1. Palliative Care at the Front Door Dr Karen Harvie Consultant in Palliative Medicine, NHS Lanarkshire

2. Background
30% of acute hospital days used by patients in the last year of life
75% of people will be admitted to hospital in the last year of life
Location of deaths in Scotland:
Acute setting 52.3% (Decreasing)
Home % (Increasing)
Hospice % (Increasing) (Sharpe et al, BMJ Supportive and Palliative Care 2015)
On a given day in Scottish hospitals:
10, 743 people were in-patients in the acute setting
28.8% of those admitted died within the next year
9.3% died during that admission
(Clark et al, Pal Med 2014)

3. Quality Markers of Death by Location
Home
Hospital
Care Home
Hospice
EOLC outstanding or excellent
53%
33%
51%
59%
EOLC ‘Good’
28%
36%
26%
EOLC Good to outstanding
81%
69%
84%
85%
Treated with dignity
72-78%
56.8%
61.4%
80-86%
Pain relieved all of the time
19%
39%
46%
63%
National Survey of Bereaved People in England (ONS, 2013b)

4. Preferred Place of Death
70-75% Home
4% Hospital
1% Care Home
Many no preference
Policy focus on improving figures of EoLC at home
...’or in a homely setting’

5. Preferred Place of Death
Is home always the best and preferred place of death?
BMJ 2015;351:h4855 Pollock K
Oversimplified
Often no option for ‘it depends’ or ‘it doesn’t matter’
Location a lower priority
Comfort and ‘not being a burden’ more important
Usually healthy people surveyed
Decreases with age and increasing ill health
Lower in patient with non-malignant conditions
Carers views different
Home environment changes
Guilt for carers if not achieved
Focus on experience not place

6. Reasons for Acute Admission at EOL
Patient factors
Uncontrolled symptoms
Progression of disease
Intercurrent illness
Care factors
Social isolation
Carer distress/fatigue
Care availability- especially overnight
Healthcare factors
Skills of team
Feeling of safety
Out of hours

8. Barriers to Good PEoLC in Acute Hospitals
Identification of patients with needs
SPICT, GSF
Identification of patients with ‘specialist’ needs
Difficulty ‘standing back’ in acute hospitals
Uncertainty
What is the aim of care?
Communication
Changing clinical teams
Environment
Skills
Training for hospital medical teams- 2/3 said they need more
Communication skills for prognosis/goals of care conversations
Confidence with analgesia

10. Assessing the Effectiveness of a Hospital Palliative Care Team
Ellershaw et al, Palliative Medicine, Vol 9, Issue 2, 1995
HPCT involvement
Kings College Hospital, London
125 hospital inpatients
Significant improvements in symptom control
Pain, nausea, insomnia, anorexia
Improved understanding of diagnosis and prognosis

11. Acute Medical Receiving Project

12. Acute Medical Unit Project
Hairmyres Hospital- Mar –June 2018
Aim to improve delivery of palliative care in AMRU
HPCT involved earlier in admission
Early holistic assessment of needs
Help define goals of care
EOLC support for patients, carers and staff
Get patient to most appropriate place of care sooner
Education and feedback for medical and nursing staff
Proactive daily visit from HPCT to medical receiving ward
Similar project in Ninewells Hospital, Dundee 2016

13. Method Increased medical sessions
From 2 per week to 5 (consultant or experienced specialty doctor)
Attend after post-receiving ward round
Discuss with AMRU medical team and senior nurses to identify patients with palliative care needs
Review or advise as needed
Run in period then data collection for 8 weeks
Record data on all HPCT referrals admitted through AMRU
Compared to corresponding 8 weeks 2017

14. Methods- Outcome Measurements
Length of time from admission to referral/review
Reason for referral to HPCT
Length of hospital stay
Outcome- died, discharged, transfer
Intervention by HPCT
Investigation rates
Readmission rates
Place of death

15. Results- Patient Demographics
2018
2017
Number of patients referred to HPCT 64 24
Age (mean, years) 71
Female sex 45 58
% with non-malignant disease
89%
79%

16. Results
2018
2017
Time from admission to HPCT referral
(median, days) 2 7
Time from admission to HPCT review 10
% of patients referred directly from AMRU rather than later in admission
66%
(42 pts)
13%
(3 pts)
% of patients seen within 48hrs of admission
52%
17%

17. Results
2018
2017
Length of hospital stay, all medical HPCT referrals (median, days) 8 26
-excluding patients who died in hospital 18
-patients admitted to medical ward from AMRU 13
Discharged/transferred directly from AMRU %
34% 0%

18. Intervention by HPCT

19. Results
2018
2017
Readmitted within 8 weeks of end of study period %
21%
29%

20. Duration of HPCT Involvement
2018
2017
Duration of involvement (median, days) 6 11
Total days of HPCT involvement
384
264

21. Investigations Performed

22. Place of Death 2017 2018 - All Patients 2018- Patients seen in AMU
Acute Hospital
58%
53%
36%
Home
24%
30%
42%
Hospice
12%
13%
21%
Other Hospital 6% 3% -

23. Other Benefits Improved links between HPCT and medical team
Increased referrals for outpatients?
Integration of HPCT
Improved communication with community HPCT
Referrals both ways

24. Discussion Those not seen in AMRU moved out before am reviews
weekend admissions
new diagnosis/change in aim of treatment during admission

25. Conclusion PEOLC is big business in acute hospitals
This approach delivered
Holistic HPCT review more quickly
Fewer days in acute hospital
Reduced re-admission rate
Patients less likely to die in acute hospital
Similar results seen in Tayside
Goals consistent with Realistic Medicine
Important for patients with life-limiting illnesses

26. Next Steps Application to repeat project in University Hospital Wishaw
Experienced CNS
Present results to SPIG
Lobby for increased resource to continue
Overall cost-saving?