Introduction

This guide provides the core operating principles that should underpin extended emergency medicine ambulatory care (EEMAC) activity. These principles establish a consistent, structured approach to implementation of an EEMAC service that supports the national commitments in the 2025/26 Urgent and emergency care plan and aligns with the 10 Year Health Plan for England.

NHS England developed these principles in consultation with external stakeholders, including the Royal College of Emergency Medicine and the Society for Acute Medicine.

This guidance should be read alongside The Model Emergency Department: high performing urgent and emergency care pathways, which sets out the core principles and components of high-performing emergency departments.

By following these principles and leveraging best practices for same day discharge, hospitals can improve patient experiences and outcomes, enhance patient flow and reduce waiting times.

EEMAC adheres to the national same day emergency care (SDEC) principles outlined in the SDEC service specification and is designed for patients who require extended management by an emergency department (ED) clinician. These are patients who are unlikely to need an inpatient bed but do require timely access to senior clinical decision-making and diagnostics.

Context

EEMAC services are an emerging model of care being adopted by hospitals across England. While these services are currently delivered under a range of local names – such as ‘emergency medicine department same day emergency care’, ‘extended emergency care unit’ and ‘emergency assessment unit’ – they are all underpinned by the same day emergency care (SDEC) ethos. For clarity, this guide uses the term EEMAC for services delivered by emergency medicine teams and reserves SDEC for same day emergency care services delivered by inpatient medical and surgical specialties, including acute medicine.

Both clinical decision units (CDUs) and the emerging EEMAC models involve management of patients by emergency medicine teams but are otherwise distinct. CDUs typically operate as a step between the ED and an inpatient ward, with emergency medicine supporting patients who have already been assessed and require a short stay (up to 24 hours) for observation, additional tests or a decision regarding admission. The cohorts of patients suitable for an EEMAC model of care can be safely cared for in a streamlined same day assessment, treatment and discharge pathway.

Who is this guide for?

This guide is designed for providers, including:

• emergency department leaders (medical, nursing and operational leaders) considering implementing an EEMAC model
• hospital managers responsible for service implementation and resource allocation
• emergency department workforce (medical, nursing, allied health professions and administration) involved in patient triage, assessment and treatment

How to implement EEMAC successfully

• emergency department leadership team should establish the intended role and desired outcomes of EEMAC
• emergency department leadership team should ensure there is a well-understood model of emergency medicine, purpose and direction of travel
• Board-level medical, nursing and operational leadership should ensure multidisciplinary collaboration between local service teams
• emergency department clinical leaders and wider clinical teams should define clear patient pathways that align with the inclusion and exclusion criteria
• Estates teams and the ED team should together design the physical environment to optimise patient flow and comfort
• emergency department leadership team should establish a dedicated staffing model with appropriate clinical leadership
• Business intelligence and analytics teams should support the ED team to implement robust data recording practices for tracking and evaluating service performance

Core principles

These principles apply to patients who attend the ED with an acute presentation.

• this EEMAC model applies to adult patients only
• The term EEMAC applies to patients expected to be discharged on the same day and whose care can be concluded by the ED team within 8 hours of transfer to the EEMAC unit. Patients requiring longer periods of observation will usually require admission to an inpatient area (for example, a CDU or short-stay ward)
• in common with other forms of SDEC, some EEMAC patients will require hospital admission – between 5% and 15% is expected
• patients suitable for existing medical, surgical, frailty or other SDEC pathways should be managed within those pathways as usual

Inclusion criteria

• patients who at initial assessment or via the rapid assessment and treatment (RAT) process are classified as acuity 3 or 4. Some acuity 2 patients, depending on individual patient needs and local departmental factors
• patients requiring advanced diagnostics, for example, CT or MRI or troponin result and senior clinical decision-making, but who have a high likelihood of being discharged within 8 hours
• patients whose investigation, management and treatment of their clinical condition is likely to take more than 4 hours, but who are likely to be suitable for discharge within 8 hours

Exclusion criteria

• patients under the age of 16
• patients suitable for existing medical, surgical, frailty or other SDEC pathways should follow those established routes
• low-risk primary care presentations should be directed to urgent treatment centres (UTCs). Acuity 5 patients are excluded
• patients requiring resuscitation facilities, those who are clinically unstable or those with presentations highly likely to result in admission should remain in the ED or be directed to appropriate alternative assessment and inpatient pathways
• patients with an acute mental health crisis who are at risk to themselves or the public or who are likely to require a medical or mental health admission
• patients who are acutely confused or intoxicated
• patients who are awaiting discharge or transfer; an EEMAC area is neither a discharge lounge nor an ‘overflow’ unit for other services
• patients awaiting admission to an inpatient bed
• patients who are being transferred from the ED without a valid clinical reason, where the only benefit from doing so would be to improve service time-based metrics – that is, the 4-hour standard
• patients requiring planned care (for example, follow-up or hot clinic activity)

Location and environment

• EEMAC should ideally be co-located with ED but not within the ED footprint
• this estate should not be used for additional inpatient capacity or as an escalation space as part of a full capacity protocol
• the environment should be designed as an ambulatory clinic model, with chairs and minimal reliance on trolleys promoting efficient patient turnover. Comfortable waiting areas with access to refreshments should be available, and all other estate requirements should comply with the standards set out in the SDEC specification
• patients should have access to toilet facilities
• there should be no thoroughfare for staff or the public
• EEMAC facilities and estate should not compromise delivery of existing SDEC services or the ED.
• there should be provision for private discussions with patients, and the design of examination facilities should ensure patient comfort and support patient mobility (for example, access to recliner chairs and trolleys)

Staffing and process

• the EEMAC area should have dedicated staffing, including a designated senior clinical decision-maker available during opening hours to ensure patient safety and maintain flow by ensuring rapid assessment and decision-making. There should be a separate, dedicated staff roster for EEMAC that includes, but is not limited to, senior decision-makers, medical and nursing staff, supported by administrative and operational support staff
• investigation and diagnostic turnaround times must be the same as for the ED
• all patients must have observations recorded at initial assessment to support assessment of acuity before transfer to the EEMAC area
• patients should be transferred to the EEMAC area as soon as possible after initial assessment
• patients who deteriorate while in EEMAC should be returned to the ED, following the hospital’s local standard process used in other specialty SDEC areas. Patients requiring admission should only remain in EEMAC while they wait for a bed and only if bed allocation is anticipated within the 8-hour time standard

Recording activity

EEMAC activity should be recorded in trust data and reported via the Emergency Care Data Set (ECDS). EEMAC activity and patients must be distinguishable from the rest of ED activity and patients in this data.

A counting and coding review of A&E activity is expected to be completed in the first quarter of 2026/27. This will advise on the detail of reporting EEMAC activity and counting and coding guidelines for performance management and reporting. Trusts are likely to be asked to record type 5 activity on ECDS to report EEMAC activity, but this has yet to be confirmed.

Measurement resource

The standards and metrics that apply to EEMAC activity are the same as those for SDEC activity:

1. The time spent in the ED or UTC before transfer to EEMAC should be kept to a minimum.

2. Activity in EEMAC must be protected, including during periods of escalation when the hospital is under pressure. Loss of this activity will likely increase pressure.

3. Waiting times for patients in EEMAC should be minimised.

• observations contributing to a NEWS2 score (National Early Warning Score version 2 – a system to standardise response to acute illness) should be obtained within 15 minutes of a patient’s arrival
• patients who have not already been assessed should be seen promptly (within 60 minutes) by a clinician capable of assessing and investigating their signs and symptoms

4. A discharge summary should be written and sent to the patient’s GP on the day the episode of care is completed. This should detail the investigations undertaken, any new therapies instigated and the follow-up plan.

5. Patients should not remain in the EEMAC service for longer than 8 hours.

Publication reference: PRN02374