Leading change

The Senior Sister, Practice Educator and Lead Surgical Emergency Nurse Practitioner in the Surgical Assessment Unit (SAU) at Portsmouth Hospitals NHS Foundation Trust have collaborated to implement a new ambulatory care model. The programme has led to improved outcomes, experiences and use of resources within the hospital.

Where to look

NHS Improvement (2018) provide information and resources for Trusts to support colleagues to improve quality, effectiveness and productivity across same day emergency care and acute frailty care service provision. Ambulatory care is the provision of same day emergency care for patients being considered for emergency admissions on an outpatient basis. The NHS Improvement guide highlights the value of ambulatory emergency care (AEC) and same day emergency care (SDEC) in streamlining clinical processes, so that patient care can be delivered on the same day, reducing admissions and reliance on hospital beds — to improve patient flow. Much of the growth in admitted, non-elective activity is for patients who spend 1-2 days in hospital. Whilst it is a relatively new care model, the AEC/SDEC aims to minimise and remove delays in the patient pathway.

The SAU team observed that although an ambulatory care environment was available, current practice did not always support this model of working. For example, the ward hadn’t adopted nurse-led discharge and allocated investigation time slots weren’t real-time available. There was unwarranted variation in practice. The Lead Surgical Emergency Nurse Practitioner identified an opportunity to support the team to implement the new ambulatory care models on the unit.

What to change

Portsmouth Hospitals NHS Trust is a large district general hospital providing comprehensive acute and specialist services. The SAU is a 28-bed acute admissions ward with a recently added ambulatory unit compromising of a 3-bed assessment bay, treatment room and waiting area. Ambulatory allows patients to be assessed, investigated and diagnosed, with a treatment plan established. This can include onward referral General Practice, other hospital wards, specialist services and outpatient clinics. Admission to the unit is possible as needed, but largely, the clinical pathway supports triage to other, appropriate services.

A review of the ambulatory care models’ literature, including current guidance was conducted. A project team of a ward sister, nurse practitioner and led by the practice educator was established. Supported by the Foundation of Nursing Studies, patient feedback was collected via patient diaries, phone call feedback, and patient focus groups. This informed the status in the unit regarding processes and pathways and where improvements could be made.

How to change

The information demonstrated that the following actions were needed to facilitate ambulatory care within the unit:

1. Improve the patient environment to include updating the facilities in the waiting area, patient information posters, and information leaflets;
2. Ensure a Registered Nurse was rostered specifically to Ambulatory care;
3. Development of documentation to support the ambulatory unit, including the initial assessment sheet, a Right Iliac Fossa pathway and ambulatory clerking proforma;
4. Rostering of a designated Surgical Registrar to be available for prompt review of patients within ambulatory care;
5. Liaison with Ultrasound scan and X-ray department to allow for designated time slots to reduce patient waiting times;
6. Increase ward clerk hours to support the fast pace of care in the SAU;
7. Increase operating hours of the Ambulatory care unit from 09:00–17:00 Monday to Friday to 08:00–20:00 7 days a week; and
8. Introduction of a twilight shift of the nurse practitioner (to 23:00hrs) to ensure the safety of patients awaiting investigations and decisions after 8pm.

Adding value Better

Better outcomes – An initial strength of the programme is increased awareness of the individualised ambulatory pathway. This is supported across the nursing and medical multidisciplinary team by relevant patient information leaflets, and improved communication. A post implementation audit has shown that the new way of working is showing signs of:

• Reductions in time waiting for assessment, plan and review of patients;
• Reductions in wait times for pain relief due to the new initial assessment documentation which allows for the prompt prescribing and the designated registered nurse to administer;
• Increased numbers of patients seen, assessed, treated and discharged through SAU Ambulatory;
• Reductions in wait times for Ultrasound scans;
• Planned reassessment times for appropriate patients are preventing unnecessary hospital in-patient stay and streamlined care;
• Improved links with Day Surgery is minimising a need for an in-patient stay;
• Reductions in patient complaints and increase in compliments; and

Better experience – Friends and Family test feedback forms indicate this has been welcomed by staff and patients. This feedback will be collated routinely to adapt the evolving service to meet patient needs. This positive feedback is also reflected regarding overall experiences and the levels of information provided during their treatment.

Better use of resources – The streamlined ambulatory service now means patients can be seen in a timely way, receive high-quality care and be discharged home on the same day, where possible. The use of designated roles within ambulatory care has been beneficial. Recent figures of Ambulatory in December 2018 – January 2019 (2 months) showed that 900 patients were seen and 236 (26%) were admitted to SAU or other wards. A significant 664 (74%) were discharged home with either no need for ongoing care, for further review or further out patient investigation.

Challenges and lessons learnt for implementation

Ensure that all members of the ward team feel part of the project and change. This was achieved by regular meetings with the steering group (ward sister, nurse practitioner, practice educator, staff nurse and health care support worker) and effective communication via a newsletter to all clerical and nursing members of the team.

Remember the importance of patient and staff experience when implementing improved processes.

Having a flexible approach in the project team helps, as well as utilising all the individual skills within the department, to ensure project success.

Next steps are towards establishing a fully nurse-led unit.

For more information contact

Rachael Wheeler
Lead Surgical Emergency Nurse Practitioner
Portsmouth Hospitals NHS Foundation Trust
Rachael.wheeler@porthosp.nhs.uk