1. Symptom Management: Terminal Agitation L21

2. Aim Primary Drivers Secondary Drivers
Improving the Management of Terminal Agitation (TA) with or without Delirium
Aim Primary Drivers Secondary Drivers
Staff education
Role modelling
Awareness of signs & symptoms
Identify signs and symptoms of TA
Motivated workforce
Recognition of impact on family
All staff feel empowered to highlight patients that have TA
All staff recognise the importance of managing TA
All dying patients who are experiencing terminal agitation have an effective individualised plan of care by September 2017 on the pilot wards (L21, J28 & J29)
Culture of accountability & team work
Identification & treatment of reversible causes
Role of non-pharmacological measures
Aware & confidence in using medications
Role of the family in management of TA
Care supported by CoDP multidisciplinary documentation
Driver diagram
To increase staff confidence in the recognition and management of terminal agitation
To improve the documentation and evaluation of all interventions
To improve the recognition of terminal agitation
To improve identification of causes of terminal agitation and the use of non-pharmacological interventions
To standardise the use of medications to manage symptoms
Clear guidance on TA

3. Excellent examples

4. Staff confidence questionnaires Referral audit Interventions:
Measures:
Case note audit to determine baseline repeated during and post interventions
Staff confidence questionnaires
Referral audit
Interventions:
Ward based role modelling care of the dying (Weekly for 4 months)
Ward based teaching sessions
Clinical educator would help to relieve staff to attend teaching
Attended 2 clinical governance meetings – attended by HoN, matrons, consultants, AHPs
Junior doctors very keen and engaged and pharmacist
Teaching session for junior doctors, informal teaching when on ward

6. Audit Proforma
Yes No
N/A
1. Care supported by the care of the dying person multi-disciplinary documentation
2. Assessment of TA documented in medical notes?
3. Plan of care for management of TA documented in medical notes?
4. Evidence of reassessment & evaluation of interventions in medical notes?
5. Daily assessment and plan of care complete (for all relevant days) for symptom management for nursing care plan (page 22 of CoDP)
6.Daily evaluation completed (for all relevant days) for symptom management nursing care plan (page of CoDP)
7.Overall Score (excellent, good, average, poor)
Based on 5 deaths per month
L21 Have average 9 deaths per month
Baseline March 16-March 17
During intervention April 17-August 17
Post intervention Sept 17-March 18
CoDP= Care of the Dying Person (multi-disciplinary) documentation/care plan

7. Run chart demonstrates statistically significant improvement in the rate of assessment of terminal agitation (p<0.05).
Run charts were created with baseline data and on-going data collection during the project
Each point = 5 deaths per month
12 data points to gather baseline
Re-phasing run charts – new median describes new level of performance
Shift is detected – more than 6 data points above the median.

8. Run charts were created with baseline data and on-going data collection during the project
Run charts demonstrated statistically significant improvements in the rate of assessment, reassessment and evaluation of terminal agitation (p<0.05).

9. Run chart demonstrates statistically significant improvement in the rate of re-assessment & evaluation of interventions of terminal agitation (p<0.05).
Run charts were created with baseline data and on-going data collection during the project
Run charts demonstrated statistically significant improvements in the rate of assessment, reassessment and evaluation of terminal agitation (p<0.05).

11. Excellent examples of care

12. Excellent examples

13. Intervention bundle for neurosciences (L12, L17, L24 & L25)
Next Steps
Intervention bundle for neurosciences (L12, L17, L24 & L25)
Ward based role modelling (involving link nurses/clinical educators)
Ward based education (involving clinical educators)
Medical staff education
Juniors education session
Clinical governance meetings
Discussion of dying patients in safety huddle with a focus on terminal agitation
Linking in with clinical educators
Plan for band 6 on each ward
Meet every 6-8 weeks
Ask about

14. Through collaborative working, ward based role modelling and weekly data collection we have demonstrated it is possible to improve the overall management of terminal agitation
Linking in with clinical educators
Plan for band 6 on each ward
Meet every 6-8 weeks
Ask about

15. Well done to L21 on improving care for patients towards the end of life
Our palliative care team in Leeds was selected to be part of a national QI collaborative 'Building on the Best (BOTB)' a Quality improvement collaborative aimed at improving the care of patients towards the end of life. On Thursday Dean Royles and the palliative care team presented the L21 team with a certificate congratulating them on making significant positive improvements in the way patients are cared for on the ward. This work will now be scaled up to other wards across neurosciences as a result of its success, supported by the BOTB team. Thanks to all involved for your hard work and improving care for our patients!