Acute medical assessment units (AMAU) improve the efficiency in the admission process for unplanned patients by providing assessment, investigation and management of acute medical patients. The emergency department stay is eliminated or drastically reduced in this model of care. AMAU provide specialist physician assessment, review and evaluation of the patient at point of entry to hospital.

The AMAU at Wexford General Hospital conducted a rapid improvement event in June 2018 to improve patient flow through the department and improve patient experience time (PET) in accordance with the National Acute Medicine Programme (NAMP). 

In supporting the Ireland East Hospital Group (IEHG) unscheduled care programme, a key priority is the need to increase the flow of patients through and have a fully operational AMAU. In June 2018 the AMAU was open Monday to Friday 8am-9pm, with last patient admission by approximately 3pm. There were approximately 13 patients per day flowing through AMAU and the potential demand was found to be greater than available capacity.

Aims of the project

The aim was to improve the flow into and increase the flow of patients through AMAU. Specifically to:

• Identify staffing requirements for the 5/7 service operating 12-14 hours per day
• Determine the appropriate medical patient pathways to AMAU:

– GP direct to AMAU

– Direct admission to relocation of patients from ED to AMAU transfer, admission or discharge and related logistics

– Stream patients from out-of-hours CareDoc/GP from ED to AMAU where possible

• Meet critical AMP quality and safety indicators:

– First seen by a nurse (20 minutes) 

– First seen by a doctor (60 minutes)

– Six-hour patient experience time (discharge or admit)

– Admit/discharge rates.

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Methodology

As this required multidepartmental input and facilitation, a multidisciplinary meeting was held involving representation from AMAU, ED, cardiac diagnostics, radiology, physiotherapy, occupational therapy departments and all the consultant physicians at the hospital. All team members were spared from their respective duties for one week and sat in one room to assess the data.

Using lean methodology, wastes and gaps were identified in the processes. Data from the hospital and the National Acute Medical Programme was assessed. A plan was formulated to implement solutions and responsibility for this was assigned to the team members. 

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Results and discussions

A rapid experiment plan was undertaken. This involved a trial of seeing 17 patients per day and restructuring the unit with dedicated triage/assessment-only bays and an AMAU physician doing rounds in ED twice a day in order to ‘pull’ medical patients from the ED to AMAU.

This resulted in improved patient flow and patient experience times. It reduced waste of time and resources of medical and nursing staff. This action was continued. The AMAU clinical nurse manager attends ED every day to determine medical patients suitable for assessment in AMAU. The AMAU physician has IPIMS (Integrated Patient Information Management System) access to facilitate ‘pull’ of patients from ED. The triage and assessment bays have been maintained to improve first nurse and first doctor time. 

AMAU standard operation procedure (SOP) including inclusion/exclusion criteria in guidance with the NAMP has been implemented. Electronic documentation of clinical, nursing and allied health professionals has been initiated with guidelines for most common clinical presentations to standardise patient care. 

On the implementation of the above mentioned changes at the end of 90 days, it was observed that:

• The activity through AMAU increased by 31% 
• The patients pulled from ED increased from approximately 60 patients/month to 160 patients/month
• The first doctor time improved from 89 minutes to 53 minutes
• This resulted in generation of an additional €318,000 for the hospital.

Conclusion

The rapid improvement event was considered to be successful as it helped to reduce unnecessary burden on the nursing and medical staff. It helped to improve the number of assessments and allowed us to improve the quality of patient care. We realised that improved communication and departmental relationships improve performance of the unit. The multidisciplinary input was very positive. The flexibility in the culture of the department is paramount in achieving targets and goals. A solution-based approach was the key to success.

A poster based on this report was presented at Ireland East Hospital Group Adoption of LEAN in Healthcare Transformation Conference at Freeman Auditorium Mater Misericordiae University Hospital on April 4, 2019.