Opinion

Triage by ACPs eases pressure on ambulatory care and admissions unit

Advanced clinical practitioners who can order X-rays and CT scans are helping a hospital to achieve timely treatment

Advanced clinical practitioners who can order X-rays and CT scans are helping a hospital to achieve timely treatment 


Picture: John Houlihan

Attendances at emergency departments in England during the winter period of 2017-2018 rose by 1.6%, with 22.9% of patients waiting longer than four hours - up 2.2% on 2016-2017.

Inevitably, patients requiring admission to hospital rose, to an average of 944 patients per day. Combined with a reported 1,100 fewer acute hospital beds available and an above average bed occupancy rate of 95.2%, this meant NHS services were struggling to meet demand.

NHS Improvement said detrimental operational factors affecting the performance of NHS trusts that winter included demand on services, low supply of acute beds and poor patient flow.

Trial demonstrated team’s ability

To help manage increased pressures, triage led by advanced clinical practitioners (ACPs) for medically expected patients referred mainly from primary care was introduced in December 2018 into an expanded ambulatory care unit at Great Western Hospital in Swindon.

The concept was developed following a trial of triage in the medical admissions unit using ACPs. This was in response to long waiting times for medically expected patients to be clerked, as well as a lack of acute medical beds.

The ACPs triaged and provided initial emergency management, which helped to maintain patient safety. The trial demonstrated the ACP team’s ability to make competent clinical first assessments with diagnostic investigations, guaranteeing suitable, timely and efficient treatment, combined with appropriate streaming of patients between the medical admission unit or ambulatory care.

Business case for funding

Following the success of this trial a business case was submitted for funding for a new ACP triage area attached to the ambulatory care unit to enable all medically expected patients to be filtered through one unit.

A triage area comprising four trolley spaces has been developed for this triage service, open between 9am and 10pm on weekdays. A new ACP triage proforma has been created to supplement the medical clerking proforma with the intention of minimising the time patients need to wait for investigations and treatment.

As the Royal College of Physicians said in its report Acute Medical Care in 2007, efficient, high-quality, timely assessment and treatment within the first 48 hours of a patient’s presentation at hospital is ‘an important determinant of their clinical outcomes’.

Achieving timely and efficient treatment

This service ensures patients are rapidly assessed by the ACP following presentation to the unit, which helps to achieve the timely and efficient treatment that patients require. For example, initial emergency management such as the sepsis six or fluid resuscitation can be started.

Collaborative working with the radiology team has enabled the ACP workforce to receive the training needed to be able to request chest X-rays and CT scans. This allows early requests to be made at the hospital’s ‘front door’ for a CT head scan as part of an investigation of intracranial bleeds, for example. Access to rapid diagnostics further helps timely and efficient treatment and appropriate streaming of patients, and can help to achieve an earlier discharge or management plan.

Funding has been agreed to expand point-of-care testing capability, and the unit will shortly receive a new blood gas analyser and equipment to test for white cell differentials. This will further improve patient streaming.

Effectiveness and value

For example, the testing of white cells is to be introduced to help identify within a few minutes if a patient is neutropenic, enabling rapid diagnosis, prompt treatment and streaming to the most appropriate clinical area.

The service is being audited and an evaluation is being made of the effect of ACP triage on admission on clerking times for medically expected patients referred to a single medical admissions unit.

Initial feedback about the service has been positive. The effectiveness of ACP triage and the quality of the documentation and decision-making has been welcomed by medical colleagues. This demonstrates the significant added value of having a senior decision-maker at the ‘front door’ of the hospital. The service provided by these ACPs, all registered nurses, demonstrates the effectiveness and value of advanced practice in a modern NHS.


 Neal Scott Aplin is an advanced nurse practitioner     

  Lucy Moxham is a trainee advanced nurse practitioner at Great Western Hospitals NHS Foundation Trust

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