University Hospitals Dorset

Bournemouth Medical SDEC

Streaming and referral criteria, plus alternative pathways for patients who are safe for discharge.

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SDEC streaming number x 6080 For Medical SDEC streaming and referral.
What is Medical SDEC?

Medical SDEC is an admission avoidance service. It should be used for patients who would otherwise need admission to hospital for investigation, treatment or medical review.

Core SDEC criteria

Mobility Independently mobile
NEWS NEWS <5
Age / frailty <85 years old; if >75, CFS must be <6

Exclusions

  • Diagnostic uncertainty for specialty — review prior to referral to ensure the most appropriate specialty.
  • Requires a hospital bed / overnight stay.
  • STEMI or stroke.
  • Social admission.
  • Confusion.
  • Requires isolation / infection control / D&V.
  • Oxygen requirement.
  • Acute asthma exacerbation.
  • Seizures.

Direct stream following initial triage

Chest pain

ECG required prior to referral.

  • Pleuritic chest pain / suspected PE
  • Cardiac history and/or risk factors
  • Known or suspected pericarditis
Breathlessness
  • Non-resolving LRTI despite antibiotics
  • Heart failure with no oxygen requirement (increasing SOB/oedema)
Headache
  • Known migraine, failed to improve with own triptan
  • Non-traumatic headache with red flags — GCS must be 15
  • Known IIH with headache and/or visual disturbance
Suspected GCA should use the rapid access GCA pathway via EFORM.
Other direct-stream presentations
  • Cellulitis — systemically unwell/febrile or worsening despite PO antibiotics
  • Haemoptysis
  • AF not rate controlled (>110) and/or ongoing symptoms
  • Severe vertigo
  • Worsening symptoms with recently diagnosed PE or DVT

Suitable following brief face-to-face clinician assessment

Assessment should be undertaken by a senior clinician/ACP or discussed with EPIC.

Unexplained TLOC

Vasovagal, postural or situational syncope can be discharged direct from ED and does not require SDEC unless there are additional concerns.

Open TLOC policy
New neurological symptoms

Neurology must not be consistent with stroke or TIA.

Rash with systemic symptoms / clinical concern

For example vasculitis. Most rashes can be managed by GP/UTC.

Severe hypertension (>180/120) with suspected end-organ damage

Symptoms associated with EOD include visual changes, confusion, altered neurology or seizures, chest pain, SOB, oedema and reduced UOP. Headache in isolation is not evidence of EOD.

Severe HTN without EOD does not require hospital admission unless there are additional concerns.
Open Acute Medicine policies

SDEC referral following assessment by ED clinician

  • Any of the direct-stream or brief-assessment categories above.
  • AKI stage 1.
  • Unresolved UTI or suspected pyelonephritis.
  • Overdose — discharged by liaison psych, or accidental overdose, accepting treatment with <6 hours of treatment/monitoring required.
  • New diagnosis brain lesion requiring further imaging.
  • New or worsening hyponatraemia (>125).
  • Fever or infection with unclear source.
  • Fever in returning traveller with no need for barrier/isolation.

Usually dischargeable directly from ED

Not suitable for routine SDEC streaming. May be "pulled" at the discretion of the SDEC Consultant or ACP depending on capacity.

  • Palpitations with no other symptoms and normal ECG.
  • Rate-controlled AF (HR <110) with no ongoing symptoms.
  • Headache with no red flags.
  • Headache with history of migraine — has not taken triptan.
  • Deranged LFTs with clear cause (e.g. viral) — GP to repeat bloods.
  • Cellulitis, systemically well, not yet trialled PO antibiotics.
  • LRTI with no oxygen requirement.
  • Chest pain <40 years, normal ECG, no FH.
  • Severe hypertension (>180/120) with no suspicion of end-organ damage.

Alternative pathways for patients safe for discharge

Suspected GCA Rapid access GCA clinic referral via EFORM.Management flow chart available within the referral form.
Suspected lower limb DVT DVT clinic referral via EFORM.
New heart failure / AF / stable angina Ambulatory cardiac clinic referral via EFORM.
Suspected TIA Neurovascular SDEC via bleep.
Suspected malignancy 2-week-wait referral to the appropriate specialty.
Incidental findings Referral to the appropriate specialty for follow-up.Nodule MDT referrals via EFORM.
Specialty review / advice Consider A&G via GP, OP referral or specialty helplines.SDEC cannot facilitate specialty reviews e.g. Derm/Rheum/Gastro unless agreed in advance with specialty and AMU Consultant.
Elective procedures For example drains, iron infusions or blood transfusions — arrange via TIU.Drains, infusions and transfusions cannot be facilitated in SDEC.
Hypertension without end-organ damage GP follow-up.See "Managing severe hypertension and hypertensive emergencies in Acute Medicine" policy.
First seizure (fully recovered) Neuro referral for first fit OP review.
Chronic / non-urgent health Consider GP follow-up.
Information for patients: Please inform all patients that SDEC is an Emergency clinic and they may be required to wait up to 4 hours in the department. This time may be longer if further tests are required.