Dr Darren Leech  Director, NHS Elect

At the BADS conference this year, ambulatory care in surgery was a hot topic¹. It is increasingly recognised that safeguarding an effective and efficient ambulatory care service - both medical and surgical - is a key step towards any hospital ensuring sustainable patient flow for urgent and emergency care patients².

With an updated directory of ambulatory sensitive emergency conditions³, an ambulatory model of care is something that many hospitals are currently looking to introduce, or to develop further.

Clinical teams already running ambulatory care services have previously cited the ‘invasion and closure’ of their units as a risk to service continuity and quality. Typically, a depressing pattern of overnight invasion and incremental retreat the following day occurs. Of course, all hospitals face ‘peaks and troughs’ in demand, on a fairly predictable basis. Operationally, clear plans are needed to deal ‘everyday business’ along with ‘escalation plans’ for situations where demand and flow conspire to cause problems. Of course, clinicians need to influence both ‘everyday business’ and the process of escalation by engaging in the design and review of policy and practice at their hospitals.

Clinicians determined to ‘protect’ precious ambulatory care areas may be interested in a series of practical design ‘tips’ for the built environment, developed by the Ambulatory Emergency Care (AEC) network⁴. Derived from experiences across a broad range of hospital sites, the primary objective of these straightforward measures is to help safeguard the provision of ambulatory emergency care and in doing so, support the effective flow of emergency patients in hospitals.

The design ‘tips’ are as follows;

• Use recliner chairs and trolleys, not beds (the greater the proportion of chairs, the better)
• Ensure any space designated for a chair or trolley space, is smaller than that required for a hospital bed
• Reduce the width of access doorways, to allow the safe entry and exit of mobile, wheelchair and trolley bound patients but not those in hospital beds
• Use partial partitions, not curtains and remove curtain tracking
• Use clinic rooms for consultation and examination wherever possible, to maintain privacy and dignity
• Ensure that lighting is configured in such a way that all lights are either ‘off’ or ‘on’ - preventing the use of dimmers or zoned lighting commonly used in areas where patients sleep
• Aim for open plan design, ensuring ambulatory care areas are as flexible as possible in terms of the location and ratio of chairs and trolleys
• Restrict key-holding wherever possible
• Decorate (or redecorate) the area in the style of a clinic, not a ward - for example look at Dialysis or Macmillan Units
• Create a clear external AEC Unit entrance that is well signposted
• If possible, avoid connecting thoroughfares from/to wards and wherever possible, corridors through which beds are routinely transported
• Use cylinders for medical gas supply rather than piped gases
• Remove dedicated kitchen areas (vending perhaps, as per clinic design – remember, it is not a ward)
• Think carefully about toilet configuration and privacy and dignity requirements for an ambulatory unit - people will be dressed, unlike requirements for bedded single sex inpatient areas

It is recognised of course that hospitals will often be creatively adapting clinical or non-clinical space when developing or expanding ambulatory care services and each hospital site is different. That said, it is still recommended that as many of these practical design features are adopted, wherever possible. For new units, there is obviously a greater opportunity to design these features in, at the outset.

Architects and estates professionals have no authoritative guidance on how to design an ambulatory care facility, having only guidance for A&E or Ward areas to adapt. This can also lead to problems when new units are commissioned for what is still a relatively new concept for the NHS. The AEC network is currently working with the Department of Health to promote the development of a ‘Hospital Building Note’ (HBN) specific to ambulatory care environments - in the meantime, it is hoped that these practical measures might help.

References

1. BADS – 28^th Annual Scientific Meeting & Exhibition, 23^rd & 24^th June 2017
2. Transforming urgent and emergency care services in England. Safer, Faster, Better: good practice in delivering urgent and emergency care. A guide for local health and social care communities. Department of Health, August 2015
3. Directory of Ambulatory Emergency Care for Adults (5^th Edit). Ambulatory Emergency Care Network, August 2016
4. www.ambulatoryemergencycare.org.uk