symptoms without CC

HD26B Musculoskeletal Signs and Symptoms with CC

ICD-10 M109, M101-4, M1090, M130-1, M1091, M138, M1092, M050-3, M1093, I528, M1094, I39, M1095, I418, M1096, G737, M1097, I328, M1098, G63.6, M1099, M058, M139, M059, M255, M060-9, M1390, M45.X, M1391, M1392, M1393, M1394, M1395, M1396, M1397, M1398, M1399, M2550, M2551, M2552, M2553, M2554, M2555, M2556, M2557, M2558, M2559







Evidence

56


Appendicular fractures not requiring immediate internal fixation

HA91Z Hip Trauma Diagnosis without Procedure

High – 60–90%

Neuro-vascular assessment. A significant proportion of those currently admitted are frail older people who have fallen and sustained a fracture. Consider acute illness precipitating the fall which resulted in the fracture. Admission only required if the acute precipitating illness requires admission in its own right. In those requiring internal fixation, consider the possibility of fast-track day case surgery if feasible. Osteoporosis assessment and falls assessment where appropriate.

Osteoporosis – secondary prevention. The clinical effectiveness and cost effectiveness of technologies for the secondary prevention of osteoporotic fractures in postmenopausal women http://tinyurl.com/8uk2q87 Osteoporosis. Clinical guidelines for prevention and treatment. Update on pharmacological interventions and an algorithm for management http://tinyurl.com/8dn4wba

Falls. The assessment and prevention of falls in older people http://tinyurl.com/8aly3qx

HA92Z Knee Trauma Diagnosis without Procedure

HA93Z Foot Trauma Diagnosis without Procedure

HA94Z Arm Trauma Diagnosis without Procedure

HA95Z Hand Trauma Diagnosis without Procedure

HB91Z Other non Trauma Diagnosis without Procedure





Evidence

57


ICD-10 S420 ,S4200 ,S422 ,S4220 ,S423 ,S4230 ,S424 ,S4240 ,S520 ,S5200 ,S521 ,S5210 ,S522 ,S5220 ,S523 ,S5230 ,S524 ,S5240 ,S525 ,S5250 ,S526 ,S5260 ,S528 ,S5280 ,S529 ,S5290 ,S620 ,S6200 ,S621 ,S6210 ,T10X ,T10X0 ,S820 ,S8200 ,S823 ,S8230 ,S824 ,S8240 ,S825 ,S8250 ,S826 ,S8260 ,S828 ,S8280 ,S829 ,S8290 ,S920 ,S9200 ,S923 ,S9230 ,S929 ,S9290

Non-traumatic vertebral fractures

HD36C Pathological Fractures or Malignancy of Bone and Connective Tissue without CC

Very high – >90%

Neuro-vascular assessment. Consider metastatic disease or sepsis. Osteoporosis assessment.

Osteoporosis – secondary prevention. The clinical effectiveness and cost effectiveness of technologies for the secondary prevention of osteoporotic fractures in postmenopausal women http://tinyurl.com/8uk2q87 Falls. The assessment and prevention of falls in older people http://tinyurl.com/8aly3qx

HD36B Pathological Fractures or Malignancy of Bone and Connective Tissue with CC

HC92Z Spine non Trauma Diagnosis without Procedure

ICD-10 M800, M8008, M8009, M805, M8058, M8059, M808, M8088, M8089, M809, M8098, M8099





Evidence

58


Low risk pubic rami fractures

HA91Z Hip Trauma Diagnosis without Procedure

Very high – >90%

Low energy fall. Consider visceral injury. Osteoporosis assessment and falls assessment.


ICD-10 S3250, S325





Evidence

59

Hip pain secondary to a fall and non weight bearing

HD31C Sprains, Strains, or Minor Open Wounds without CC

High – 60–90%

These patients require same day MRI to exclude a fracture. Once a fracture is excluded, admission for pain relief and mobilisation should not be required unless aspiration of the joint is necessary.


HD31B Sprains, Strains, or Minor Open Wounds with CC

ICD-10 S760, M2555





Evidence


General Surgery

61

General Surgery

General Surgery

Acute abdominal pain not requiring operative intervention

FZ36F Intestinal Infectious Disorders with length of stay 0 days


Rapid (same day) access to ultrasound/CT scanning.

Education and decision support for junior doctors. Computer-aided diagnosis of acute abdominal pain from the Clinical Information Science Unit, University of Leeds and Media Innovations Ltd http://tinyurl.com/8resraj

FZ47B Non-Malignant General Abdominal Disorders with length of stay 1 day or more without Major CC

FZ47C Non-Malignant General Abdominal Disorders with length of stay 0 days

FZ47A Non-Malignant General Abdominal Disorders with length of stay 1 day or more with Major CC

ICD-10 R100, R101, R102, R103, R104, K59.0, K59.1, K59.8, K59.9





Evidence

62

General Surgery

Abscesses requiring surgical drainage - perianal, breast wound

FZ23Z Minor Anal Procedures High – 60–90%

Consider conversion to fast-track day case surgery if cannot be drained in outpatient assessment area setting.

Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised) http://tinyurl.com/9bgr6q6 Loftus IM, Watkin DF – Provision of a day case abscess service, Annals of the Royal College of Surgeons of England, 1997, July, 79(4): 289–290

FZ22A Intermediate Anal Procedures 19 years and over

JAI5C Minor Breast Procedures without CC

JA15B Minor Breast Procedures with Intermediate CC

JA15A Minor Breast Procedures with Major CC

FZ41F Anal Disorders with length of stay 0 days

FZ41E Anal disorders with length of stay 1 day or more without major CC

JA13Z Non-Malignant Breast Disorders

JA13Z Non-Malignant Breast Disorders

ICD-10 K610, N61X





Evidence

63

Head injury HD37C Head Injury without CC High – NICE Guideline. 60–90%

See NICE Guideline.

Head Injury: triage, assessment, investigation and early management of head injury in infants, children and adults. National Collaborating Centre for Acute Care. Guideline commissioned by the National Institute for Clinical Excellence, June 2003http://tinyurl.com/8hnvw5h

Geijerstam JL, Oredsson S, Britton M – Medical outcome after immediate computed tomography or admission for observation in patients with mild head injury: randomised controlled trial, BMJ, 2006, 333: 465 (2 September), doi:10.1136/bmj.38918.669317.4F http://tinyurl.com/8h6ou3d

ICD-10 S000-9, S010-9, S020-9, S030-5, S040-9, S050-9, S060-9, S070-1, S078-9, S080-1, S088-9, S090-2, S097-9

General Surgery





Evidence

Urology

65

Urology





Evidence

Acute painful bladder outflow obstruction

LB16C Lower Urinary Tract Findings without CC

High – 60–90%

Renal function. Beware acute retention without pain.

Urological emergencies www.kingstonpct.nhs.uk/_assets/documents/ORNG%20BOOK%2019%20urological.pdf

http://tinyurl.com/9zf5wegLB16B Lower Urinary Tract

Findings with Intermediate CC

ICD-10 R33X, R391

Renal/ureteric stones LB40B Urinary Tract Stone Disease without CC

High – 60–90%

Beware single functioning kidney. Fever suggesting ascending sepsis. Renal function. Persistent pain despite analgesia.

Wright PJ, English PJ, Hungin APS and Marsden SNE – Managing acute renal colic across the primary – secondary care interface: a pathway of care based on evidence and consensus, BMJ, 2002, 325: 1408 – 1412 (14 December) http://tinyurl.com/9tnk2wz NHS Clinical Knowledge Service guidance http://tinyurl.com/9udg2gf

LB40A Urinary Tract Stone Disease with CC

ICD-10 N200, N201, N202, N209, N210, N218, N219, N23X

Urology

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Urology





Evidence

Gross haematuria LB38B Unspecified Haematuria without Major CC

High – 60–90%

Acute renal failure. Sepsis. Clot retention.

Khadra MH, Pickard RS, Charlton M, Powell PH and Neal DE – A prospective analysis of 1,930 patients with hematuria to evaluate current diagnostic practice, The Journal of Urology, 2000, February, 163(2): 524–7

LB37B Miscellaneous Urinary Tract Findings without CC

LB37A Miscellaneous Urinary Tract Findings with CC

LA09H General Renal Disorders with length of stay 1 day or less

LB38B Unspecified Haematuria without Major CC

LB38A Unspecified Haematuria with Major CC

LA09F General Renal Disorders with length of stay 2 days or more with Intermediate CC

LA09G General Renal Disorders with length of stay 2 days or more without CC

LB37A Miscellaneous uniary tract findings with CC

LB37B Miscellaneous uniary tract findings without CC

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Urology





Evidence

ICD-10 R31X

Chronic indwelling catheter related problems

LB20B Infection and Mechanical Problems Related to Genito-Urinary Prostheses, Implants and Grafts without CC

High – 60–90%

Sepsis. Acute renal impairment. HCAI risk.

Essential steps to safe clean care: Urinary catheter care http://tinyurl.com/8sfoy2n

LB20A Infection and Mechanical Problems Related to Genito-Urinary Prostheses, Implants and Grafts with CC

LB15C Bladder Minor Procedure 19 years and over without CC

LB15B Bladder Minor Procedure 19 years and over with Intermediate CC

ICD-10 T830, T835, T838

Acute scrotal pain LB35B Scrotum, Testis or Vas Deferens Disorders without CC

High – 60–90%

US scan to assess risk of torsion.

American College of Radiology, ACR Appropriateness Criteria®. Clinical condition: acute onset of scrotal pain – without trauma, without antecedent mass http://tinyurl.com/8ar3k5s

LB35A Scrotum, Testis or Vas Deferens Disorders with CC

Obstetrics and Gynaecology

69







Evidence

Early pregnancy bleeding

MB08Z Threatened or Spontaneous Miscarriage Very high – >90%

Access to early pregnancy unit. Signs of sepsis or excessive bleeding. ERPC can be performed as a fast-track day case.

Association of Early Pregnancy Units Guidelines – Organisational, Clinical, Supportive 2004 http://tinyurl.com/8fptsl7

ICD-10 O020, O028, O029, O034, O039, O054, O059, O064, O069, O200, O208, O209

Ectopic pregnancy MB04B Ovary, Fallopian Tube or Pelvic Disorders without CC


Haemodynamically stable. HCG level. Size of gestational sac. Fast-track laparoscopic day surgery or in highly selected cases, medical management using methotrexate.

Association of Early Pregnancy Units Guidelines – Organisational, Clinical, Supportive 2004 http://tinyurl.com/8fptsl7 BADS Directory of Procedures 2009 http://tinyurl.com/94haa5e

MB04A Ovary, Fallopian Tube or Pelvic Disorders with CC

MA09Z Upper Genital Tract Laparoscopic / Endoscopic Intermediate Procedures

MA11B Upper Genital Tract Intermediate Procedures without CC

MA11A Upper Genital Tract Intermediate Procedures with CC

ICD-10 O001, O002, O008, O009

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Evidence

Hyperemesis gravidarum

NZ08C Ante-natal or Post-natal Investigation age between 16 and 40 years with length of stay 1 day or more


Exclude other causes of vomiting. Frequency of review (possibly daily) in early pregnancy unit. Degree of ketonuria. Monitoring of electrolytes. Thiamine and folate supplementation. Consider use of ambulatory IV hydration.

Pregnancy, Hyperemesis Gravidarum http://tinyurl.com/8f3ojfh This US website provides guidance on criteria for admission.

NZ04D Ante-natal or Post-natal Investigation age under 16 or over 40 years with length of stay 1 day or more

NZ05C Ante-natal or Post-natal Investigation age between 16 and 40 years with length of stay 0 days

NZ05D Ante-natal or Post-natal Investigation age under 16 or over 40 years with length of stay 0 days

NZ08C Ante-natal or post natal Investigation age between 16 to 40 years with length of stay 1 day or more

NZ08D Ante-natal or Post-natal Investigation age under 16 or over 40 years with length of stay 1 day or more

71





Evidence

ICD-10 O210, O211, O212, O218, O219

Diseases of Bartholin’s gland

MA05B Lower Genital Tract Minor Procedures without CC

Very high – >90%

Fast-track day case surgery.

BADS Directory of Procedures 2009 http://tinyurl.com/bt4t2r7MA05A Lower Genital Tract Minor Procedures

with CC

MB01Z Lower and Upper Genital Tract Very Complex Major Procedures

ICD-10 N750, N751, N758, N759


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3. Further information and support for implementing ambulatory emergency care

73

Further information and support for implementing ambulatory emergency care

The field of ambulatory emergency care is constantly evolving and we hope that this Directory will act as an initial ‘step off’ point for you to learn more about this work.

Further information, support, tools and ideas to help you are available from the NHS Institute Ambulatory Emergency Care website www.institute.nhs.uk/aec

Please visit the website for the latest ideas on AEC, join the discussion and actively contribute to the continued evolution of ambulatory emergency care.

If you would like information on the current cohort of the Ambulatory Emergency Care Delivery Network or future cohorts, please register your interest at www.institute.nhs.uk/aec

Further information and support for implementing

ambulatory emergency care

74

This Directory has been developed through the co-production process outlined by the NHS Institute for innovation and improvement work process. It is with the sincerest gratitude that we acknowledge the contribution from the NHS in England in assisting in the development of this Directory.

Individual contributions would be too numerous to acknowledge, but we would like to acknowledge everyone’s efforts in the creation of this publication.

Particular thanks must be given to Denise Blackman from East Kent Hospital NHS Foundation Trust for her invaluable and meticulous help with coding conditions correctly

Acknowledgements

If you require further copies contact: 01922 742 555 or [email protected] quoting ‘NHSIDQVDirectory – Ambulatory Care’

www.institute.nhs.uk/aecwww.institute.nhs.uk

© Copyright NHS Institute for Innovation and Improvement 2012

ISBN 978-1-907805-24-0

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