Same Day Emergency care (SDEC)

It has been recognised for many years that there is a growing pressure facing hospitals to treat increasing numbers of patients with increasingly complex needs at the same time as resources are getting increasingly stretched[i]. There is also an increasing realisation that treatment in hospital can be deleterious to some patients and may in fact cause harm[ii].

In 2013 The Royal College of Physicians Future Hospital Programme had a focus on care model design and aimed to deliver more acute treatment outside the hospital[iii].  It discussed a dedicated ambulatory care centre within the Acute Care Hub with dedicated resources.

Since then several key NHS documents also mention Ambulatory Care/SDEC;

• NHS England. Five year forward view 2014
• NHS Improvement 2017
• NHS Long Term Plan 2019
• NHSE Winter Plan 2021
• NHSE delivery plan for recovering urgent and emergency care services 2023
• NHSE winter plan 2023/4

The Ambulatory Care network was a key initiative in supporting hospitals to set up ambulatory care services. Initially this was focused around conditions such as pulmonary embolus, DVT, cellulitis and community acquired pneumonia, but the AEC directory quickly broadened its remit and the number of conditions grew. It was primarily directed at medical teams, but surgical teams also focused on conditions including renal colic and bladder outflow obstruction.

In 2017 a paper by Dan Lasserson[iv] outlined the evidence base for this approach and the different models used. Trusts all over the country were discussing the ways that their ambulatory teams were growing at meetings hosted by the Ambulatory Care Network.

As the service developed over the years, the hallmark remained the same, this service was to provide a service to look after patients who would have traditionally been admitted and who will sleep in their own bed.

In 2018 the name of Ambulatory Emergency Care (AEC) was switched to Same Day Emergency care (SDEC) despite the fact that many patients will need ongoing care /reviews given that the focus of the service is admission avoidance.

Trusts throughout the country continue to call their units by different names and in Scotland the service is known as Rapid Assessment and Care (RAC). For simplicity we have used the term SDEC/AEC to incorporate all services from this point

In 2024, the Society of Acute Medicine were open about concerns they had with a use of SDEC/AEC. Acute Medicine teams across the country were reporting that these units were being used to decant low risk patients from Emergency Departments rather than being used as a hospital admission avoidance. Furthermore, units were being bedded which prevented them being used to full capacity. Another common theme was that units were being discouraged to bring patients back and were being judged on the number of new attendances from the Emergency department. These concerns are discussed in more detail below.

The Society for Acute Medicine then wrote two documents to re-emphasize what the role of an SDEC/AEC was to help units “pause and reset”  ^{[v], [vi]}

Data

Up until this point it has been hard to review how many patients are flowing through SDEC/AEC and how many patients could have benefitted from this service. GIRFT have used zero day length of stay as a proxy figure. However, we recognise that many patients, especially those more vulnerable, who benefit from an SDEC/AEC service, may spend many days, weeks or even months in hospital if the opportunity to go to SDEC/AEC is missed at the beginning of their patient journey.

The Society for Acute Medicine has audited the use of SDEC/AEC as part of its national audit (SAMBA). The SAMBA audit looks at trusts all over the United Kingdom on a specified day (usually in June).

During this time the number of hospitals with an SDEC/AEC has increased, in 2018 it was 83%, in 2023 this was 98.6%

GIRFT found over 90% of SDEC/AEC are run by acute physicians.

As well as an increase in the number of hospitals with an AEC/SDEC service, SAMBA data also found that these units were seeing an increasing number of the acute admissions.

In 2018 18% of patients had their initial assessment in AEC/SDEC (figure 1)

Figure 1: Patients seen in SDEC/AEC 2017-2019

*In SAMBA18 only data for first clinical assessment was collected

This is a number that has increased over the years, and in 2023 35.5% of hospitals were achieving the target of seeing over a third of medical take via AEC/SDEC

 Whilst over 75% of acute hospitals have a service 12 hour 7 days a week service (the suggested national standard) there remains a large variation. In 2023 SAMBA data, 6% of units are open 24 hours, 7 days per week. It also showed that 25% of the take arrive to hospital between 8pm and 8am (figure 2). By arriving outside of the SDEC/AEC opening hours, this may mean eligible patients are not be able to access the SDEC/AEC service.

Figure 2: Finish time for accepting referrals 2023

Over the years the performance (against the SAM metrics) has consistency been better in AEC/SDEC areas for time to triage, initial clinical assessment and also consultant review compared to those arriving direct to the emergency department (ED) or admissions units (AMU). This was also seen when we performed a SAMBA in winter 2020 (figure 3)

Figure 3: Location and percentage of patients seen within target time by a consultant, (CQI3 = consultant review within 8 hours of arrival if arrive 8:00-18:00 or within 14 hours if outside these hours)

As services have been developed there has also been a variation with the way these units are run including; staffing models, patient selection and levels of complexity that can be dealt with.

Challenges

It hasn’t all been plain sailing. During COVID a lot of units were closed to make more space for COVID positive patients. Since that time “bedding” of SDEC areas has become a problem and a SITREP report conducted by the Society for Acute Medicine in 2024 showed that 44% of units that responded were bedded.

Other challenges have also caused issues for units. The enormous pressures facing the urgent and emergency care teams (In January more than 50,000 people waited more than 12 hours for a bed in the emergency department, In 2019 it was 627[vii]) has led to some units being used for inappropriate patients whose needs were best met elsewhere.

Targets to improve the number of patients being admitted, transferred or discharged within four hours from March 2024 put pressure on units to stream patients from the emergency department into SDEC/AEC. This carried the risk that inappropriate patients were being selected and the units were not able to be used for admission avoidance. The Society for Acute Medicine and the Royal College of Emergency Medicine worked together to create a document to outline the challenges and redefine the scope of SDEC/AEC ^vi.

We can also see from the figures above that the patients in SDEC/AEC are seen more quickly by both junior and senior staff. At the same time these patients are often the patients with the lowest NEWs scores (which usually but not always suggests lower acuity). This has led to some debate about whether we are deploying our staff correctly and whether we should indeed focus on those in areas where the acuity tends to be higher.

Follow up

Whilst it is possible for many patients to be managed the same day in units with slick radiology services and specialty input, a lot of our patients require follow up. In fact, those who we are truly avoiding admission and those vulnerable patients who get the most benefit nearly always need a follow up of some sort. Ideally, we could do this in the community, with domiciliary bloods or clinical review, but a lot of hospitals do not yet have this facility and therefore require a review of the patient in person. It is really important that this follow up service is seen as evidence of successful patient selection. The majority of these follow up reviews required clinician input as per SAMBA data (box 1)