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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  9-10 th  March 2011
End of Life Care Strategy: Aims ,[object Object],[object Object],[object Object],[object Object],[object Object]
End of Life Care Strategy England   ,[object Object],Raising awareness of death and dying Integrated service delivery Workforce,  measurement, research, funding, national support Societal level Individual level Infrastructure
National End of Life Care Programme workstreams Step 2 Assessment, care planning and review ,[object Object],[object Object],[object Object],[object Object],Step 3 Coordination of care ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Step 4 Delivery of high quality services in different settings ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Step 5 & 6 Care in the last days of life and care after death ,[object Object],[object Object],[object Object],[object Object],Pre pathway Raising Awareness ,[object Object],[object Object],[object Object],[object Object],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 ,[object Object],[object Object],[object Object],[object Object],Step 1 Cross boundary working/sharing good practice, communications strategy, events ,website  Measurement - Intelligence network ,quality markers , VOICES Social care
End of Life Care Programme ,[object Object],[object Object],[object Object],[object Object]
Overview ,[object Object],[object Object],[object Object],[object Object],[object Object]
The challenge
Issues around end of life care in an acute setting ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Identification ,[object Object],[object Object],[object Object],[object Object]
Method ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Being realistic around identification ,[object Object],[object Object],[object Object],[object Object]
Screening questions ,[object Object],[object Object],[object Object]
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
Innovation – why a care bundle?
Reliability and Bundles   ,[object Object],[object Object],[object Object],[object Object]
Methods to improve reliability ,[object Object],[object Object],[object Object],[object Object],[object Object]
Care bundle ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Innovation    AMBER care bundle
AMBER = Action ,[object Object],[object Object],[object Object],[object Object],[object Object]
Key processes Identification AMBER = action Effective discharge communication Effective communication:   day -> night Assessment unit -> ward ward rounds handover multi-disciplinary team meetings
 
AMBER bundle
What it means to ward staff ,[object Object],[object Object],[object Object],[object Object],[object Object]
How to change clinical practice ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],“ I hear and I forget I see and I remember I do and I understand” Confucius, 551-479BC
Results and learning
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Case study
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
The Testing Cycle ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Outcome of patients who received the AMBER care bundle (Jan 2010 - Jan 2011)
Patients who died on pilot wards  (Jan 2010 - Jan 2011)
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
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)
Sustainability www.institute.nhs.uk/sustainability
Conclusions and benefits to the broader agenda
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Innovation Accepted
[object Object],[object Object],[object Object]
AMBER care bundle supports: ,[object Object],[object Object],[object Object],[object Object],[object Object]
Questions and answers Contact: [email_address]

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Acute hospitals end of life care best practice

  • 1. Acute Hospitals Best Practice Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain
  • 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
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  • 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. Innovation – why a care bundle?
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  • 19. Innovation AMBER care bundle
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  • 21. Key processes Identification AMBER = action Effective discharge communication Effective communication: day -> night Assessment unit -> ward ward rounds handover multi-disciplinary team meetings
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  • 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
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  • 30. Outcome of patients who received the AMBER care bundle (Jan 2010 - Jan 2011)
  • 31. Patients who died on pilot wards (Jan 2010 - Jan 2011)
  • 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
  • 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)
  • 35. Conclusions and benefits to the broader agenda
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  • 39. Questions and answers Contact: [email_address]

Editor's Notes

  1. 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
  2. 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.
  3. 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
  4. 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”
  5. 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.
  6. Before we go on to discussion of care bundles, this is a visual representation of where we see the AMBER care bundle fitting.
  7. Use of a care bundle in a complex clinical area
  8. Use of a care bundle in a complex clinical area
  9. 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
  10. 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.