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