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 discussionsInformed decisionsInformed 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 & ed to GP Practice mailbox

Deterioration at the End of Life 53% 53% of all deaths (n=958) ‘expected death’ End of life care plan commenced: median 32 hrs prior to death 28% 28% of all deaths = ‘rapid decline’ Both groups: indicators of ‘limited reversibility’, uncertainty of recovery, risk of deterioration = need for active upstream planning

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 % of patients medicine of the elderly % 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