Supporting delivery of high quality end of life care in hospitals Welcome to our Webex / ECHO Meeting 13th December, 2017 18/09/2018

Agenda for Today’s webex meeting: Agenda item Duration Welcome and introductions 10 minutes Didactic discussion – the sustainability model 15 minutes Presentation 1 – East and North Herts – followed by discussion and questions 30 minutes Presentation 2 – Leeds - followed by discussion and questions Any other business 18/09/2018

The Sustainability Model Claire Henry 18/09/2018

18/09/2018

Tuesday, September 18, 2018

2. Credibility of benefits  Are benefits to patients, staff and the organisation visible? • Do staff believe in the benefits? • Can all staff describe the benefits clearly? • Is there evidence that this type of change has been achieved elsewhere? Benefits of the change are widely communicated, immediately obvious, supported by evidence and believed by stakeholders. Staff are able to fully describe a wide range of intended benefits for this initiative.   Benefits of the change are not widely communicated or immediately obvious even though they are supported by evidence and believed by stakeholders. Benefits of the change are not widely communicated or immediately obvious even though they can be supported by evidence. They are not widely believed by stakeholders. Benefits of the change are not widely communicated, they are not immediately obvious, nor are they supported by evidence or believed by stakeholders. Tuesday, September 18, 2018

Tuesday, September 18, 2018

Tuesday, September 18, 2018

East & north HERTS trust building on the best Dr Dee Traue, Palliative Medicine Consultant Jemma Finch, Lecturer Practitioner EOLC Ursula Reeve, Lead Palliative Care

Pain & Symptom Management - Anticipatory prescribing

Aim Regional Develop a regional guidance for anticipatory prescribing in line with national recommendations for use in all care settings across South Beds & Herts (+/- West Essex and North & Central Beds) Local Develop a policy to sit alongside guidance Trust renal anticipatory prescribing guidance being developed – due to regional timescales this will not be completed by March deadline Implementation Baseline and post-implementation audits

What did you do? Baseline electronic survey Determine current and future preferences for anticipatory guideline 32 responses from a variety of professionals across the region Consultation electronic survey Modified Delphi Sent to individuals and groups 44 responses so far Regional task and finish group Chair from ENHT Two members from each locality MDT Core representatives from Herts & South Beds Variable input from West Essex and North & Central Beds CCG pharmacist CCG project manager Mix of conference calls and face to face meetings

Impact and evidence Local baseline review Trust-wide retrospective notes based audit of 30 deaths Themes Breathlessness and delirium as the “forgotten” symptoms Poor use of dose ranges Repeat audit to be undertaken in February 2017 Agreed Anticipatory prescribing guidance for Herts & S Beds

What next?

Most significant learning Project development and initiation Having a clear terms of reference and project plan Trying to avoid scope creep Pros and cons of collaboration Delays at several stages due to lack of progress in other organisations Benefits of technology for facilitation of regional meetings and consultation Innovation will be needed for launch Know when to cut your losses

Use of palliative care and ACP section minimal Effective communication on transfer of care Phase One Pilot Training for Elderly care team (doctors / CNS) Identification Conversations Advance care planning Attend weekly Elderly Care MDTs Board round identification of last year of life Team to have general discussion with patient on frailty or “serious illness” DNACPR / TEP as appropriate Discharge summary “This person is appropriate for GSF & EPaCCS” DNACPR / TEP decisions ENH CCG ADA 20% of patients who died within 30 days had no EOLC plan in last discharge summary AUDIT What happens now Use of palliative care and ACP section minimal Launch October 2017 Elderly care ward have “extended summary” with mandatory field for Palliative Care & ACP Phase Two Alert on EPR for GSF / EPaCCS Automatically pulls through to discharge summary

Aim Facilitate transfer of ACP discussions in discharge summaries and reduce inappropriate hospital admissions at the end of life Extended Elderly Care discharge summary has been developed and implemented for patients on elderly care wards The extended summary includes a mandatory field on “Palliative and advance care planning recommendations”. Review use of this extended summary Scope the potential for spread to other clinical areas

Baseline evidence Trust-wide retrospective notes based audit of 30 discharges from Elderly Care ward Benchmark advance care planning information documented in Elderly Care Extended Discharge Summaries Proportion of extended discharge summaries with information in ACP box = 0% Conclusion - Process change does not change outcomes

What are we doing? Scoping on frailty ward (MDT) underway with support from ward consultants Scoping on ortho–geriatric wards – Board round unsuccessful due to lack of medical attendance. Patient leaflet explaining GSF and EPaCCs Education 2 sessions planed on elderly departmental meeting 1 session on medical divisional teaching programme

What will we do Identification Communication Documentation SPICT Skills training Role modelling Documentation Discharge summary completed by most junior staff Keep messages simple GSF / EPaCCS / DNACPR

What will you do? Advance care planning Focus group to explore views Appreciate concerns Consider what can be reliably done in acute hospital setting Consider focus on treatment escalation planning Highlight that this is a process and back up with clear plan for handing over to community

Most significant learning Work with areas that are interested and when you have proof of concept roll out Don’t make assumptions Be flexible with your plans Process alone will not deliver change - need to engage hearts and minds Consider sustainability from the start

The Outpatients Project Oncology and Heart Failure OPD Building on the Best The Outpatients Project Oncology and Heart Failure OPD

Top 3 points Patient involvement Staff involvement Survey banner and leaflet Case note audit what is happening discussions early referral Staff involvement Learning from both sides Integration in to OPD Resources to bring this together Training E resources HF and Oncology are not mutually exclusive and have many commonalities

The Background Research – ‘early referral to specialist palliative care can improve quality of life at the end of life’. In Leeds referral to SPCT is (on average) 6 weeks before death Enhanced supportive care – the Christie’s Project - dovetailing Unnecessary hospital admission avoidance Outpatient interface between hospital and community Previous SPCT service into OPD – can it be re-energised? Advance care planning – a good place to start? Information and resources

Measurements and Evaluation Focus group - ‘Knit and Natter’ (stitch and bitch) Staff Confidence questionnaires Survey of banner and leaflets – patients and carers in the Oncology OPD Audit of electronic information (PPM) (HF and Onc) Date of diagnosis to referral to SPCT (Onc) Date of referral to SPCT to death (Onc) Recording ACP (HF and Onc) Number of days/episodes of admission in last year of life (Onc)

The Questionnaire – Onc OPD What would Prompt you to Consider a Referral to the Palliative Care Team? What Palliative Care Services are you aware of locally? How confident are you about discussing Advance Care Planning/EOLC/local resources? How regularly do you discussing Advance Care Planning/EOLC/local resources? Is there enough written information in the OPD?

What Palliative Care Services are you Aware of Locally? How confident are you about discussing the following? (out of 5) What Palliative Care Services are you Aware of Locally? EoLC issues- average 3.4 Consultants- 4.67 Registrar- 4 Staff Nurse- 2.5 CNS- 4.14 CSW- 2.29 ACP- average 2.89 Consultants- 3.67 Registrar- 3 Staff Nurse- 2 CNS- 3.86 CSW- 1.67 Resources Information- average 3.35 Staff Nurse- 3 CNS- 4.57 CSW- 2.14 Symptom Management- average 3.21 Consultants- 4.33 CSW- 1.5 On average- 2.42 CSW- 1.43 CNS- 2.67 Consultant- 3.67 Registrar- 5 (only one Registrar respondent) Staff Nurse- 2 Most commonly known: Hospices, Hospices Team and Community Team, Internal SPCT Others mentioned by a few: Macmillan, Robert Ogden Centre, Psycho-oncology Regularity of Discussing Advance Care Planning

Banner and Leaflet Survey

Your Building on the Best Package Banners and Leaflets supporting Advance Care Planning Outpatients Palliative Care Intranet Page Start the Conversation Teaching Sessions Resources to Support Referral to Palliative Care Services Specialist Palliative Care Eligibility Criteria VIA …

Impact Here and Elsewhere Legacy and sustainability Personal & professional impact ACP and conversations ‘slow burner’ RN confidence in having conversations/making referrals to general palliative care services e.g. DN versus specialist palliative care services RN confident in providing advice to other professionals Scale-up to other Oncology outpatient departments of the BOTB package Cardiology - MDT and education Information lounge Earlier referrals to community SPCT from OPD Interest in banner out of area e.g. GP practice in York, DGH in Harrogate, nationwide through the Trust in BOTB community Advertising/Media/Publishing

Heart Failure Learning transferable from Oncology to HF OPD Community Palliative Medicine Consultant involvement (1 session per week - legacy) Excellent relationship between teams involved Virtual clinic/joint MDT Audit - Does ACP happen in clinics?

Challenges, Support and Case Study Education Stakeholder engagement and unknown territory Case study template

Any other business? 18/09/2018

Thank You 18/09/2018