Anticipatory Care Planning in the Acute Hospital: A Structured Approach

What are we trying to achieve?

Patients in the last year of life will receive care aligned to their needs and wishes

Early & reliable identification of patients where anticipatory planning is appropriate Involvement of patients and families: Goals of Care Clear plan for management Reliable response to deterioration / change

Information Reconciliation

On Admission to Hospital

KIS/ ePCS, GP letter, previous admissions,

clinical case-notes

Primary Care

Key information used to create or update KIS/

ePCS.

Deterioration

Out of Hours services- informed care at home

Admission to hospital- key information

included in GP letter

Access, Review & Share

Informed discussions Informed decisions Informed care

During Hospital Stay

Structured Ward Round

Key information fields in clinical case-notes

Deteriorating Patient

Package

Discharge From Hospital

Immediate Discharge Letter

Key information fields included in the immediate

discharge letter & emailed to GP Practice mailbox

Deterioration at the End of Life

53% of all deaths (n=958) ‘expected death’

• End of life care plan commenced: median 32 hrs prior to death

28% of all deaths = ‘rapid decline’

Both groups: indicators of ‘limited reversibility’, uncertainty of recovery, risk of deterioration = need for active upstream planning

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What changes are we testing first?

• Structured Ward Round: tested vehicle for improvement in acute care

• Templates: documentation fields to prompt & record

• Key fields: Identification (SPICT) Escalation and treatment plan DNACPR status Communication with patient and family Goals of care

NHS Lothian Deteriorating Patient Programme

Two pilot areas: Acute Medicine & Medicine of the Elderly wards

Local ownership & leadership: Scottish Patient Safety Fellows

The picture so far….

Baseline Data Capture

Case note review 20 patients that died in hospital 17 patients observed on ward round + track post discharge : 3, 6, 12 months

Observation Ward rounds (n= 4) MDT meetings Nursing handovers

Patient interviews 10 patients observed on ward round

Staff perspectives Interviews (n=3)

Area 1: Electronic templates- refining key fields- PDSA 1

Area 2: Paper template- refining key fields- PDSA 3

Early lessons….

• Target group: acute medicine 54- 74% of patients

medicine of the elderly 80 - 100%

• Complexities of care: time to complete ward rounds/ per patient

communication ‘dams’

terminology

• Declining functional ability = key indicator- AHP involvement• Patient experiences and expectations• Power of ‘ fresh’ local data• Limitations of case-note review alone for improvement …

Key Questions…..

• ‘Conversation Ready’: staff ?

patients and families ?

• Glossary of terms

• Immediate discharge letters

• Measurement and reporting: Clinical Quality Indicator for End of Life care: 5 deaths per month within Morbidity & Mortality reviews