Acute hospitals end of life care best practice


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Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain. Including details of the AMBER care bundle. Presentation from Anita Hayes and colleagues from England's National End of Life Care Programme as part of the Department of Health's QIPP end of life care workstream seminar series at Healthcare Innovation Expo 2011

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  • Challenge: issues around end of life care in hospital, including identification Innovation: Use of care bundles to standardise hospital care in complex areas Impact and learning: AMBER care bundle Conclusion and benefits
  • Examples of good practice but also fo singular focus on treatment at times. The findings are consistent with national work carried out across a number of different hospitals in the Modernisation Agency. Lack of standardisation – good practice based on individuals rather than the system.
  • We wished to test a tool to identify people at significant risk of dying in the next month or so in order to assess the number for whom a targeted intervention would be applicable
  • The detail of how we went about this is a longer story than we can tell today. In esscence we employed a number of methodologies which included a 1 day cross-trust ward census, also attendance at heamato-oncology / elederly care mdm. We tracked to see what happened to those patients ie did they die within 1 -2 months. We also tracked the patients who were identified as being not likely to die as a natural comparator group. We did not intervene in their care. Pretty quickly it became apparent that the clinical teams were disengaging from the testing process as they felt “so what”
  • All of these limitations and difficulties, however, reflect the real world of acute hospital care and the real environment in which we are seeking to improve the identification and therefore care of this patient group. A complex tool which cannot be reliably implemented is of no use. A simple tool which does not differentiate groups is of no use. A tool which incorporates some of the tested tool and acknowledges the important features of clinician reluctance to “label” or “write off” patients; clinician reluctance to use the language of “surprise” rather than of “risk”; relevance of consultant/ Spr knowledge regarding individual patients in reaching a judgement; relevance of explicit MD team discussion regarding prognosis; documentation is not always optimal . Quantitative findings as above and qualitative feedback from pilot sites resulted in the design team changing the identification questions and incorporating these into the target intervention with a view to testing both the identification tool and impact of the intervention alongside each other to enable rapid change and refinement. This is being managed through ward-based senior clinical facilitation and utilising the senior medical team who know the patient after a prompt from nursing staff caring for them.
  • Before we go on to discussion of care bundles, this is a visual representation of where we see the AMBER care bundle fitting.
  • Use of a care bundle in a complex clinical area
  • Use of a care bundle in a complex clinical area
  • Projects teams discussed issues and what actions they needed to take to improve their sustainability score. Examples of how their plans changed include: Process - benefits beyond helping patients : future proof plans to support skills and confidence for staff to hold difficult conversations with patients Staff - clinical engagement: existing clinical champions needed to ensure a broader ownership among medical staff Organisation - effectiveness of the system to monitor progress: moving from project measurement systems to use organisation measurement and performance systems
  • The AMBER care bundle complements QIPP by ensuring the best possible death and bereavement for hospital patients and their carers. The care bundle supports: quality through enhanced patient and carer experience and satisfaction through early and consistent conversations about care and treatment choices and providing a clear pathway and package of care; productivity , helping to avoid hospital admissions through early recognition of end of life care needs, earlier decision making and involvement and better team communication and best practice; prevention by cutting out the delay in recognising and responding to end of life care needs. This helps close a gap in the quality of care for a larger group of patients than those who receive the Liverpool Care Pathway.
  • Acute hospitals end of life care best practice

    1. 1. Acute Hospitals Best Practice Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain
    2. 2. 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 9-10 th March 2011
    3. 3. End of Life Care Strategy: Aims <ul><li>Quality: To bring about a step change in the quality of care for people approaching the end of life </li></ul><ul><li>To enhance choice at the end of life </li></ul><ul><li>To reduce inequalities (e.g. Geographical and cancer vs. Non-cancer) </li></ul><ul><li>To prepare for the demographic challenge: increasing numbers of deaths, particularly amongst people over 85 years </li></ul><ul><li>To raise the profile of end of life care </li></ul>
    4. 4. End of Life Care Strategy England <ul><li>Key elements: </li></ul>Raising awareness of death and dying Integrated service delivery Workforce, measurement, research, funding, national support Societal level Individual level Infrastructure
    5. 5. National End of Life Care Programme workstreams Step 2 Assessment, care planning and review <ul><li>Advance care planning - patient and professional information – planning for your future care (evaluation) </li></ul><ul><li>PPC </li></ul><ul><li>ADRT information for patients </li></ul><ul><li>Assessment framework/ pilot (EoE) </li></ul>Step 3 Coordination of care <ul><li>Locality wide registers pilots </li></ul><ul><li>(8 sites) </li></ul><ul><li>DH initiatives Transforming </li></ul><ul><li>community services </li></ul><ul><li>Integrated care pilots </li></ul><ul><li>Personal budgets </li></ul>Step 4 Delivery of high quality services in different settings <ul><li>Acute </li></ul><ul><li>Hospitals </li></ul><ul><li>Primary care – GSF/ADA </li></ul><ul><li>“ Route to Success” </li></ul><ul><li>Care homes (volunteers) </li></ul><ul><li>Extra care housing evaluation </li></ul><ul><li>Prisons </li></ul><ul><li>Hostels </li></ul><ul><li>Learning disabilities </li></ul><ul><li>QIPP </li></ul>Step 5 & 6 Care in the last days of life and care after death <ul><li>LCP neurological /hospital Audit </li></ul><ul><li>Environments of care - King’s Fund </li></ul><ul><li>Last offices </li></ul><ul><li>Bereavement </li></ul>Pre pathway Raising Awareness <ul><li>Supporting NCPC National Coalition Dying Matters </li></ul><ul><li>Member of Dying Matters </li></ul><ul><li>National Awareness raising week </li></ul><ul><li>Peer education programme </li></ul>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 Discussions as the end of life approaches <ul><li>Communications skills (introductory, intermediate, advanced) 12 pilots </li></ul><ul><li>Clinical triggers - kidney, dementia </li></ul><ul><li>Heart cancer </li></ul><ul><li>neurological </li></ul>Step 1 Cross boundary working/sharing good practice, communications strategy, events ,website Measurement - Intelligence network ,quality markers , VOICES Social care
    6. 6. End of Life Care Programme <ul><li>Phase 3: three year service improvement programme </li></ul><ul><li>Funded by Guy’s and St. Thomas’ Charity, King’s College Hospital Charity, South London and Maudsley NHS Foundation Trust Charitable Funds </li></ul><ul><li>Working with health and social care, voluntary sector and local residents across Lambeth and Southwark </li></ul><ul><li>Building on good practice to provide exceptional care for the dying across all settings </li></ul>
    7. 7. Overview <ul><li>Guy’s and St Thomas’ NHS Foundation Trust </li></ul><ul><li>Challenge </li></ul><ul><li>Innovation </li></ul><ul><li>Impact and learning </li></ul><ul><li>Conclusion and benefits </li></ul>
    8. 8. The challenge
    9. 9. Issues around end of life care in an acute setting <ul><li>Case-note review (14/20 consecutive deaths) – </li></ul><ul><ul><li>Singular focus on treatment </li></ul></ul><ul><ul><li>Identification of patients likely to die while ongoing active medical therapy </li></ul></ul><ul><ul><li>“ add on” to care </li></ul></ul><ul><ul><li>Decision making/ escalation planning, patient/carer involvement, capacity/best interests assessment, symptoms </li></ul></ul><ul><ul><li>Timely referrals including palliative care </li></ul></ul><ul><ul><li>Communication flows within and between organisations </li></ul></ul><ul><li>Recommendations </li></ul><ul><ul><li>Identification tool </li></ul></ul><ul><ul><li>Best practice </li></ul></ul>
    10. 10. Identification <ul><li>1 – 2 month prognosis </li></ul><ul><li>Simple enough to pass the “junior doctor at 2am test” </li></ul><ul><li>Can be utilised in existing ward functions </li></ul><ul><li>Makes life easier - sustainability </li></ul>
    11. 11. Method <ul><li>Cross-sectional ward census </li></ul><ul><ul><li>Screen: “would you be surprised…still alive 1 month?” </li></ul></ul><ul><ul><li>Case notes: </li></ul></ul><ul><ul><ul><li>Rapidly deteriorating, clinically unstable, limited reversibility </li></ul></ul></ul><ul><ul><ul><li>3 or more hospital admissions past 6 months? </li></ul></ul></ul><ul><ul><ul><li>Surprise question </li></ul></ul></ul><ul><li>Haemato-oncology/ elderly care MDM </li></ul>
    12. 12. Being realistic around identification <ul><li>Tool does not predict all deaths within timescales (e.g. positive 19 to 53%) </li></ul><ul><li>Clinical reluctance to “write off” / use “surprise” vs “risk” </li></ul><ul><li>Too simple / too complex  no use </li></ul><ul><li>Pragmatic combination of identification tool (“so what?”) and intervention alongside each other </li></ul>
    13. 13. Screening questions <ul><li>Is the patient rapidly deteriorating, clinically unstable and with limited reversibility? </li></ul><ul><li>2. Is the patient at risk of dying within the next 1-2 months? </li></ul><ul><li>Yes to both  proceed to AMBER CARE BUNDLE </li></ul>
    14. 14. 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 Instructions If yes to both questions proceed to implementation of AMBER bundle. AMBER Care Bundle LCP AMBER care bundle Early planning
    15. 15. Innovation – why a care bundle?
    16. 16. Reliability and Bundles <ul><li>Every system delivers the outcome for which it is designed </li></ul><ul><li>Most routine healthcare is “chaotic” in reliability terms (50 – 80% process reliability) </li></ul><ul><li>Impacts quality and productivity </li></ul><ul><li>Need to design in reliability - standardisation </li></ul>
    17. 17. Methods to improve reliability <ul><li>Pathway </li></ul><ul><li>Guideline </li></ul><ul><li>Audit </li></ul><ul><li>Checklist </li></ul><ul><li>Care bundle </li></ul>
    18. 18. Care bundle <ul><li>Bundle has: </li></ul><ul><li>- Four to five components </li></ul><ul><li>- Can be rapidly answered yes/no </li></ul><ul><li>- Based on good evidence or self evident good practice </li></ul><ul><li>Can be locally implemented / quality controlled </li></ul><ul><li>Helps communication and team working </li></ul><ul><li>Easy to measure </li></ul>
    19. 19. Innovation AMBER care bundle
    20. 20. AMBER = Action <ul><li>Assessment </li></ul><ul><li>Management </li></ul><ul><li>Best practice </li></ul><ul><li>Engagement </li></ul><ul><li>Recovery uncertain </li></ul>
    21. 21. Key processes Identification AMBER = action Effective discharge communication Effective communication: day -> night Assessment unit -> ward ward rounds handover multi-disciplinary team meetings
    22. 23. AMBER bundle
    23. 24. What it means to ward staff <ul><li>Day one- Identification and initiation </li></ul><ul><li>AMBER follow-up </li></ul><ul><ul><li>A- “Is patient still AMBER?” </li></ul></ul><ul><ul><li>C - “Has medical plan changed?” </li></ul></ul><ul><ul><li>T – Touch base with carers - Is everything OK?” </li></ul></ul>
    24. 25. How to change clinical practice <ul><li>Part of a package </li></ul><ul><ul><li>Facilitation </li></ul></ul><ul><ul><li>Education </li></ul></ul><ul><ul><li>Guidelines </li></ul></ul><ul><li>Build into ward processes </li></ul><ul><li>Sustainability </li></ul>“ I hear and I forget I see and I remember I do and I understand” Confucius, 551-479BC
    25. 26. Results and learning
    26. 27. <ul><li>42year old patient with advanced lung cancer </li></ul><ul><li>Staff felt patient had deteriorated </li></ul><ul><li>There was no medical plan in place and scans had shown disease progression; patient was unaware </li></ul><ul><li>Patient identified as AMBER </li></ul><ul><li>Discussed with consultant in clinic – Came to ward </li></ul><ul><li>Discussion took place with patient </li></ul>Case study
    27. 28. Case study Comments 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
    28. 29. The Testing Cycle <ul><li>What we found out: </li></ul><ul><li>Medical decision making inconsistent </li></ul><ul><li>Ineffective communication within team </li></ul><ul><li>Patient/carer discussions did not include: </li></ul><ul><ul><li>Preferences </li></ul></ul><ul><ul><li>Uncertainty </li></ul></ul><ul><li>What we’re doing differently </li></ul><ul><li>Generating multidisciplinary team discussion and understanding </li></ul><ul><li>Consultant support for escalation framework where uncertainty exists </li></ul><ul><li>Early pro-active patient/ carer discussions about uncertain recovery and preferences </li></ul><ul><li>Follow-up with visual prompt </li></ul><ul><li>Systematic </li></ul>
    29. 30. Outcome of patients who received the AMBER care bundle (Jan 2010 - Jan 2011)
    30. 31. Patients who died on pilot wards (Jan 2010 - Jan 2011)
    31. 32. Preferred place of care (Jan 2010 - Jan 2011) 76% preferred place of care achieved for all patients who have died 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
    32. 33. Sustainability 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)
    33. 34. Sustainability
    34. 35. Conclusions and benefits to the broader agenda
    35. 36. <ul><li>End of life care in hospital must be addressed </li></ul><ul><li>Recognition </li></ul><ul><li>Care planning </li></ul><ul><li>Communication </li></ul><ul><li>Uncertainty must be addressed </li></ul><ul><li>Earlier recognition alongside active treatment </li></ul><ul><li>Multi-disciplinary care bundle </li></ul><ul><li>Standardisation of individualised care </li></ul><ul><li>Practical tool to make “accepted” practice happen </li></ul>Innovation Accepted
    36. 37. <ul><li>It needs to have both nursing and medical support </li></ul><ul><li>For the AMBER care bundle to be sustained it needs to mean something to each clinical area </li></ul><ul><li>It needs to be built into the daily routine and other Trust initiatives e.g. releasing time to care, acutely ill patient pathway </li></ul>
    37. 38. AMBER care bundle supports: <ul><li>Ensures best possible death and bereavement for hospital patients and their carers </li></ul><ul><li>Quality: enhanced patient and carer experience and satisfaction through early and consistent conversations about care and treatment choices; </li></ul><ul><li>Productivity: helping to avoid hospital readmissions through early recognition of end of life care needs, efficient team working and fewer unwanted tests and treatments; </li></ul><ul><li>Prevention by cutting out the delay in recognising and responding to end of life care needs. </li></ul><ul><li>Helps close a gap in the quality of care for a larger group of patients than those who receive the Liverpool Care Pathway </li></ul>
    38. 39. Questions and answers Contact: [email_address]