Maximising the impact of Same Day Emergency Care
- Mar 6
- 5 min read
Same Day Emergency Care (SDEC) has been around for years under various names. I remember setting up the service with one of the best doctors I've ever met back in Basildon Hospital in 2015. Hagen isn't with us anymore, but I know I'm not the only person who is still influenced by his passion, his over-caffeinated excitement, and, most importantly, his absolute focus on patients and on making sure SDEC (or Ambulatory Care, as it was back then) was as efficient and effective as possible.
When SDEC works well, I think it's one of the most important operational levers available in the NHS. It can tick all the boxes, usually:
avoiding unnecessary admissions
improving patient experience
protecting inpatient bed capacity
improving hospital flow
But, this might be controversial, I haven't seen many places that really maximise its potential. I think a big part of that is the 'focus' and targets that NHS England has put on it from activity and opening hours to the percentage of the medical take. I'm sure this all came from a good place, but I don't think it's led the service to where it was intended.
What is SDEC?
Fundamentally, it should be a philosophy across organisations, an operating system built to deliver rapid, specialist input to acutely unwell patients to avoid admissions.
In practice, this isn't often the case. It's frequently just a place or a unit, somewhere constrained by time and resources, with limited access to rapid diagnostics needed to really make a difference. All the units will avoid some admissions and usually receive GP referrals, but I see these units increasingly used to relieve pressure on A&E. The signs are above the doors, the pathways are written (and stored somewhere 🤷🏻♂️), but admission rates remain high and hospital flow remains fragile.
The difference between units that work and those that could do more is rarely the concept.
It is the operating model around it.
Maximising the effectiveness of SDEC requires focusing on the few things that truly determine whether the model works.
Reasons your SDEC probably isn't fulfilling its potential
Culture: If you're really busy, and if the people that 'matter' like to see how busy you are, you're almost certainly not as effective as you could be. The targets and focus passed down to SDEC units have, unsurprisingly, led many units to prioritise volume of patients and activity over a smaller number of the right patients. Culturally, if you measure vanity metrics like activity over outcome metrics like admission rates by condition, you'll almost always get busy units, tired SDEC staff, annoyed A&E teams (who can't get the right patients in), and a service that doesn't deliver what it was created for.
You're probably seeing the wrong patients: This is linked to point 1, but it isn't entirely dependent on it. In every hospital (bar none) I've ever been to, where I specifically looked at SDEC, 20-30% of patients in the SDEC process shouldn't be there. These might be the face-to-face follow-ups that could have been done by virtual health, the 'breach avoidance' patients moved to reduce pressure in A&E, the patients who A&E would have sent home anyway, and occasionally, patients who are just unsuitable for SDEC. Seeing the wrong patients kills your capacity and will limit your ability to do the work that really matters.
Slow diagnostics: SDEC services should have access to diagnostics at the same speed as A&E. No ifs, buts, or maybes. If you want teams to develop a mindset of speed, and to get decisions and diagnoses early enough to get someone home the same day, the worst thing you can do is make them wait 4 hours for a diagnostic. Many units will have access to some rapid modalities but will have inpatient-paced responses for others. Some units and pathways have bookable slots for the following day. This is great, kind of. Not so great for the patient who goes home unsure and has to make the trip back to the hospital again the next day (I mean, who has loads of spare time for this?). And probably not great for the clinicians who now have to finish off yesterday's work as well as today's.
Approaches to maximise SDEC using improvement principles
Firstly, don't try to make changes everywhere at once. It doesn't work. Below are three simple approaches you could consider. There are plenty more. You can mix and match, or make up your own. The most important thing in improvement is to find something that fits your culture and do it in a way where you remain conscious of your impact and learning.
The Pareto Principle: focus on the vital few
Our recent article on the Pareto Principle explores a simple truth:
A small number of causes often drive the majority of outcomes.
In most acute hospitals:
A small number of conditions drive many short-stay admissions
A small number of operational delays drives most SDEC processing problems
A small number of referral pathways will make up the majority of referrals
Every organisation is different, but it won't be hard to identify which conditions make up most of your short-stay admissions. Find those, pick one, and focus your improvement there. A 5% improvement in a high-volume pathway will give you far more impact than a 25% improvement in a low-volume one.
(See our article on applying the Pareto principle in real-world systems for more information.)
The Theory of Constraints: identify the bottleneck
The second concept is the Theory of Constraints (TOC).
Every system has a constraint — the step that limits overall throughput. Right now, do you know what process is the constraint in your SDEC? Is it physical capacity, senior decision-maker's availability, or access to a specific diagnostic test? Of even demand at any given time? What process affects most pathways and constrains the flow?
You need to find it, then maximise it. Focus here will have a greater impact than improving any other individual process.
Our recent article on Theory of Constraints explores this idea in more detail, but the key leadership question is simple:
What single step most limits the ability of SDEC to discharge patients the same day who otherwise would have been admitted?
Lean thinking: remove friction in the pathway
Lean thinking focuses on eliminating delays, duplication and unnecessary steps in processes.
Applied to SDEC, Lean often highlights several common issues:
patients being assessed and asked the same questions multiple times
duplication between ED, SDEC and speciality teams
batching of diagnostic requests
unclear referral routes
variation between specialities
Lean approaches such as pathway mapping and rapid improvement cycles can help teams simplify the patient journey and reduce delays. Remember, Lean isn't about working harder; it's about making things simpler so that processes flow more smoothly.
(See our article on Lean approaches to improving complex systems for more information.)
Protecting SDEC during operational pressure
One of the most important leadership challenges comes during escalation. Under pressure, SDEC areas are often converted into inpatient beds. This is short-term thinking, releasing pressure now at the expense of creating more pressure later. It's a really hard call. I know. I've been the on-call ops manager and the on-call exec on a Sunday evening with pressure to bed SDEC.
I can't say never do it. That's not practical. But what I would suggest is that, if this happens, make sure that part of your learning system looks at the number of very short-stay admissions of your SDEC target cohort that occur whilst SDEC is closed, and the delays these admissions cause for patients who truly need admission. That might give you some food for thought and data to make a different, evidence-based decision in the future.
A final question for leadership teams
Across many hospitals, a significant proportion of emergency admissions stay less than 48 hours.
That raises a simple question:
Do you know how many of your <48 hour admissions could have been safely treated and discharged the same day?
If you know already. Great. If you don't, now might be a good time to find out.
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