1. Symptom Management: Terminal Agitation J28 & J29

2. 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

3. 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

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

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

6. 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

7. 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

8. 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

9. 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

10. 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 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

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

12. 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%

13. 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%

14. 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)

15. 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)

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

17. No. of Referrals per Month

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

19. 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: 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: Post : 3.9
How Confident do you feel in Identifying Signs of Terminal Agitation with Delirium? Pre: Post : 3.5
How Confident do you Feel with your Knowledge of the Causes of Terminal Agitation? Pre: 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: Post 3.8
How Confident do you feel with your Knowledge of the Medications used to Manage Terminal Agitation?
Pre: Post: 4.1
How Confident do you feel with your Knowledge of Medications used to Manage Terminal Agitation with Delirium? Pre: Post: 3.9

20. 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: 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: Post : 3.4
How Confident do you Feel with your Knowledge of the Causes of Terminal Agitation? Pre: Post: 3.4
How Confident do you feel with your Knowledge of the Causes of Terminal Agitation with Delirium? Pre: Post : 3.3
How Confident do you feel with your Knowledge of Non-Pharmacological Measures to Manage Terminal Agitation (with or without delirium)? Pre: 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