A specific criteria-based guideline improves compliance with General Surgery ambulatory care standards and reduces overcrowding in “Hot Clinic”: Quality Improvement Study

The number of emergency General surgery admissions has been increasing steadily over the past decades resulting in a significant strain on National Health Service (NHS) clinical and financial resources.1 In order to reduce the costs to the healthcare provider and the inpatient burden to the acute surgical team, General surgery Hot Clinic has been introduced.2 Hot clinic is designed for assessment and management of acute General surgical patients in ambulatory setting. It has been argued that up to 30% of acute General surgical patients could be managed via ambulatory pathway where unnecessary hospital admissions can be avoided.3 Although General surgery hot clinic can help to improve patient flow in acute General surgical setting, lack of specific criteria-based guideline for identifying eligible patients for ambulatory care could have contrary effects. Overcrowding in Hot Clinic is a major issue in many General surgical settings, negatively affecting the efficiency of ambulatory care and patient satisfaction. Overcrowding mainly occurs for two reasons. Firstly, due to lack of specific criteria-based guideline for including a patient in Hot Clinic, many patients not meeting the criteria for ambulatory care who can be managed in outpatient setting are inappropriately booked in Hot Clinic. Secondly, the increasing number of daily referrals to emergency General surgery team from community, accident and emergency, and other specialities can easily tempt the on-call General Surgery clinician to utilise the Hot Clinic as an excuse for not reviewing the referred patient on the same day as referral and booking the patient in Hot Clinic. The second reason also contributes to the problem caused by the first reason making a vicious circle resulting in overcrowding in Hot Clinic. We believe that the criteria specified in Table 1 would help to prevent the overcrowding in General Surgery Hot Clinic. Booking a patient in Hot Clinic without reviewing the patient is not acceptable and contributes to including ineligible patients for review in Hot Clinic; therefore, in order to decide whether a patient is eligible for ambulatory care, as an absolute requirement the patient must be reviewed clinically by the on-call General Surgery team on the same day as referral. Once the referred patient is reviewed, the on-call General Surgery team should decide to investigate and manage the patient as an inpatient, ambulatory patient, or outpatient. The patient should be booked in Hot clinic as an ambulatory patient only for the following reasons: review of already organised investigations for a patient who has already been seen; reassessment of a patient who has already been seen; and reassessment of a recently discharged inpatient. We aimed to perform a prospective baseline audit to assess on average how many patients are seen in General Surgery Hot Clinic and what proportion of Hot Clinic patients meet the criteria for ambulatory care. Our second objective was to implement a specific criteria-based guideline and monitoring programme to improve the compliance with the ambulatory care criteria.