ED attendance and admissions avoidance

ED Attendance/Admission
Miss Ruchi Joshi, Clinical Director
– Emergency and Acute Care
24 September 2014
• In the last few years, there has been exponential rise
in the acuity of patients attending ED
• There is increased attendance of elderly patients
attending ED with complex medical and social
• There is evidence of confusion amongst patients as to
which service suits them best
• Increased patient expectations – ‘1 stop shop’
• 2013 – a record 24 million people attended ED with up
to ¼ saying that they were there because they could
not get a GP appointment (Imperial College London)
• Unplanned attendance/admission is seen
as a sign of community failure by DOH
• It is seen as a sign that the health of
community in general is not good
• The present tariff system is not fit for
purpose – although out of hours service is
provided at premium rates, the tariff does
not reflect that. Hence ED is set up to fail
as a business
Recent Study
• University of Bristol – 24 July 2014 –
attendances at EDs can be reduced by
enabling patients to see the same GP
everytime they visit their doctor’s surgery
(result in published in open access journal
–BMJ open, and was carried out in
collaboration with Universities of
Manchester, Oxford and UCL
Further Factors Affecting ED
• How easy is it for patients to access the
GP surgery and primary care provider
• The distance the patient lives away from
the ED
• The number of confusing options patients
have for accessing emergency care
Suggestions from Kings Fund
• Admission amongst people with long term
conditions that could have been managed in
primary care costs the NHS £1.4 billion per year.
This could be reduced up to 18% through
investment in primary and community based
• Providing continuity of care and making it easier
for patients to get access to their GPs can help
achieve this reduction in unplanned
• Targeted increase in continuity of care by GPs,
with special reference to nursing/residential homes
Overcrowding in ED
• Increased alcohol and mental health
• Increased re-attendance rate
• Increased failed discharges
• Path of least resistance – ED is seen as a
path of least resistance by patients
Knock on Effect
• Overcrowding in ED results in poor quality
and standard of care provided to the patient.
It leads to safety issues within the department
• It also has a knock on effect on the rest of the
organisation, i.e. regular theatre lists get
cancelled leading to failure of the targets
• Patients are admitted in the wrong place on
the wrong wards resulting in safety concerns
Example 1
• Patient (DH)
• 24 ED attendances since January 2014
• Out of 24 attendances, there were 4
• Presenting condition – abdominal pain
• Patient has had a diagnosis of
pancreatitis. ? How should she be
Example 2
Patient (DH)
5 ED attendances since March 2014
On all 5 attendances he was admitted
Presenting condition – chest pain
? Patient education and expectation is not
being dealt with adequately and
Example 3
• Patient (TW)
• 31 ED attendances since April 2014
• Out of the 31 attendances she was admitted
on 3 occasions
• Presenting conditions – chest pain/abdominal
• She is an IVDU and she presents with vague
and non-specific symptoms
• ? Who should be managing her
Example 4
• Patient (JR)
• 14 ED attendances since January 2014
• Out of the 14 attendances, on 5 occasions
he was admitted
• Presenting conditions ?overdose/intoxication/withdrawal/vomiting
• The patient does not engage with any of
the services offered to him
Example 5
Patient (JD)
8 attendances to ED since January 2014
Out of the 8 attendances, 5/8 admissions
Presenting conditions – overdose/self
harm/abdominal pain
• The patient suffers with mental health
problems and frequents ED
Inappropriate Referrals to ED from
the Walk in Centre
• CWS – had cauterisation of nose at BCH for
recurrent epistaxis
• Second post-operative day, Mum took patient to
Walk in Centre due to crusting around the nasal
• Walk in Centre referred to the ED for ? Infection
• Ideally the patient goes back to BCH for postoperative complication or the patient is referred to
• Sending to the ED should not be the option
Walk in Centre
Inappropriate referrals example:• A well patient with a history of 4 day diarrhoea was
referred to ED at the weekend for renal function
tests. No history of vomiting. The patient was
eating, drinking and well hydrated.
• Inappropriate referral to ED
• Also the walk in centre doctor told the patient that
ED will do blood tests, hence the expectation by
the patient that he will have his bloods checked.
• This further embeds false expectations amongst
Walk in Centre
• A patient visited the Walk in Centre during
lunchtime because she had taken a few
tablets of Lorazepam the night before due
to stress
• The patient was referred to ED for ?
Management of Lorazepam overdose and
? referral to mental health services
• This patient could have been managed in
the community by the mental health team
Alcohol Re-attendances
What have we done so far:• The top 10 alcohol re-attendances and readmissions – a letter has been sent to their
GP, the Commissioner for Alcohol, and
• I would like to arrange a multi-disciplinary
meeting which should involve the patient and
his/her family, GP, Addaction Services,
Mental Health Services
• A management plan should be written up
Chronic Disease managementintegration of community services.
• Re-attenders with chronic conditions are identified by
the community services – Donna Chaloner is working
on this
• Multi-disciplinary team approach (Community Nurse,
GP and Secondary Care Consultant) should be
involved in active management of such patients to
prevent acute exacerbations their chronic conditions
• Her plan is to continue with the analysis of data and
also to develop a database specifically for patients
with long term conditions. This will ensure that all
community teams have an active caseload of patients
that are known to have frequent re-admissions
How can we support GPs?
• AMU telephone line
• Access to Ambulatory care: the Ambulatory
team would like to offer their services to the
GPs between the hours of 10am to 4pm via
the bleep number 2039 held by the
dedicated Ambulatory nurse
• Access to hot clinics, i.e. gastro, respiratory,
• Access to On-call Specialist Consultant
• Timely sharing of good quality information.
Future Plans
• As per the Bruce Keogh report, plans to be
made for elderly patients. This will reduce
multiple admissions into the hospital.
• Amalgamation of all urgent care services,
i.e. ED/Urgent Care Centre/Walk in
Help From DOH
• Department of Health to change the way
that commissioning is done
• Department of Health and Government to
address patient expectations
• Patient education – both in primary and
secondary care

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