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

2. 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

3. The Sustainability Model
Claire Henry
18/09/2018

4. 18/09/2018

5. Tuesday, September 18, 2018

6. 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

7. Tuesday, September 18, 2018

8. Tuesday, September 18, 2018

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

10. Pain & Symptom Management - Anticipatory prescribing

11. 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

12. 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

13. 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

14. What next?

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. 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

25. 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

26. 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)

27. 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?

28. 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

29. Banner and Leaflet Survey

30. 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 …

31. 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

32. 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?

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

34. Any other business?
18/09/2018

35. Thank You
18/09/2018