1 Thursday 24 th September 2015 Treatment Escalation Plan Seminar WELCOME

2 Welcome & Introduction Alison Richardson

Introduce Wessex CLAHRC Aims of project Objectives of meeting Programme 3

What do CLAHRCs do? In 2008, the National Institute for Health Research (NIHR) created Collaborations for Leadership in Applied Health Research and Care (CLAHRCs). We all have a specific aim : To bridge the gap between the world class research conducted by academics and its implementation on the NHS frontline, where it can impact on patient lives and the quality of service provided to them. We bring together local NHS providers and commissioners with academics, other relevant local organisations, industry partners and health research infrastructures together with our local Academic Health Science Network (AHSN). We undertake high quality applied research and evidence based implementations that are responsive to, and in partnership with, our collaborating organisations, patients, carers and the public, the outcome being an improvement in both the health and wealth of our population.

There are 13 CLAHRCs in England and they work together as a college ensuring we share our learning across the country and work in a cohesive and collaborative way. CLAHRC Wessex is physically based at the University of Southampton and University Hospital Southampton, with researchers working in many of the Wessex NHS Trusts. “Bridging the gap between research and the frontline NHS”

CLAHRC Wessex Established in January 2014 with a five year programme of work. We are a Wessex wide partnership of providers, commissioners, patients, the public, clinicians and researchers. We aim to put into practice what we learn from undertaking research. Our focus is on bringing benefits to people living in Wessex through better integration of pathways of care for people with long term conditions and to reduce hospital admissions through more appropriate use of health care Patient and Public Involvement Methodological hub Identify variation in outcomes Improve diagnosis Improve case management, self- management and rehabilitation Ageing and Dementia Integrated Respiratory Care Identify early cognitive impairment Improve assessment Implement volunteer mealtime and mobilisation assistants Identify deficiencies in fundamental care Test strategies to improve safety, nursing capacity and patients physical needs Fundamental Care in Hospital Public Health and Primary Care Reduce antibiotic prescribing Improve early detection and prevention of chronic liver disease and acute kidney injury Self-management long term conditions Create tools to support management of conditions and care pathways Improve commissioning of self management resources Complexity and end of life care Improve patient experience by better understanding complexity Develop resources to help more effective navigation of care pathways and support interactions with care professional and health services

Our partners

Theme 6: Complexity, patient experience & organisational behaviour Focus on people with complex and often co-morbid conditions Towards the end of life Whose management moves back and forth between primary and secondary care Develop and test interventions that acknowledge and mobilise patient preferences, reduce complexity & burden of treatment Exploit theoretical models to promote and implement change across healthcare services 8

Seminar objectives Introduce CLAHRC Wessex treatment escalation planning project Hear about experiences of Devon TEP team Learn about relevant projects underway in Wessex Brief about work underway nationally to develop Emergency Care and Treatment Plan Present findings from scoping exercise to determine who is using what and where in NHS Trusts in England Work together to identify implementation challenges and how to evaluate impact and outcome 9

Treatment escalation plans: making shared decisions about treatment TEPs set out individualised patient plans for those at risk of suffering clinical deterioration Can be shared between patients, families, urgent care providers and clinicians in primary and secondary care Can be a means to empower shared decision making and ensure decisions are enacted Underpinned by process to enable positive conversations about treatment actions to be pursued and agreement about other options, including CPR, agreed to be inappropriate 10

Our project Working with NHS partners and other providers in Wessex co-produce, implement and evaluate a TEP Started in April 2015 Initial partners: University Hospital Southampton, Salisbury District Hospital and Hampshire Hospitals Currently securing involvement from primary and community care providers in these 3 localities These sites will be involved in prototype design, testing, implementation across organisation Evaluation will focus on factors that promote and inhibit implementation Plan to develop wider implementation plan in conjunction with Wessex End of Life Care Programme Board Will now incorporate involvement in national work under auspices of Resuscitation Council (UK) and Royal College of Nursing to develop a form about CPR and other life sustaining treatment Build on learning from South Central unified DNACPR policy development 11

Aims of our project By the end of 2017 anticipatory decisions about CPR and other life sustaining treatments will be recorded using the same documentation, be valid across all care settings, in three localities in Wessex and a plan agreed to support implementation in Wessex 12

Learning from others Experiences of developing and implementing Devon TEP across care settings Speakers: Dr Michael Mercer and Mr George Lillie 13

Introduction to national work David Pitcher, Co-Chair of national working group & Alison Richardson, Member of national working group

Findings from a scoping exercise to determine who is using what and where. A survey of NHS Trusts in England Dr Susi Lund Consultant Nurse, Royal Berkshire NHS Foundation Trust Clinical advisor to CLAHRC Wessex 15

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Components of ACP The negotiation of an ACP between a patient, family, and clinicians is therefore a good deal more than a personal, existential, set of decisions. It is both a rite of passage that defines a person’s shifting identity and clinical status in relation to both the self and others, and a procedural device intended to reduce uncertainty about the actions that different groups will take in response to that status in a specific set of clinically defined circumstances 17

Methods for scoping exercise Letter to all medical directors and directors of nursing of acute hospital Trusts in England Signposted to most appropriate person to respond Follow up telephone interview and request to share any documentation used Tabulating and comparing results Internet searching 18

Results Out of the 150 Trusts contacted there was no response from 90. Of the 60 (40.4%) Trusts from which responses were received 66.6 % (n=40) provided information. The responses came from either leads for resuscitation, palliative care or acute medicine/ITU/Anaesthetists Thirty three Trusts were using, or had used, records that are recognised as having been implemented and audited in other areas, such as; Modified Devon TEP (11) Amber (7) positive and negative Deciding Right (3) Own design of TEP (12) including the Cambridge UFTO. Seven trusts reported having no formal process for documenting decision-making. Internet searches and ongoing contact with interested clinicians identified 5 other TEPs in use by NHS Trusts not identified through the survey exercise. 19

20 ColourTEP used OrangeAMBER PurpleUFTO GreenDeciding right Yellow Trial AMBER unsuccessful BlueModified Devon TEP RedOwn version of TEP

Analysis Transferable vs organisational DNACPR as part of form or separate Colour Tick box versus free text Condition specific (2) versus generic MCA record Review Only one version electronic 21

Table work briefing Alison Richardson

Table work Context: intention to develop a national form and a process that will cross boundaries Work together to identify implementation challenges to considering, recording and communicating anticipatory decisions about CPR and other life sustaining treatment and how to overcome these… –Processes –Products –People How to evaluate impact and outcome Tables will address different questions Feedback by facilitators at 15.50, top 3 points from each table 23