Palliative and End of Life Care in Acute Hospitals

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Presentation transcript:

Palliative and End of Life Care in Acute Hospitals Derek Blues, Project Manager Scottish Partnership for Palliative Care derek@palliativecarescotland.org.uk

Palliative Care in Acute Hospitals SLWG5 Palliative Care in Acute Hospitals

58% of people die in hospital 30% of all acute bed days are used by people in their last year of life 75% of people are admitted to hospital during their last year of life

Building on Progress 1.5 million bed days

28 days in hospital in last year of life Building on Progress 28 days in hospital in last year of life

Action 9 The Scottish Partnership for Palliative Care will set up a National Group for Palliative Care in Hospitals to provide support for the implementation of SLWG 5 recommendations. This may include providing advice, guidance, disseminating learning and sharing good practice.

A Person Centred Reliable Response to the Deteriorating Patient Alison Hunter, Improvement Advisor, Acute Adult Safety Programme Healthcare Improvement Scotland What is SPSP

Deteriorating Patients : SPSP so far Focus on recognition & rescue Outcome measure= crash calls Emphasis on Rapid Response Teams General Ward Early Warning Scoring SBAR communications Safety Briefs

Can we do even better ? New aim that 95% of people experiencing acute care (in general ward) be free from avoidable harms by the end of 2015 Cardiac Arrest is one of the harms Cardiac arrest (outwith ITU, CCU, Front Door) can be seen as a surrogate marker for failed recognition, anticipatory care and rescue of the deteriorating patient

Lots of opportunities to intervene

Intervention Opportunities CPR attempts in acute care settings are usually preceded by period of physiological deterioration and can be seen as a marker of failure to anticipate or plan care appropriately Community/ Primary Care Care Transitions Admission or discharge from acute care On ward round When the patient has physiological deterioration CPR attempts/Cardiac Arrest Call

Identification; Decision making and Actions Patient with Physiological Decline Identification; Decision making and Actions NEWS, Identification tools with ACP and early and effective engagement with person and family, Crucial Lynchpin DNAR CPR decisions End of Life care including Integrated end of life pathway Structured person centred response to clinical deterioration Invasive Organ Support (Critical Care)

Abnormality recognised Decision making and therapy Responding to deteriorating patients is a complex system requiring a sequence of events and interactions to occur reliably, linked by pivotal reliance on communication between and within teams. Only the final step adds value to the patient (or person) EWS monitoring Abnormality recognised Responder activation Decision making and therapy If each step is 80% reliable reliability for whole system is 0.84 = 41% Andy- should the box about clear decision making be an absolute requirement to all steps? E.

THE DETERIORATING PATIENT Reliable recognition Reliable response Escalation On ward Critical care Palliative care Two sides of the same coin???

Poor patient flow from AAU starts Safety meetings start Rescue stickers start Poor patient flow from AAU starts Move to FVRH

Oncology/palliative care referrals Shift in median Move to FVRH

ANDY

Script the Critical Moves – when triggering Scottish Structured Response (SSR) to any triggering patient Forcing Function for Teamwork Identifies Key Processes Required Modification of existing models of successful rescue approaches Require strong team safety culture

Script the Critical Moves – ward round Structured Review Forcing Function for Teamwork Identifies Key Processes Required Modification of existing models of successful review approaches Require strong team safety culture

AIM PRIMARY DRIVER 95% of people with physiological deterioration in acute care will have a structured response and plan   A reduction of inappropriate interventions 50 % reduction in CPR attempts (with chest compressions and/or artificial respirations) in general ward setting by December 2015 Early Anticipation, collaborative planning and decision making Scottish Structured Response Processes Reliably Implemented Infrastructure

RED OR ORANGE STICKER DEPENDING ON EWS SCORE DRAFT OF DANS VERSION 22/11/2018 05:01 Patient admitted to FVRH CHECK EXISTING INFORMATION FROM PRIMARY CARE IF APPROPRIATE START RED OR ORANGE STICKER DEPENDING ON EWS SCORE SEPSIS 6 WITHIN 1 HOUR EWS >=4? YES Inform nurse in charge and increase observations Commence stickers, complete Part A Responding clinician completes sticker Part B NO NO Needs ICU? YES For escalation? Monitor in AAU Monitor in AAU YES NO NO For discharge? NO Admit to ward? Monitor in AAU Admit to ICU Sensitive discussion with family and carers YES YES STOP Prepare discharge plan and send copy to GP Screen all patients with SPICT tool YES Admit to ward? NO STOP RECORDED BY GP ACP needed? YES Ongoing monitoring for EWS triggers with escalation where needed Use ACP stickers (being developed) Refer to ePCS for information already documented NO Monitor in downstream ward Ensure all decisions are fully documented Sensitive patient discussion to document ACP ACP DISCUSSION TO INCLUDE ; - FUTURE CARE OPTIONS - RESUSCITATION STATUS - PREFERRED PLACE OF CARE - OTHER MATTERS (LEGAL ETC) - CAPACITY CONSIDERATION - PROGNOSIS (IF APPROPRIATE) NO For discharge? NO For discharge? Monitor in downstream ward Sensitive discussion with family and carers YES YES Prepare discharge plan and send copy to GP for ePCS update Prepare discharge plan and send copy to GP GP TO CREATE OR UPDATE EPCS IF APPROPRIATE STOP

DOWNSTREAM WARD PART ONLY FOR FVRH 22/11/2018 05:01 START Screen all patients with SPICT tool RECORDED BY GP ACP needed? YES Ongoing monitoring with escalation where needed Use ACP prompt sheet(being developed) Refer to ePCS for information already documented NO Monitor in downstream ward Ensure all decisions are fully documented Sensitive patient discussion to document ACP ACP DISCUSSION TO INCLUDE ; - FUTURE CARE OPTIONS - RESUSCITATION STATUS - PREFERRED PLACE OF CARE - OTHER MATTERS (LEGAL ETC) - CAPACITY CONSIDERATION - PROGNOSIS (IF APPROPRIATE) NO For discharge? For discharge? Monitor in downstream ward NO Sensitive discussion with family and carers YES YES Prepare discharge plan and send copy to GP Prepare discharge plan and send copy to GP for ePCS update GP TO CREATE OR UPDATE EPCS IF APPROPRIATE STOP

ACP prompt sheet Patient admitted to downstream ward – all patients assessed using SPICT If SPICT criteria is fulfilled, use a “thinking ahead approach” Prompts for consideration upon admission AND discharge

Driver diagram and change package presented to NHS Boards at SPSP Learning event 10 last month.