Working in ambulatory care
I am going to share my experience of working in ambulatory care.
Some useful links:
https://www.ambulatoryemergencycare.org.uk/
https://improvement.nhs.uk/resources/ambulatory-emergency-care-guide-same-day-emergency-care-clinical-definition-patient-selection-and-metrics/
Please note that each trust has its own pathways, guidelines and which patients are acceptable for the ambulatory pathway.
The team- This varies from trust to trust and how big the ambulatory care unit is.
1. HCA who can do cannulas, bloods, ECGs.
2. Nurse who runs ambulatory care unit.
3. ACP - This stands for advanced clinical practioner.
Their role is explained here: https://www.nhsemployers.org/your-workforce/plan/workforce-supply/education-and-training/advanced-clinical-practice
4. SHO
5. Registrar
6. Consultant.
Some units have additional team members like:
1. Occupational therapists
2. Physiotherapists
These are mainly in Elderly ambulatory units.
The process of admission to the ambulatory unit varies from trust to trust.
In some trusts, the consultant takes phone calls from ED, GPs and outpatient clinics to accept patients.
In other trusts, the ED team discusses referrals with the doctors/ACPs who then accept the patient.
The usual criteria for ambulatory care is:
1. Can the patient walk in an out of the unit in a day
2. Is the patient hemodynamically stable.
3. Is the patient low risk
4. Does the patient meet the local trusts ambulatory pathway criteria?
The timing of ambulatory units vary from trust to trust- some are from 0900 to 2100 and some run 24 hours a day with rotation of shifts at 0900 and 2100.
The doctors role in ambulatory care:
1. Take a history, examine the patient and request the necessary investigations.
2. Chase the results and make a management plan
3. Request the consultant to see the patient ( ONLY if necessary/ as per trust policy - in some trusts, the 'pathway' patients do not need to be seen by a consultant unless they are complicated/ the team is concerned about anything).
4. Discharge the patient with/without a follow up plan and further investigations - ie, make a discharge summary with all these details.
5. If there is a follow up plan, add the details of the patient to the follow up list ( it may be a matter of sticking an ID sticker in the diary or doing it electronically).
I am going to discuss the cases I have seen in ambulatory care unit, system wise.
CNS
Headache ? SAH
This varies from trust to trust but if they meet the criteria for lumbar puncture, you can easily do it in the ambulatory care unit. I have explained this in more detail here:
https://omarsguidelines.blogspot.com/2020/04/common-emergencies-i-see-on-acute-take.html
Tips:
If the patient is unable to walk into the unit with a severe headache, it will be very unlikely that they will be able to be discharged. It is best to admit them to the acute medical unit for a lumbar puncture and analgesia otherwise they will bounce back immediately.
TIA?
This varies from trust to trust. In some trusts, the patients presenting to ED are sent home with necessary medications, out patient requests to return to the stroke clinic within a day or 2.
In some trusts, the ED team sends the patients to ambulatory care unit immediately so that they can have the necessary investigations and then referred to the appropriate teams if necessary ( ie vascular team if they have significant carotid stenosis ).
Tip:
Follow your trusts protocols.
Never forget to give treatment ( primary and secondary prevention) and request the necessary investigations.
RESPIRATORY
Chest pain? PE
These patients are hemodynamically stable with normal ECGs.
They follow the PE pathway - ie Wells score, routine bloods including D dimer, CXR and then have treatment ( treatment dose low molecular weight heparin) and then are booked for a CTPA the same day/ discharged and then come for a CTPA in a day.
PE's can be provoked or unprovoked. The treatment duration is different for each ( however this may vary from trust to trust)
Tip:
Do not discharge a patient who has any red flags - ie blood pressure has dropped by more than 40/20mmhg ( and may be a candidate for thrombolysis/ high risk), ongoing chest pain, requiring oxygen.
If you are worried - admit them. PE's kill!
There is a clear ambulatory pathway for PE's - follow it.
Think about the possible provoking factors - undiagnosed malignancy is one of them and can be missed. Hence, ask about features of malignancy and examine the patient thoroughly. If there are red flag features ( like weight loss, strong family history, a CT chest, abdomen and pelvis with contrast may be indicated- it might be worth discussing whether the radiology consultant is happy to do both CT PA and CT TAP at the same time- they do have different modes though however some consultants in my trust have agreed to do it and we have been able to find an underlying malignancy and referred the patient to the urgent cancer care services the same day)
CARDIAC
Chest pain? trop, D Dimer negative. Refer to ambulatory care for repeat trop.
This is a very common scenario.
The most important thing is taking a history, examining the patient, doing a CXR, bloods including first and second ( if indicated) troponin, calculating their risk score ( GRACE vs TIMI) and then either discharging them, admitting them to CCU or referring them to the cardiology team as O/P with necessary investigations ( eg- rapid access chest pain clinic).
Tips:
1. ALWAYS look at the ECG carefully - even if they have come from ED.
2. History is very important, if it sounds ischemic, do not take it lightly.
3. Calculate the risk score - TIMI, GRACE or whatever policy our trust has.
4. Think about common differentials - PE being one of the most common causes ( Doing a D dimer, calculating the Wells score might help).
5. Wait for the repeat trop.
I have seen missed STEMIs and a trop rise from 4.9 to 500 in a fit and well middle aged gentleman walking about in the waiting room. Hence be very careful in taking a detailed, relevant history, looking at the ECG and WAITING for the results to come back.
DVT
Every ambulatory unit has its own DVT pathways. Some acute physicians are trained to do bed side ultrasounds and rule in DVTs ( https://www.acutemedicine.org.uk/what-we-do/training-and-education/famus/ ).
This is an excellent opportunity to learn doing ultrasounds. However remember that you still need a formal USS scan unless the AMU consultant is very confident that it is not needed.
This is a typical case:
Right leg painful swelling after long haul flight.
Such patients have the usual routine bloods done ( FBC, U and E's , CRP , coagulation profile ) plus a D dimer.
A detailed history and examination is important - like PE's, it is important to find out whether these are provoked or unprovoked.
Such patients, like PEs either have treatment and a USS scan the same day or treatment on that day and a USS scan the following day.
Tips:
Remember that a DVT can lead to a PE. Ask about symptoms of PE. Do an ECG to check for right heart strain if there are any concerns and request a CTPA.
Think of common differentials - cellulitis, ruptured bakers cyst.
If bilateral, it could be heart failure - follow the pathway for that ( https://pathways.nice.org.uk/pathways/acute-heart-failure )
A DVT may occur in the arms as well - differentials of this may include axillary lymphadenopathy secondary to tumor therefore do not forget to examine the lymph nodes.
CELLULITIS
There is a clear ambulatory pathway for cellulitis in each trust.
The common scenario is :
Erythematous left leg which is painful.
This is what we usually do:
Detailed history and examination
Bloods including blood cultures.
Ask about allergies and prescribe the appropriate antibiotics as per ambulatory pathway if the history, examination and bloods suggest that it is cellulitis.
If they need IV antibiotics, such patients are usually discharged if they are safe to go home and come in again the following day for another shot of IV antibiotics - but this varies from trust to trust.
Tips:
Remember to do blood cultures- this is very important!
Patients who are able to walk into the ambulatory unit may still become very unwell- if you are worried about sepsis, admit them. Remember, sepsis kills!
The team- This varies from trust to trust and how big the ambulatory care unit is.
1. HCA who can do cannulas, bloods, ECGs.
2. Nurse who runs ambulatory care unit.
3. ACP - This stands for advanced clinical practioner.
Their role is explained here: https://www.nhsemployers.org/your-workforce/plan/workforce-supply/education-and-training/advanced-clinical-practice
4. SHO
5. Registrar
6. Consultant.
Some units have additional team members like:
1. Occupational therapists
2. Physiotherapists
These are mainly in Elderly ambulatory units.
The process of admission to the ambulatory unit varies from trust to trust.
In some trusts, the consultant takes phone calls from ED, GPs and outpatient clinics to accept patients.
In other trusts, the ED team discusses referrals with the doctors/ACPs who then accept the patient.
The usual criteria for ambulatory care is:
1. Can the patient walk in an out of the unit in a day
2. Is the patient hemodynamically stable.
3. Is the patient low risk
4. Does the patient meet the local trusts ambulatory pathway criteria?
The timing of ambulatory units vary from trust to trust- some are from 0900 to 2100 and some run 24 hours a day with rotation of shifts at 0900 and 2100.
The doctors role in ambulatory care:
1. Take a history, examine the patient and request the necessary investigations.
2. Chase the results and make a management plan
3. Request the consultant to see the patient ( ONLY if necessary/ as per trust policy - in some trusts, the 'pathway' patients do not need to be seen by a consultant unless they are complicated/ the team is concerned about anything).
4. Discharge the patient with/without a follow up plan and further investigations - ie, make a discharge summary with all these details.
5. If there is a follow up plan, add the details of the patient to the follow up list ( it may be a matter of sticking an ID sticker in the diary or doing it electronically).
I am going to discuss the cases I have seen in ambulatory care unit, system wise.
CNS
Headache ? SAH
This varies from trust to trust but if they meet the criteria for lumbar puncture, you can easily do it in the ambulatory care unit. I have explained this in more detail here:
https://omarsguidelines.blogspot.com/2020/04/common-emergencies-i-see-on-acute-take.html
Tips:
If the patient is unable to walk into the unit with a severe headache, it will be very unlikely that they will be able to be discharged. It is best to admit them to the acute medical unit for a lumbar puncture and analgesia otherwise they will bounce back immediately.
TIA?
This varies from trust to trust. In some trusts, the patients presenting to ED are sent home with necessary medications, out patient requests to return to the stroke clinic within a day or 2.
In some trusts, the ED team sends the patients to ambulatory care unit immediately so that they can have the necessary investigations and then referred to the appropriate teams if necessary ( ie vascular team if they have significant carotid stenosis ).
Tip:
Follow your trusts protocols.
Never forget to give treatment ( primary and secondary prevention) and request the necessary investigations.
RESPIRATORY
Chest pain? PE
These patients are hemodynamically stable with normal ECGs.
They follow the PE pathway - ie Wells score, routine bloods including D dimer, CXR and then have treatment ( treatment dose low molecular weight heparin) and then are booked for a CTPA the same day/ discharged and then come for a CTPA in a day.
PE's can be provoked or unprovoked. The treatment duration is different for each ( however this may vary from trust to trust)
Tip:
Do not discharge a patient who has any red flags - ie blood pressure has dropped by more than 40/20mmhg ( and may be a candidate for thrombolysis/ high risk), ongoing chest pain, requiring oxygen.
If you are worried - admit them. PE's kill!
There is a clear ambulatory pathway for PE's - follow it.
Think about the possible provoking factors - undiagnosed malignancy is one of them and can be missed. Hence, ask about features of malignancy and examine the patient thoroughly. If there are red flag features ( like weight loss, strong family history, a CT chest, abdomen and pelvis with contrast may be indicated- it might be worth discussing whether the radiology consultant is happy to do both CT PA and CT TAP at the same time- they do have different modes though however some consultants in my trust have agreed to do it and we have been able to find an underlying malignancy and referred the patient to the urgent cancer care services the same day)
CARDIAC
Chest pain? trop, D Dimer negative. Refer to ambulatory care for repeat trop.
This is a very common scenario.
The most important thing is taking a history, examining the patient, doing a CXR, bloods including first and second ( if indicated) troponin, calculating their risk score ( GRACE vs TIMI) and then either discharging them, admitting them to CCU or referring them to the cardiology team as O/P with necessary investigations ( eg- rapid access chest pain clinic).
Tips:
1. ALWAYS look at the ECG carefully - even if they have come from ED.
2. History is very important, if it sounds ischemic, do not take it lightly.
3. Calculate the risk score - TIMI, GRACE or whatever policy our trust has.
4. Think about common differentials - PE being one of the most common causes ( Doing a D dimer, calculating the Wells score might help).
5. Wait for the repeat trop.
I have seen missed STEMIs and a trop rise from 4.9 to 500 in a fit and well middle aged gentleman walking about in the waiting room. Hence be very careful in taking a detailed, relevant history, looking at the ECG and WAITING for the results to come back.
DVT
Every ambulatory unit has its own DVT pathways. Some acute physicians are trained to do bed side ultrasounds and rule in DVTs ( https://www.acutemedicine.org.uk/what-we-do/training-and-education/famus/ ).
This is an excellent opportunity to learn doing ultrasounds. However remember that you still need a formal USS scan unless the AMU consultant is very confident that it is not needed.
This is a typical case:
Right leg painful swelling after long haul flight.
Such patients have the usual routine bloods done ( FBC, U and E's , CRP , coagulation profile ) plus a D dimer.
A detailed history and examination is important - like PE's, it is important to find out whether these are provoked or unprovoked.
Such patients, like PEs either have treatment and a USS scan the same day or treatment on that day and a USS scan the following day.
Tips:
Remember that a DVT can lead to a PE. Ask about symptoms of PE. Do an ECG to check for right heart strain if there are any concerns and request a CTPA.
Think of common differentials - cellulitis, ruptured bakers cyst.
If bilateral, it could be heart failure - follow the pathway for that ( https://pathways.nice.org.uk/pathways/acute-heart-failure )
A DVT may occur in the arms as well - differentials of this may include axillary lymphadenopathy secondary to tumor therefore do not forget to examine the lymph nodes.
CELLULITIS
There is a clear ambulatory pathway for cellulitis in each trust.
The common scenario is :
Erythematous left leg which is painful.
This is what we usually do:
Detailed history and examination
Bloods including blood cultures.
Ask about allergies and prescribe the appropriate antibiotics as per ambulatory pathway if the history, examination and bloods suggest that it is cellulitis.
If they need IV antibiotics, such patients are usually discharged if they are safe to go home and come in again the following day for another shot of IV antibiotics - but this varies from trust to trust.
Tips:
Remember to do blood cultures- this is very important!
Patients who are able to walk into the ambulatory unit may still become very unwell- if you are worried about sepsis, admit them. Remember, sepsis kills!
ASCITIC FLUID DRAIN
Some patients with decompensated liver disease attend O/P clinics to get an ascitic drain. This could be ambulatory care or a gastroenterology ward.
I have mentioned this procedure here:
https://omarsguidelines.blogspot.com/2020/02/procedures-sho-is-expected-to-do-in-nhs.html
Tips:
Follow your trusts guideline.
Read the old letters to check what protocols to follow.
Remember to sort out human albumin solution if the patient has decompensated chronic liver disease.
OTHER PRESENTATIONS
These may include syncopal episodes, dehydration, falls ( these mainly go to the elderly ambulatory unit- if there is a department like this in the trust)
In some trusts ambulatory care may be coupled with routine O/P management like
- Intravenous immunoglobulins for neurological conditions
- Intravenous fluids for hypercalcaemia
- IV electrolyte replacement
- Pre-contrast and post contrast hydration for a CT scan with contrast in patients who are at high risk of developing acute kidney injury.
- Benign intracranial hypertension lumbar puncture to remove CSF ( The neurology letters will clearly state how much needs to be removed)
Important things I have learnt when doing ambulatory clinics.
The cohort of cases you get depends on the trusts guidelines and what sort of consultant you have - I worked with an amazing acute medical consultant who used to check the ED list himself and fish out appropriate patients and used to ask the SHOs to clerk them, request the relevant investigations, oversee them examining the patient, discuss the case with him and sign their case based discussions, mini-CEX, SLEs in their e portfolios.
Some registrars, ACPs and nurses in charge are equally active and this helps improve patient flow and avoiding unnecessary admissions.
Make discharge summaries as you go along- do not wait till the end of the day to make the discharge summaries. I usually do them as soon as I have clerked the patient.
Update the nurse in charge. In most trusts, there is a 'board round' every few hours so that the whole team is updated. In some trusts, there is a white board which the team needs to update as soon as they have seen a patient. Either way, keep the team updated on a regular basis.
Inform the team if the patient needs to be followed up the following day/in a few weeks.
Ambulatory care is all about effective communication.
Some patients with decompensated liver disease attend O/P clinics to get an ascitic drain. This could be ambulatory care or a gastroenterology ward.
I have mentioned this procedure here:
https://omarsguidelines.blogspot.com/2020/02/procedures-sho-is-expected-to-do-in-nhs.html
Tips:
Follow your trusts guideline.
Read the old letters to check what protocols to follow.
Remember to sort out human albumin solution if the patient has decompensated chronic liver disease.
OTHER PRESENTATIONS
These may include syncopal episodes, dehydration, falls ( these mainly go to the elderly ambulatory unit- if there is a department like this in the trust)
In some trusts ambulatory care may be coupled with routine O/P management like
- Intravenous immunoglobulins for neurological conditions
- Intravenous fluids for hypercalcaemia
- IV electrolyte replacement
- Pre-contrast and post contrast hydration for a CT scan with contrast in patients who are at high risk of developing acute kidney injury.
- Benign intracranial hypertension lumbar puncture to remove CSF ( The neurology letters will clearly state how much needs to be removed)
Important things I have learnt when doing ambulatory clinics.
The cohort of cases you get depends on the trusts guidelines and what sort of consultant you have - I worked with an amazing acute medical consultant who used to check the ED list himself and fish out appropriate patients and used to ask the SHOs to clerk them, request the relevant investigations, oversee them examining the patient, discuss the case with him and sign their case based discussions, mini-CEX, SLEs in their e portfolios.
Some registrars, ACPs and nurses in charge are equally active and this helps improve patient flow and avoiding unnecessary admissions.
Make discharge summaries as you go along- do not wait till the end of the day to make the discharge summaries. I usually do them as soon as I have clerked the patient.
Update the nurse in charge. In most trusts, there is a 'board round' every few hours so that the whole team is updated. In some trusts, there is a white board which the team needs to update as soon as they have seen a patient. Either way, keep the team updated on a regular basis.
Inform the team if the patient needs to be followed up the following day/in a few weeks.
Ambulatory care is all about effective communication.
Ambulatory clinic is an excellent way of getting assessments done. The nurses are very friendly and pro-active ( they will even set up trolleys for procedures). So treat them with respect and even teach them as well.
Never ever take any chances! If you are concerned, admit the patient.
Ideally, there should be consultant cover for the whole duration ambulatory care is running. If there is no consultant present, always ask for advice by contacting the medical on call consultant ( Some trusts may have an ambulatory consultant on call - follow your trusts policy).
Each trust has its own way of running ambulatory care. So do not assume that the protocols, patients which are acceptable will be the same everywhere.
Contact the respective specialty teams when concerned - ie, neurology for benign intracranial hypertension cases when the letters are not very clear, gastro team for complicated ascetic fluid drainage, etc.
ACPs are excellent clinicians. Teach them, show them how you do procedures and listen to them when they are concerned about a patient. Some ACPs have been working in ambulatory care for months and may know more than us doctors and can be extremely helpful in escalating any issues when the consultant is not available.
This is in no way a complete guide and this is just to give doctors an idea of what it is like working in ambulatory care.
Some useful links:
https://www.ambulatoryemergencycare.org.uk/
https://improvement.nhs.uk/resources/ambulatory-emergency-care-guide-same-day-emergency-care-clinical-definition-patient-selection-and-metrics/
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