Symptom Management: Terminal Agitation J28 & J29

Background LTHT one of 13 acute Trusts across the UK to take part in the ‘Building on the Best’ programme. QI programme to build on ‘Transforming End of Life Care in Acute Hospitals’ programme Supported by NCPC, Macmillan Cancer Support, NHS England, and the NHS TDA Two year project. Lessons learned will be used to contribute to improvement work on palliative and end of life care in acute hospitals across the country. BotB Pilot wards Baseline audit results

Aim Primary Drivers Secondary Drivers Improving the Management of Terminal Agitation (TA) with or without Delirium Aim Primary Drivers Secondary Drivers Staff education Role modelling Awareness of signs & symptoms Identify signs and symptoms of TA Motivated workforce Recognition of impact on family All staff feel empowered to highlight patients that have TA All staff recognise the importance of managing TA All dying patients who are experiencing terminal agitation have an effective individualised plan of care by September 2017 on the pilot wards (L21, J28 & J29) Culture of accountability & team work Identification & treatment of reversible causes Role of non-pharmacological measures Aware & confidence in using medications Role of the family in management of TA Care supported by CoDP multidisciplinary documentation Driver diagram Clear guidance on TA

Pilot wards Average 9.8 per month 14 had pall care flag on pas Average age 85 BotB Pilot wards Baseline audit results

Pilot wards 14 pall care flag on pas Average 12 per month Average age 84.2 BotB Pilot wards Baseline audit results

What we did Baseline and prospective case note audit of patients who died J28 and J29 (elderly admission wards) Ward working November 16 – Feb 17 role modelling good care / helping out Informal and formal teaching Confidence questionnaires – pre and post ward work and teaching BotB Pilot wards Baseline audit results

Intervention -Ward Work J28 & J29 Nov 16- Feb 17 (16 week period) 29 days 90 hours Input with 31 patients (30/31 died) BotB Pilot wards Baseline audit results

Number of nursing staff captured during intervention   J28 & J29 J28 J29 Teaching & Ward Work 11 RN=8 CSW=3 4 RN=3 CSW=1 7 RN=5 CSW=2 Ward work (only) 22 RN= 11 CSW=10 Student=1 10 RN=5 CSW=4 Stu=1 12 RN=6 CSW=6 Teaching (only) 16 RN=5 CSW= 7 TAP=2 Student Nurse=2 9 RN=3 CSW=4 TAP=1 Stu=1 RN=2 CSW=3 TAP=1 Stu=1 Total 49 RN=25 CSW = 19 TAP=2 Student =3 23 RN=11 CSW=9 TAP=1 Stu=2 26 RN=13 CSW=9 TAP=1 Stu=1 BotB Pilot wards Baseline audit results

Audits Baseline audit to determine how well terminal agitation is recognised, assessed and managed A retrospective case note audit of 17 patients who died on J28 & J29 March 16-May 16 And on going audit 24 patients who died on J28 & J29 Nov 16 – Feb 17 BotB Pilot wards Baseline audit results

Audit Proforma BotB Pilot wards Baseline audit results   Yes No N/A 1. Care supported by the care of the dying person multi-disciplinary documentation 2. Assessment of TA documented in medical notes? 3. Plan of care for management of TA documented in medical notes? 4. Evidence of reassessment & evaluation of interventions in medical notes? 5. Daily assessment and plan of care complete (for all relevant days) for symptom management for nursing care plan (page 22 of CoDP) 6.Daily evaluation completed (for all relevant days) for symptom management nursing care plan (page 22-23 of CoDP) 7.Overall Score (excellent, good, average, poor) Additional Comments: Anticipatory medications prescribed for Terminal Agitation Drug: Dose: Route: Frequency: Indication: Max dose in 24 hours: Has p.r.n medication for TA been given? How many doses given?_____ Is there a CSCI in place? If yes, CSCI regime________________________________ BotB Pilot wards Baseline audit results

Results J28/J29 – Baseline N= 17 March 16-May 16

Results J28/J29 ongoing audit N = 24 Nov 16 – Feb 17 Improvement in all areas apart from assessment of TA in medical notes CoDP – Post - 92% v Pre- 82% Assessment (medical) – Post 36% V Pre – 41% Plan (medical) – Post 82% v Pre – 82% Reassessment if interventions (medical) – Post 64% v Pre 50% Daily assessment nursing – Post 40% v Pre – 21% Daily evaluation nursing – Post 40% v Pre – 21%

Results J28/J29 pre & during intervention % CoDP –intervention- 92% v Pre- 82% Assessment (medical) – intervention 36% V Pre – 41% Plan (medical) – intervention 82% v Pre – 82% Reassessment if interventions (medical) – intervention 64% v Pre 50% Daily assessment nursing – intervention 40% v Pre – 21% Daily evaluation nursing – intervention 40% v Pre – 21%

Results J28/J29 – Baseline Intervention stage measured Nov ‘17-March ‘17 (5 deaths per month) Re-audit 6 month Post intervention measurement : Sept ’17 –Nov ‘17 (5 deaths per month)

Results J28/J29 – Ongoing Intervention stage measured Nov ‘17-March ‘17 (5 deaths per month) Re-audit 6 month Post intervention measurement : Sept ’17 –Nov ‘17 (5 deaths per month)

Referrals to SPCT Prior to Interventions April – Oct 2016 Total no. of Patient Referrals Assessed: 43 J28- 24 Patients J29- 19 Patients During Interventions Nov – Feb 2017 Total no. of Patient Referrals Assessed: 18 J28- 5 Patients J29- 13 Patients

No. of Referrals per Month

No. of Agitation Referrals / Patients Supported for Agitation per Month

Average Overall Confidence Rating: Pre: 2.4 Post: 3.78 Confidence Qs Nurses Summary of results Pre N = 17 Post N = 13 Average Overall Confidence Rating: Pre: 2.4 Post: 3.78 (5= Extremely confident, 1= Not Confident At All) Average Confidence Ratings by Question: How Confident do you feel in Identifying signs of Terminal Agitation? Pre: 2.8 Post : 3.9 How Confident do you feel in Identifying Signs of Terminal Agitation with Delirium? Pre: 2.3 Post : 3.5 How Confident do you Feel with your Knowledge of the Causes of Terminal Agitation? Pre: 2.4 Post: 3.7 How Confident do you feel with your Knowledge of the Causes of Terminal Agitation with Delirium? Pre: 2 Post : 3.4 How Confident do you feel with your Knowledge of Non-Pharmacological Measures to Manage Terminal Agitation (with or without delirium)? Pre: 2.3 Post 3.8 How Confident do you feel with your Knowledge of the Medications used to Manage Terminal Agitation? Pre: 2.9 Post: 4.1 How Confident do you feel with your Knowledge of Medications used to Manage Terminal Agitation with Delirium? Pre: 2.1 Post: 3.9

Average Overall Confidence Rating: Pre: 2.5 Post : 3.2 Confidence Qs CSWs Summary of results Pre N = 13 Post N = 10 Average Overall Confidence Rating: Pre: 2.5 Post : 3.2 (5= Extremely confident, 1= Not Confident At All) Average Confidence Ratings by Question: How Confident do you feel in Identifying signs of Terminal Agitation? Pre: 3 Post : 3.4 How Confident do you feel in Identifying Signs of Terminal Agitation with Delirium? Pre: 2.8 Post : 3.4 How Confident do you Feel with your Knowledge of the Causes of Terminal Agitation? Pre: 2.8 Post: 3.4 How Confident do you feel with your Knowledge of the Causes of Terminal Agitation with Delirium? Pre: 2.5 Post : 3.3 How Confident do you feel with your Knowledge of Non-Pharmacological Measures to Manage Terminal Agitation (with or without delirium)? Pre: 2.3 Post: 2.9 How Confident do you feel with your Knowledge of the Medications used to Manage Terminal Agitation? Pre: 2.3 Post: 2.9 How Confident do you feel with your Knowledge of Medications used to Manage Terminal Agitation with Delirium? Pre: 2 Post: 2.9