Acute hospitals end of life care best practice

Acute Hospitals Best Practice

Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain

Delivering reliable best practice in an acute hospital setting for patients whose recovery is

uncertain Anita Hayes, Deputy Director National End of Life Care

Programme Dr Irene Carey, Carole Robinson, Susanna Shouls, Linda Briant

Modernisation Initiative, Lambeth & Southwark

9-10th March 2011

End of Life Care Strategy: Aims

1. Quality: To bring about a step change in the quality of care for people approaching the end of life

2. To enhance choice at the end of life

3. To reduce inequalities (e.g. Geographical and cancer vs. Non-cancer)

4. To prepare for the demographic challenge: increasing numbers of deaths, particularly amongst people over 85 years

5. To raise the profile of end of life care

End of Life Care Strategy England

Key elements:Raising awareness of death and dying

Integrated service delivery

Workforce, measurement, research, funding, national support

Societal level

Individual level

Infrastructure

Step 2

Assessment,care planning

and review

•Advance care planning - patient and professional information –

planning for your future care

(evaluation)•PPC•ADRT

information for patients

•Assessment framework/ pilot

(EoE)

Step 3

Coordinationof care

•Locality wide registers pilots

(8 sites) •DH initiatives Transforming community

servicesIntegrated care pilots Personal budgets

Step 4

Delivery ofhigh qualityservices in

differentsettings

•AcuteHospitals• Primary care – GSF/ADA•“Route to Success”•Care homes

(volunteers)• Extra care housing evaluation •Prisons•Hostels•Learning disabilities •QIPP

Step 5 & 6

Care in thelast daysof life and

care after death

•LCP neurological /hospital Audit•Environments of care - King’s Fund•Last offices•Bereavement

Pre pathway

RaisingAwareness

•Supporting NCPC National Coalition

Dying Matters•Member of Dying Matters •National

Awareness raising week

•Peer education programme

Commissioning, currency and pricing, provider development, service improvement

Spirituality, User involvement, Information/support for patients and carers

Workforce – competences, E-learning, methods of delivery, facilitators network

Discussionsas the end

of lifeapproaches

•Communications skills (introductory, intermediate,

advanced) 12 pilots

•Clinical triggers - kidney, dementia Heart cancer neurological

Step 1

National End of Life Care Programme workstreams

Cross boundary working/sharing good practice, communications strategy, events ,website

Measurement - Intelligence network ,quality markers , VOICES

Social care

End of Life Care Programme

• Phase 3: three year service improvement programme

• Funded by Guy’s and St. Thomas’ Charity, King’s College Hospital Charity, South London and Maudsley NHS Foundation Trust Charitable Funds

• Working with health and social care, voluntary sector and local residents across Lambeth and Southwark

• Building on good practice to provide exceptional care for the dying across all settings

Overview

• Guy’s and St Thomas’ NHS Foundation Trust

• Challenge

• Innovation

• Impact and learning

• Conclusion and benefits

The challenge

Issues around end of life care in an acute setting

• Case-note review (14/20 consecutive deaths) – – Singular focus on treatment

– Identification of patients likely to die while ongoing active medical therapy

– “add on” to care – Decision making/ escalation planning, patient/carer involvement,

capacity/best interests assessment, symptoms– Timely referrals including palliative care– Communication flows within and between organisations

• Recommendations– Identification tool– Best practice

Identification

• 1 – 2 month prognosis

• Simple enough to pass the “junior doctor at 2am test”

• Can be utilised in existing ward functions

• Makes life easier - sustainability

Method

• Cross-sectional ward census– Screen: “would you be surprised…still alive 1

month?”– Case notes:

• Rapidly deteriorating, clinically unstable, limited reversibility

• 3 or more hospital admissions past 6 months?

• Surprise question• Haemato-oncology/ elderly care MDM

Being realistic around identification

• Tool does not predict all deaths within timescales (e.g. positive 19 to 53%)

• Clinical reluctance to “write off” / use “surprise” vs “risk”

• Too simple / too complex no use

• Pragmatic combination of identification tool (“so what?”) and intervention alongside each other

Screening questions

1. Is the patient rapidly deteriorating, clinically unstable and with limited reversibility?

2. Is the patient at risk of dying within the next 1-2 months?

Yes to both proceed to AMBER CARE BUNDLE

Well Uncertain recovery Last 48 hours

Recognition of the dying phase.

Recognition of uncertain recovery

Full intervention with added symptom

control

Critical care, full medical intervention,

responding to treatment expected

recovery

AMBER Care Bundle

LCPAMBER care bundleEarly planning

Innovation – why a care bundle?

Reliability and Bundles

• Every system delivers the outcome for which it is designed

• Most routine healthcare is “chaotic”in reliability terms (50 – 80% process reliability)

• Impacts quality and productivity

• Need to design in reliability - standardisation

Methods to improve reliability

• Pathway

• Guideline

• Audit

• Checklist

• Care bundle

Care bundle

Bundle has:

- Four to five components - Can be rapidly answered yes/no - Based on good evidence or self evident good practice Can be locally implemented / quality controlled

Helps communication and team working

Easy to measure

Innovation

AMBER care bundle

AMBER = Action

• Assessment

• Management

• Best practice

• Engagement

• Recovery uncertain

Identification AMBER = actionEffective discharge

communication

Effective communication:

day -> nightAssessment unit ->

ward

Key processes

ward roundshandover

multi-disciplinary team meetings

AMBER bundle

What it means to ward staff

• Day one- Identification and initiation

• AMBER follow-up

A-“Is patient still AMBER?”

C- “Has medical plan changed?”

T – Touch base with carers - Is everything OK?”

How to change clinical practice

• Part of a package– Facilitation– Education– Guidelines

• Build into ward processes

• Sustainability

“I hear and I forget I see and I remember I do and I understand”

Confucius, 551-479BC

Results and learning

• 42year old patient with advanced lung cancer• Staff felt patient had deteriorated• There was no medical plan in place and scans had

shown disease progression; patient was unaware• Patient identified as AMBER• Discussed with consultant in clinic – Came to ward• Discussion took place with patient

Case study

Case studyComments from Patients/Staff/Relatives:

“ Without AMBER I do not feel the consultant would have come up to

the ward, I feel a lot happier now there is a

plan”

“ I was unaware how ill X was and so it was good to

be contacted”

“ It was a shock to know there was no more they could do but at least we all have time to say goodbye”

“ I do not want to die, but there are things I need to do. I want to write my will and plan and pay for my own funeral”

nurse

relative

patient

consultant

The Testing Cycle

What we found out:

• Medical decision making inconsistent

• Ineffective communication within team

• Patient/carer discussions did not include:

– Preferences

– Uncertainty

What we’re doing differently• Generating

multidisciplinary team discussion and understanding

• Consultant support for escalation framework where uncertainty exists

• Early pro-active patient/ carer discussions about uncertain recovery and preferences

• Follow-up with visual prompt

• Systematic

Outcome of patients who received the AMBER care bundle (Jan 2010 - Jan 2011)

Still in ward

2%

Withdrawn from AMBER

3

48%

60

48%

Survived more than 100 days

Died in community

Median no. of days on AMBER

126 5

Died in hospitalDischarged to community

78%

2%

2%

Communitysurvival rate

2 weeks

Hospital survival rate

12%2 weeks 76%

Total AMBER patients

603

52%

43

2 months 0% 2 months 33%

% PPC achieved

9

1 month 1 month

Patients who died on pilot wards (Jan 2010 - Jan 2011)

LCP

54%Total LCP

41

32%

60

AMBER first then LCP

10%

AMBER

19

22%

Total patients deaths

186

Preferred place of care(Jan 2010 - Jan 2011)

Actual place of death

Hospital Hospice Home Care Home

Preferred place of

care

Hospital 43 1 0 2

Hospice 4 15 0 0

Home 11 3 22 2

Care Home 1 0 0 0

76% preferred place of care achieved for all patients who have died

Sustainability

Sustainability Score - the AMBER Care Bundle

4.7

3.1

3.4

2.4

4.9

5.1

5.7

5.5

3.3

3.3

0 2 4 6 8 10 12 14 16

Benefits beyond helping patients

Credibility of the evidence

Adaptability of improved process

Effectiveness of the system to monitor progross

Staff involvement and training to sustain the process

Staff attiudes towards sustaining the change

Senior leadership and engagement

Clinical leadership engagement

Fit with the organisation strategic aims and culture

Infrastructure for sustainability

Initial assessment Current Score Max Score

Up to 70% of improvement projects fail to sustain their initial results

“The challenge is not starting but continuing after the initial enthusiasm has gone.” Ovretveit (2003)

Sustainability

Who initiated the care bundle may indicate how confident staff are about the tool.

0

5

10

15

20

25

Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10

All Ward led

www.institute.nhs.uk/sustainability

Conclusions and benefits to the broader agenda

• End of life care in hospital must be addressed

• Recognition • Care planning• Communication

• Uncertainty must be addressed

• Earlier recognition alongside active treatment

• Multi-disciplinary care bundle

• Standardisation of individualised care

• Practical tool to make “accepted” practice happen

InnovationAccepted

• It needs to have both nursing and medical support

• For the AMBER care bundle to be sustained it needs to mean something to each clinical area

• It needs to be built into the daily routine and other Trust initiatives e.g. releasing time to care, acutely ill patient pathway

AMBER care bundle supports:

Ensures best possible death and bereavement for hospital patients and their carers

• Quality: enhanced patient and carer experience and satisfaction through early and consistent conversations about care and treatment choices;

• Productivity: helping to avoid hospital readmissions through early recognition of end of life care needs, efficient team working and fewer unwanted tests and treatments;

• Prevention by cutting out the delay in recognising and responding to end of life care needs.

Helps close a gap in the quality of care for a larger group of patients than those who receive the Liverpool Care Pathway

Questions and answersContact:

[email protected]