Filters
Episodes reviewed
62
Target sample 100
Overall compliance
83.2%
Target ≥ 90%
Suitability considered
80.6%
SDEC considered where relevant
Inclusion / exclusion documented
82.6%
Criteria C2 and C3
NEWS2 documented
93%
Acuity assessment recorded
Senior decision-maker
77.4%
Involved in suitability decision
Referred where suitable
83.9%
Criterion C11
Referrals accepted
76.3%
Of referrals made
Diagnostics same day
71.7%
Where required
Treatment same day
70.7%
Where required
Same-day discharge
38.7%
Admission avoided
Admission reason documented
73.7%
Where admitted
Criteria meeting target
2
Of 30 criteria
Criteria below target
28
Priority for improvement
Suitable but not referred
3
Missed SDEC opportunities
Safety concerns
5
Recorded during review
Criterion-level compliance
Compliance uses Yes and No responses only. Bars below the local target of 90% are highlighted.
SDEC suitability considered over time
Weekly run chart by arrival week.
Compliance by ward / clinical area
| Group | Episodes | % |
|---|---|---|
| Same-Day Emergency Care Unit | 13 | 86% |
| Emergency Department | 18 | 84% |
| Acute Medical Unit | 15 | 83% |
| Frailty Assessment Area | 16 | 81% |
Compliance by referral route
| Group | Episodes | % |
|---|---|---|
| Community urgent response referral | 3 | 89% |
| GP direct referral | 4 | 87% |
| ED streaming | 13 | 84% |
| NHS 111 referral | 6 | 84% |
| AMU referral | 10 | 83% |
| Ambulance direct referral | 6 | 83% |
| ED clinician referral | 8 | 83% |
| Outpatient / hot clinic referral | 8 | 82% |
| UTC referral | 4 | 76% |
Compliance by pathway group
| Group | Episodes | % |
|---|---|---|
| Renal / AKI | 3 | 94% |
| Falls / frailty | 3 | 89% |
| COPD / asthma exacerbation | 2 | 89% |
| Abnormal blood tests | 9 | 87% |
| Pneumonia / respiratory symptoms | 3 | 86% |
| Chest pain / possible ACS | 3 | 84% |
| Ambulatory IV therapy | 2 | 84% |
| Diabetes / hyperglycaemia | 5 | 84% |
| Heart failure | 2 | 82% |
| Delirium / cognitive concern | 4 | 82% |
| Abdominal pain | 4 | 82% |
| Suspected pulmonary embolism / VTE | 8 | 81% |
| Syncope / collapse | 3 | 81% |
| DVT pathway | 2 | 80% |
| Anaemia / transfusion pathway | 3 | 78% |
| Headache / neurology symptom | 2 | 76% |
| Suspected infection / cellulitis | 4 | 75% |
Reasons SDEC was not used
- SDEC closed / outside opening hours6
- Safeguarding concern4
- No reason documented3
- Cognitive / capacity concern3
- Diagnostic requirement not available same day3
- High NEWS2 / clinical instability2
- Mobility / functional safety concern2
- Social support / home circumstances concern2
- Requires resuscitation or emergency pathway2
- Requires inpatient monitoring2
- Patient declined SDEC / same-day pathway1
- Documentation unclear1
- Referral not recognised1
- Transport home unavailable1
- Treatment requirement not available same day1
- Suspected sepsis requiring admission1
- Specialty review not available same day1
- Requires urgent critical care / high-dependency review1
- No senior decision-maker available1
Suitability categories
- Referred and accepted33
- Referred and declined11
- Not suitable due to SDEC opening hours / capacity5
- Not suitable due to diagnostic need4
- Suitable but not referred3
- Not suitable due to treatment need2
- Not suitable due to capacity / safeguarding concern2
- Not suitable due to social / functional risk1
- Not suitable due to clinical acuity1
Referral acceptance by route
| Group | Episodes | % accepted |
|---|---|---|
| ED clinician referral | 8 | 88% |
| ED streaming | 7 | 43% |
| Outpatient / hot clinic referral | 6 | 100% |
| AMU referral | 6 | 83% |
| NHS 111 referral | 4 | 75% |
| UTC referral | 3 | 67% |
| GP direct referral | 2 | 100% |
| Community urgent response referral | 1 | 0% |
| Ambulance direct referral | 1 | 100% |
Same-day discharge by pathway
| Group | Episodes | % discharged |
|---|---|---|
| Abnormal blood tests | 9 | 33% |
| Suspected pulmonary embolism / VTE | 8 | 50% |
| Diabetes / hyperglycaemia | 5 | 60% |
| Suspected infection / cellulitis | 4 | 25% |
| Delirium / cognitive concern | 4 | 50% |
| Abdominal pain | 4 | 0% |
| Falls / frailty | 3 | 33% |
| Pneumonia / respiratory symptoms | 3 | 33% |
| Renal / AKI | 3 | 0% |
| Chest pain / possible ACS | 3 | 33% |
Largest contributors to non-compliance
Criteria answered No, ranked by frequency.
- C23 — Safety-netting advice was documented.1412%
- C14 — SDEC referral outcome was documented.1323%
- C20 — Pharmacy, medicines or prescribing support was completed where required.1233%
- C27 — Reason for admission after SDEC assessment was documented where admission occurred.1243%
- C28 — Alternative pathway was documented where SDEC was not used.1253%
- C7 — Senior clinical decision-maker was involved where required by local policy.1163%
- C12 — Reason for not referring to SDEC was documented where the patient appeared potentially suitable but was not referred.1172%
- C16 — Transfer from ED / UTC to SDEC occurred within local expected timeframe where applicable.1181%
- C17 — Required diagnostics were identified and available within the same-day pathway where relevant.1191%
- C18 — Diagnostics were completed same day where required for safe SDEC management.11100%
Interpretation
Strongest performance was seen in C21 (90.9%), C5 (90%), C19 (89.8%). The largest gaps were C23 (74.5%), C14 (76.8%), C28 (77.4%). Compliance was lowest in Frailty Assessment Area at 81% (n=16). 3 episodes were recorded as potentially suitable but not referred, which is the clearest admission-avoidance opportunity. Where sample size is small, findings should be treated as indicative and confirmed with further data collection.
1) Add an SDEC suitability prompt to ED streaming and AMU clerking so consideration is always recorded. 2) Make local inclusion and exclusion criteria visible at the point of decision. 3) Agree same-day diagnostic slots reserved for SDEC. 4) Require a documented reason whenever a potentially suitable patient is not referred or is declined. 5) Feed decline and non-referral reasons back to ED, AMU, ambulance and community referrers. 6) Re-audit after intervention using the same criteria and tool version.