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Ambulatory Emergency Care Pathways

TIA Services Update — When to Refer

Welcome to Harriet Patmore

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December 2011

Ambulatory Emergency Care Pathways

"Ambulatory care is to emergency care what day surgery is to elective care"

As reported in previous edition of GP News, the Trust has been actively working on the development of Ambulatory Emergency Care Pathways in accordance with the guidance contained in the NHS Institute for Innovation & and improvement. We have published a revised Directory of Ambulatory Emergency Care Pathways for Adults. The aim was to have implemented 17 of the 49 pathways by the end of March 2012, with further pathways to be developed once this initial tranche were completed. At time of writing the trust has now successfully implemented 12 of the Pathways, with a further 5 due to be completed by the end of 2011, some three months ahead of the original target date.

The 12 pathways that have been implemented are:
  • Acute Abdominal Pain
  • Community Acquired Pneumonia
  • Lower Respiratory Tract Infection
  • Pulmonary Embolism
  • DVT
  • Non-Cardiac Chest Pain
  • Renal Stones
  • Appendicular Fractures
  • Acute Bladder Outflow
  • Gastroenteritis
  • Stroke
  • Lower GI Bleed.

The following 5 pathways are on track to be implemented by the end of 2011:
  • Cellulitis (Lower Limb)
  • Deliberate Self Harm
  • SVT (with Atrial Fibrillation and Palpitations)
  • UTI
  • Painless Objective Jaundice

The process of developing the Pathways has been a lengthy one. Specialty leads have drafted pathways based on best practice and clinical knowledge. These have then been subjected to both a peer review and further review by other specialist areas such as Pharmacy, Radiography, Microbiology etc., before being assessed by A&E staff and formally approved by clinical leads and Divisional Heads.

Each Pathway document contains the key information required to understand the process to follow, including reference to trust guidance and policy on medication, such as Analgesia and Antibiotics, as well as contact points for access to other pathways services e.g. Radiography. A patient leaflet has also been provided which can be given to the patient to explain specifics about the condition and treatment regime.

These Pathways, however, do not take the place of sound clinical judgement based on clinical experience and knowledge or the support of Consultants.

This information, as well as being kept on paper within A&E, is presented via the Trust Intranet on the Clininet Portal. This enables all Trust staff to access the documentation via the portal, or by a specific Icon provided on each desktop. The document can be printed from this site so that the Pathway Algorithm can be kept with the patients notes and the patient leaflet can be handed to the patient.

The Pathway Algorithm aims to guide the patient through a course of investigation/assessment, stabilising treatment to a point where the patient needs to be admitted, or can be discharged with an agreed course of action to manage on-going assessment and treatment as appropriate. In all eventualities, the patients GP will be informed by letter of the episode and outcome.

Further information on the Ambulatory Emergency Care Pathways will be provided in the future, but in the mean time, if you have any questions, or wish to find out more detail, please contact Dr Gulam Patel by e-mail on:

TIA Services Update — When to Refer

At ASPH we are committed in providing high quality of services and care that are consistent and effective for patients who have suffered a Transient Ishaemic Attack (TIA).

Patients who have had a TIA or minor stroke also have an increased risk of myocardial infarction and other vascular events. The evidence for treating TIA has developed significantly in the past few years. A more urgent response saves lives and reduces long-term disability.

ASPH provide an urgent assessment service with a 7 day Stroke Specialist Team, which allows open access for GPs.

If you suspect a TIA, please contact the Stroke Team directly: Telephone 01932 722924

Bleep 5828 via main switchboard on 01932 782000.

An ABCD2 score needs to be documented and conveyed to the stroke team so they can advise on appropriate referral pathway:

ABCD2 Guidance:

Patients with a low risk ABCD2 score (3 or below) should be assessed within 7 days of symptoms – fax your letter to RAC on 01784 884554.

Patients with a high risk ABCD2 score (4 and above) should be assessed within 24 hours; these patients should attend A+E following discussion with the Stroke Team (contact details above).

Patients’ with crescendo TIA (two or more TIA’s in a week) should be treated as being at high risk of stroke, even though they may have an ABCD2 score of 3 or below.

If the symptoms have started within 4.5 hours, the patient may be suitable for thrombolysis, and therefore an emergency 999 call should be made.

Symbol Clinical Criterion Point
A Age >60 1
B Blood >140/90 1
C Clinical features Unilateral weakness1
Speech disturbance without weakness 1
D Duration <10 mins0
10-59 mins1
>60 mins 2
D Diabetes Present 1

Ashford & St Peters TIA clinic at the Rapid Access Centre (RAC) at Ashford Hospital provides a holistic geriatrician assessment, diagnostics and treatment plan, primarily for older people with an ABCD2 Score 3 or below, in the local community.

Providing a one-stop assessment with access to diagnostics model is a key priority for the NHS by improving patient flow, avoiding inappropriate admission to secondary care and integrating primary, community and social services.

The main function of the centre is to proactively diagnose and treat patients deemed to be at risk of requiring emergency admission to A&E.

The following diagnostic services are available:
  • Pathology
  • ECG
  • Plain X-Ray
  • Urinalysis
  • CT facility
  • Echocardiography

Who Can Refer?
  • GPs/A&E/MAU
  • The Intermediate Care Team (ICT)
  • Community Matrons
  • Specialist Nurses
  • District Nurses
  • Therapists
  • Care Home Support Team

How to Refer

Referrals should be made using the RAC single assessment process referral form. For TIA patients please use the ABCD2 referral form.

The form can be emailed or faxed with the patient’s consent to the RAC (See above for contact details).

All referrals will be acknowledged when received

You will be contacted by fax or email to confirm referral acceptance

For patients with an ABCD2 score of 4 or above then the patient needs to attend A+E immediately and refer the patient the Stroke Team.

The stroke team will ensure timely management of TIA, by ensuring rapid access to specialist assessment, investigation, diagnosis and treatment whilst responding to the needs of the patient and family/carers.

For the patient, it means they experience a seamless transfer of care – detailed personalised care plan which has been developed in partnership with themselves and family/carers.

Stroke Service Contact Details

Stroke Specialist Team 7 days a week 8am-8pm based at St Peters Hospital

Telephone 01932 722924
Bleep 5828 via main switchboard

Claire Barratt: Lead Nurse for Stroke Services
Telephone 01932 722924

Please call if you would like further information.

Rapid Access Centre
Ashford Hospital
London Road
Middlesex TW15 3AA

Telephone 01784 884500
Fax 01784 884554


Dr Zahid Dhakam
Dr. Bhaskar Mandal
Dr. Raad Nari
Dr. Radcliffe Lisk
Dr Keefai Yeong

Welcome to Harriet Patmore

Harriet Patmore happily joins the ENT department to replace Mr Patrick Chapman, who has recently retired from the Trust.

Having graduated from Southampton Medical School, Harriet moved north and completed her generic surgical training in Nottingham. From there she specialised in otorhinolaryngology, settling in Yorkshire. Here she completed a higher degree in Genetics of Head and Neck cancer and started her higher surgical training. She was awarded the George Seed Prize for her research in 2005. In 2008 she moved down to the South West Thames region to complete her ENT training. She hopes to compliment the current department by providing general clinics covering all aspects of otorhinolaryngology at both the Ashford and St. Peter’s hospital sites as well as Woking Community Hospital. By setting up a two week rule clinic she continues her interest in the diagnosis of Head and neck cancers. She will also continue to support the balance clinic at Ashford. Her other interests include facial skin lesions and their reconstruction, medical and surgical aspects of nasal mucosal disease and swallowing problems.

Referrals can be made either through Choose and Book or be post or fax.

Christmas and New Year Opening Times 2011
  • Click here to download the schedule for this year end.
Link to schedule


You have any feedback or require any further information about the Ashford and St Peter’s NHS Hospitals Foundation Trust or require this document electronically please contact:

Sue Robertson,
Marketing Manager
01932 722420

Debbie Beesley,
CAB Manager
01932 723511