1. Palliative and End of Life Care in Acute Hospitals
Derek Blues, Project Manager Scottish Partnership for Palliative Care

2. Palliative Care in Acute Hospitals
SLWG5
Palliative Care in Acute Hospitals

3. 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

4. Building on Progress
1.5 million bed days

5. 28 days in hospital in last year of life
Building on Progress
28 days in hospital in last year of life

6. 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.

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

9. 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

10. 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

11. Lots of opportunities to intervene

12. 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

13. 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)

15. 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.

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

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

18. Oncology/palliative care referrals
Shift in median
Move to FVRH

20. ANDY

21. 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

22. 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

23. 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

24. RED OR ORANGE STICKER DEPENDING ON EWS SCORE
DRAFT OF DANS VERSION
22/11/ :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

25. DOWNSTREAM WARD PART ONLY FOR FVRH
22/11/ :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

26. 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

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