Sharing Current Scottish Practice

This blog provides an opportunity for people to share examples of current Scottish palliative care practice that might be of interest to the palliative care community more widely. If you know of work underway that might be relevant for sharing on our website, please get in touch.

Poster abstracts of the month - May

Posted on May 31 2017 at 11:26

The SPPC Annual Conference in 2016 featured 36 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on:

Highland hospice - Reaching Out

Author(s)

Hamling K and Steele K

Highland Hospice has a proud history of delivering and promoting high quality palliative care for our community, geographically the size of Belgium with a population of just over 220,000.

We are currently piloting a number of innovative and creative responses to deal with these geographic and demographic challenges using digital communication, supporting more people to a higher standard at home or in a care home environment, increasing our value to the wider health and social care system and providing better quality care for those in need.

This outreaching of care includes:

Âž- using ECHO Highland Hospice © - a collaborative web-based model of education and care management that moves knowledge without moving people

- HHeLP – Highland Hospice electronically Linking People © - an interactive, secure internet portal developed to provide patients receiving palliative care with support and information in their own home

Âž- Helping Hands – a non-clinical volunteer support/ befriending service supporting patients and their families in the last year of life at home

Âž collaborative working with care homes across all sectors to improve end of life care

Âž- working with community services currently being redesigned to support and improve end of life care closer to home.

This poster presentation will report on all these projects in action.

How can a palliative care outcome measure be used in an acute care setting? An audit of the Integrated Palliative Outcome Scale (IPOS) in a Scottish teaching hospital

Author(s)

Buchanan D, Brabin E, Dickson S, Finlay M, Gaffney M, McFatter F, Paterson F and

Scott J

Background: The Integrated Palliative Outcome Scale (IPOS) has been developed to enable a streamlined, holistic approach to outcome measurement in palliative care patients. Practical experience of using IPOS in different care settings is required to develop understanding of its usability, acceptability and value for patients, relatives and staff.

Methods: A prospective audit of IPOS (3 Day Patient Version) was undertaken in a Scottish teaching hospital between November and December 2015. Consecutive referrals to the Team were considered for IPOS on first contact, after 3 days and prior to discharge.

Results: Of 68 patients screened (median age 70), 27 (40%) completed one IPOS and 7 (26%) completed two. Median Palliative Performance Scale (PPS) was lower and Palliative Prognostic Index (PPI) was higher in patients who did not complete IPOS versus those who did (PPS 40% versus 50%, PPI 6 versus 3.5). Problems reported most frequently as moderate, severe or overwhelming were family anxiety (85%), mobility (85%), pain (81%), weakness (78%) and patient anxiety (74%). 67% of patients reported ≥5 symptoms as moderate, severe or overwhelming.

Conclusion: IPOS facilitates a comprehensive holistic assessment and provides useful information about the range and severity of problems affecting patients referred to a HPCT. Patient frailty and staff resource are factors which may limit its repeatability in busy hospital wards. Population level data aggregation is required for IPOS scores to be benchmarked and contextualised.

How do palliative care specialists add value?

Author(s)

Mcmillan M

Aims: To test a tool that demonstrates the areas and complexity of care covered by a HPCT professional per patient visit.

Methods: Informed by a literature review a specialist intervention tool was developed. This scores activity within eight domains of care, commonly assessed and managed by HPCT, according to complexity. It also records the length and type of visit.

Over 4 weeks the tool was used to assess and score every patient intervention (assessment visit and resulting activity) carried out by the HPCT.

Results: In the study period 74 patients were reviewed and 277 interventions made.

60% of visits were multi-dimensional with 5 or more of the 8 domains of care assessed.

71% of interventions included assessment of patient priorities and discussions related to advanced care planning

25% of patients had very short but intense involvement from HPCT to achieve desired place of care: less than 4 visits but activity in all 8 domains.

Conclusion: The specialist intervention tool highlights areas where practitioners are adding value to patient care and where they are influencing patient outcomes. The domains of care are broad enough to be applicable to both hospital and community palliative care.

Informing practice: NHSScotland Palliative Care Guidelines 2016 Survey Results

Author(s)

Fearns N, Riches E and Winning A

The NHSScotland Palliative Care Guidelines website received over 109,000 visits between August 2015 and August 2016. The most frequently visited guidelines are: anticipatory prescribing, choosing and changing opioids, Fentanyl patches and syringe pump drug combination tables. To inform an approach to a potential update of the guidelines a national survey was issued during May 2016 and received 349 responses. 28.9% of responses came from palliative care specialists, 71.1% from non-specialists with the greatest proportion of respondents being community nurses (36.4%). 93.4% of all respondents agreed or strongly agreed that they used the guidelines to guide and inform treatment and/or care decisions for patients. Of the 101 palliative care specialists who responded 14.9% indicated that they were aware of new evidence or changes in practice impacting on use of the guidelines, such as changes in availability of medicines, new evidence on effectiveness of medicines and changes in terminology. Guidelines cited as requiring updates include: seizures, Alfentanil, care in the last days of life, vomiting and nausea and neuropathic pain. Suggestions for improvement include changes to the website layout and increased promotion of the guidelines. The survey results alongside website data will inform a potential series of guideline updates.

Lothian Care Assistant Development Programme - An education initiative

Author(s)

Cassidy L

With the Scottish Government’s integration of health and social care, social care teams are increasingly leading the care for clients and their families who are living with a terminal illness. Addressing the learning needs of social care workers is essential to ensure the provision of high quality palliative care for families’ in their preferred place of care, and to reduce emergency admissions to hospital where avoidable.

Care workers attended a single training day, with a portion going on to complete an online module. Care workers were supported in their care setting by a workplace mentor. Mentorship training and support was provided by the programme team.

500 social care workers will have completed the single day training and 75 will be completing the online professional development module by the conference date. Single day evaluation, pre and post knowledge and confidence questionnaire and focus groups are being used to evaluate the programme and its transferability.

To achieve the aims set out in the Strategic Framework for Action on Palliative and End of Life Care, it is essential that social care teams are adequately supported and trained to provide high quality palliative care for people and their families living with a terminal illness.

Poster abstracts of the month - April

Posted by Rebecca Patterson on April 5 2017 at 17:04

The SPPC Annual Conference in 2016 featured 36 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on:

Electronic key information summaries allow timely documentation of patients’ wishes out of hours

Author(s)

Finucane A, Hall C, Leiva A, Lunan C, McCutcheon H, McLoughlin P, Murray S, Rhee J, Spiller J, and Tapsfield J

Introduction: Electronic Key Information Summaries (KIS) are shared electronic patient records widely used throughout Scotland (Tapsfield et al. 2016). These allow selected parts of the GP patient record to be routinely shared with healthcare professionals across settings. The KIS may contain vital information to support out of hours palliative care decision-making, such as patient preferences for place of care, DNAPCR status and anticipatory medicines.

Aim: To identify when different information pertinent to out-of-hours palliative care decision-making was serially recorded within the KIS for patients who died with cancer, organ failure or frailty and/or dementia.

Method: A retrospective review of the primary care notes of deceased patients across nine general practices in Lothian was conducted in 2014.

Results: We analysed 605 patient notes. A KIS was shared for patients with organ failure 22 weeks before death (Mdn=22, IQR=10-31), and for those with frailty and/or dementia, 20 weeks before death (Mdn=20, IQR=8-34). For patients with cancer, KIS’s were commenced later (Mdn=14, IQR= 6-27). Information on anticipatory medicines was shared two weeks before death (Mdn=2, IQR=1-6).

Conclusion: Electronic key information summaries facilitate the timely documentation and sharing of patient information that is vital to support out of hours decision-making and prevent inappropriate hospital admissions.

End of life care in the digital age

Author(s)

Jayne E

Outline of Sue Ryder's Online Community and Support for people who are dying, their families and people who are bereaved:

Âž the need for such a 24/7 support (current lack of consistent co-ordinated support and advice overnight and at weekends)

Âž why it was established (to meet this unfulfilled need and extend Sue Ryder's services beyond physical locations of palliative services)

Âž how it works (community for people receiving end of life care, their families and people who have been bereaved to share experiences and provide peer-to-peer support, supported by bereavement counsellors; an advice section on practical issues such as will-writing through to coping when someone is dying)

Âž what impact it has had on people's lives in its first year (figures on users, qualitative feedback)

Âž relevance to Health and Social Care Partnerships (new responsibility for provision of palliative care could include services like this or signpost to services like this).

Evaluation of an Anticipatory Care planning tool for care home residents and their families

Author(s)

Boyd K, Gardner H, Highet G, Hockley J, MacKay A and McCutcheon H

The poster describes the methodology findings and conclusion of a primary care quality improvement project which evaluated the efficacy and acceptability of a tool (ACQ) being used to facilitate anticipatory care planning in two contrasting care homes in Edinburgh. An audit of acute clinical events was combined with an interview study involving 27 relatives, care home staff, and local GPs. Interviews were recorded, transcribed and analysed thematically. A focus group of 30 out-of-hours GPs discussed linked case vignettes. The project found that clear plans, recorded electronically and informed by the ACQ, ensured most acute clinical events were handled appropriately. The system was most vulnerable when protocol driven decisions were made by out of hours NHS services. The study concluded that anticipatory care planning should start before care home admission and be a coordinated, ongoing care process tailored to individual needs and embedded in the routine procedures of care homes. Further work to develop family and staff information using a patient public involvement approach is now underway.

Gleniffer Outreach Information and Support Centre as a Palliative Care Community Resource

Author(s)

Crawford A and Simpson H

Gleniffer Outreach Information and Support Centre is a Palliative Care Community Resource.

Our current Gleniffer Outreach facility relocated and opened in 2012 within the grounds of the Royal Alexandra Hospital in Paisley, a location that has proven significantly beneficial.

Our aim was to provide a facility where patients, carers, Health / Social professionals and the general public could drop in or telephone for advice, guidance or be signposted to more suited services relating to any aspect of malignant or non-malignant palliative care need(s).

The centre also provides an alternative location to the hospice, as it was reported that some individuals had difficulty with attending / returning to our hospice, especially for post bereavement support and counselling.

Initially we did not know that we were developing a public health approach to palliative care. However this transpired by encouraging a compassionate and resilient community approach, increasing public awareness around death and dying, offering practical support, networking with other local services, whilst furthering volunteer involvement.

HHeLP - Highland Hospice Electronically Linking People (in the Highlands)

Author(s)

Greenhalgh J, Keen J and Ravi G

Background: The Inverness based Highland Hospice, provides a 10 bed in-patient service, Day Therapy service, telephone advice for HCPs, outpatients, domiciliary visits and a Bereavement Counselling Service to adults with advancing life-limiting disease living in the NHS Highlands area.

The number of patients supported is the equivalent of 18% of the 2,500 people in this catchment area who die every year. HHeLP could quadruple the reach of current support.

Method: People are recruited from contact through any of the Hospice services and the primary care team is informed - as Virtual Hospice aims to complement existing care of primary care teams giving greater confidence to patients and carers in their ability to cope at home.

Individualised/prescribed resources are uploaded onto the portal and patient and carer are shown how to access and use. The portal enables secure messaging accessible by the team around the clock.

Recruitment: The pilot has recruited approximately 20 users from across Highlands.

Results: Early results have highlighted some interesting learning points

Recommendations:

Âž Increase range of resources

Âž Introduce carers to the system with resources to help them in their caring role.

Âž Training of volunteers to give IT support locally to patients/carers who struggle with the electronic access.

Poster abstracts of the month: February

Posted by Rebecca Patterson on February 23 2017 at 15:33

The SPPC Annual Conference in 2016 featured 36 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on:

Developing Documentation for End of Life Care

Author(s)

Farquharson J

Following the recommendations of the Neuberger Report1 on the use of the LCP and subsequent guidance from SG we developed a means of recording, evidencing and auditing end of life care (EOLC) which met requirements of the SG’s four principles.

Thirteen key objectives were agreed in relation to evidencing and auditing appropriate EOLC. These were translated into an End of Life Care Record (EoLCR).

The project comprised two stages:

Stage 1 (5 week pilot)

Âž Ward A: Patients identified as being in the last days/hours of life, care documented in EoLCR

Âž Ward B: Patients identified as being in the last days/hours of life, care documented in Personal Care Records (PCR).

Âž All data compared against the 13 objectives

Âž EoLCR rolled out to all wards.

Stage 2 (Retrospective Audit)

A retrospective audit was undertaken of all deaths within the hospice over 3 months of implementation

We aimed to develop a robust means of evidencing EOLC which followed SG’s 4 principles. This relates to NHS Scotland’s 2020 vision that care will be provided to the highest standards of quality and safety, with the person being centre of all decisions.

The retrospective audit showed improvements in recording EOLC.

Using the EoLCR allowed us to evidence the principles of good EOLC especially in relation to nutrition, hydration and communication with patients/ families.

Development of the Scottish Acute Palliative Care Clinical Nurse Specialist Forum

Author(s)

Ewan D

Hospital palliative care teams have developed inconsistently over the past few decades and differ in their structure and numbers of healthcare professionals involved. The main role of an acute hospital palliative care team is to work collaboratively with other healthcare clinical specialties in an advisory, supportive and educative capacity to improve care delivered to palliative patients and families. The clinical nurse specialist in palliative care provides the backbone to these services across Scotland but with increasing clinical workloads, the demands on other key dimensions of the service such as research/audit/quality and service improvement can suffer. The founder of the group wanted to heighten the work that hospital palliative care teams do and provide a forum for acute palliative care clinical nurse specialists to network, provide information and support and collaboration on joint initiatives for practice and service development for hospital palliative care services across Scotland. The group developed named the Scottish Acute Palliative Care Clinical Nurse Specialist Forum consists of 30 members from 10 health boards across Scotland. The aims, objectives and workplan for the group are displayed on the poster along with contact details.

Difficult conversations with families and patients about end of life care after stroke: what are the educational needs of health care professionals?

Author(s)

Bailey F et al

This poster shows the results of a survey monkey in to the training and educational needs around having difficult and sensitive conversations with patients and families after an acute stroke. The participants were asked 9 questions related to their experience of this difficult area of work and what they felt were the most important areas for improving their own practice in future. This was the basis for a new STARS (Stroke Training Awareness Resource) module which was published on line in January 2016.

Does a pre-visit phone call result in improvement?

Author(s)

Smyth S

An area for improvement suggested by the Care Inspectorate was to 'consider' an audit of medication procedures in the CHAS at Home (CaH) Teams. We have four CaH Teams, one based at Rachel House, Robin House, Inverness and Aberdeen. Audits were carried out in 2015 and 2016 looking at the reviewing of the medication chart at the Pre Visit Phone Call and then on the arrival at the house. The five audit questions were based upon standards set out in the Standard Operating Procedure for Checklists were introduced between round one and two looking at standardising the pre visit phone call, preparing for a visit an on arrival at a visit checks.

The focus of this poster is looking at one of the five questions, 'Was a pre-visit phone call made to the parent/ carer to confirm the visit and check for if there have been any changes to the medication prescription since CHAS's last contact with the family?' The child's prescription often will have been altered by our acute and community colleagues. The poster demonstrates the before and after results following the introduction of the checklists and the feedback we later received from the Care Inspectorate.

Poster abstracts of the month: January

Posted by Site administrator on January 26 2017 at 16:46

The SPPC Annual Conference in 2016 featured 36 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on:

Bereavement Support in a Hospice Setting

Elliott J, Jackson S and Taylor M

Bereavement can be a difficult process for people however evidence suggests that sharing experiences and feelings can help to lessen the effects on individuals. It is also known that people can struggle to access the right support at the right time following bereavement. Hospices are at the sharp end of caring for people who are dying and offering support to their families is a fundamental part of specialist palliative care. The patient and family support team at Accord Hospice consists of trained counsellors and volunteer bereavement support workers who proactively offer bereavement support and try to do so in innovative ways to meet the varying degrees of need of bereaved families within the local community. These services are offered both within Accord and off site at our outreach facility.

User experience feedback has been collected over the past 12 months. Collated results would appear to show there is definitive value to offering timely, appropriate and varied bereavement services from a skilled hospice based team. Many of the comments received from people would reinforce the evidence that suggests that support can lessen the effects of bereavement.

Children's Palliative Care in Scotland: the role of the Diana Children's Nurses

Harley D, Porter C, Reid F and Rodger E

Children's Hospice Association Scotland has employed three Diana Children's Nurses (DCNs) since 2014. They are financed through the treasury from funds set up by the government to commemorate the life and work of Diana Princess of Wales. The overarching aims of the roles are given in generic terms, encompassing strategic service development, direct and indirect clinical care, and staff training / support. The three individual roles, DCN West, East and North, focus on the specific remits of oncology and paediatric intensive care, neonates, and the community. They work within, and alongside, the NHS and other statutory and voluntary sectors to support babies, children, and young people (BCYP) with palliative care needs and their families across Scotland. This may be from the point of diagnosis or recognition, at any point through the journey, to end of life and bereavement. Their roles exemplify a holistic approach that recognises all the environments in which BCYP live their lives. More realistic choices for families can be better enabled through exploring changes to practice, whilst developing systems, skills and resources.

CNS model for identifying level of support/intervention needed for care homes

Barker L, Gardner H, Milton L and Stevenson B

Background: Continued support from palliative care specialists is recognised as a way to assist the sustained adoption of new systems and palliative care principles in care homes. (2, 3) Hospice community teams are well placed to support care homes to improve planning and delivery of palliative care. The community palliative nurse specialist team support 28 care homes by providing support to develop processes for identifying deterioration or dying, regular review of palliative care needs, education and specialist advice for individual residents.

Aim: This intervention builds on two previous projects aimed at increasing care home staff knowledge of palliative care practice and procedures, and how they can link together with other palliative care providers’.

Description: The challenges encountered especially with care home staff engagement influenced the importance of shaping any interventions to suit the needs of the individual care home.

An individual Care Home Profile and Algorithm (flowchart) was developed to assist the CNS to determine and agree, with the manager, a Level of CNS Intervention most appropriate and achievable for the individual care home.

Effects of Intervention: Issues such as staff turnover, engagement, and lack of GP resources are an on-going challenge when trying to change palliative care practice and procedures in care homes. Utilising the Care Home Profile and identifying a Level of Intervention has helped the CNS and manager to focus on the priorities for education and change in practice for each care home. Using this model has helped CNS to set achievable goals of intervention and therefore ensure their skills and times are being used appropriately.

Complex Communication Needs: Nursing the patient with Motor Neurone Disease

Alexander J and Kerr F

Case study of a hospice patient combined with a literature review to:

establish what communication difficulties can be experienced by nursing staff caring for a patient with MND
identify ways in which nurses can improve their knowledge of Augmentative and Alternative Communication (AAC) to better care for this patient group
identify assessment tools which can assisted with achieving the most appropriate AAC.

Poster Abstracts of the month: November

Posted by Rebecca Patterson on November 28 2016 at 12:30

The SPPC Annual Conference in 2016 featured 36 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on:

01. A quality improvement approach to cognitive assessment on hospice admission: could we use the 4AT or short CAM?

Author(s)

Baird L and Spiller J

Prevalence studies show that 15-42% of patients admitted to specialist palliative care inpatient units have delirium. Symptoms of delirium are often subtle and easily missed, or misdiagnosed as fatigue or even depression, and so the use of a screening tool could improve early identification and management of delirium and lead to improved outcomes. Patients admitted to the hospice are often frail and tired; therefore a quick and easy to use method of cognitive assessment is essential. A quality improvement approach was used to improve screening for delirium on admission to a hospice unit. The first cycle determined staff preference between the short CAM and the 4AT. Two further PDSA cycles embedded the 4AT (our preferred tool) into the admission process, establishing it as a usable tool in the hospice setting for up to 92% of admissions. A subsequent cycle showed poor sustainability prompting improvements to staff education and changes to admission documentation. The QI approach highlighted the need to link staff awareness of their use of the screening tool with perceived improvements in treatment of delirium which prompted the creation and implementation of a delirium checklist in the unit, which details the management of delirium, common causes and suggested investigations.

02. Addressing the Great Taboo

Author(s)

Alexander H and Beuken G

This short session was designed to address the taboo of talking about death, dying and bereavement. Although it had not been tried before and there were concerns that some participants may be distressed by the content, the observation results show that this was not a big problem. Participant responses during the session show that the audience knew quite a lot about the topic. This is helpful for peer learning but also because the session was designed as a structured conversation to encourage people to discuss the subject more openly, some mentioned that they planned some actions as a result of attending e.g. making a will or discussing their own funeral wishes with their family. Feedback from the end of the session showed that most people found the session very interesting, although others had mixed reactions, saying it was also challenging. In total 81% of those present requested more training, which indicates a strong desire for more. Some degree of discomfort was expected, however, the session appears to have been very positively received by most participants. There was a small level of not unexpected upset, and a strong desire to learn more.

03. Aiming to achieve realistic bereavement care throughout Greater Glasgow and Clyde

Author(s)

Dolan J, McNeill K, McVey H, Miller J and Neeson E

Introduction: ‘How people die remains in the memory of those who live on’. Facilitating a good death can impact positively on grief and bereavement.

57% of deaths in Greater Glasgow and Clyde occur in acute hospitals, as health care professionals we are in a privileged position to strive for good deaths. Enabling practitioners to be open and equipped to talk about death, dying and bereavement reduces negative experiences.

Aim: To increase practitioners’ confidence and competence when dealing with death, dying and bereavement.

To raise awareness of resources and processes to improve the experience of those affected by death, dying and bereavement in all care settings

Methods: Following a theoretical palliative care module practitioners returned to improve practice through various projects (in ITU, paediatrics, acute surgical receiving , orthopaedics, ENT, tissue viability, respiratory and general medicine), aiming to improve the patients and relatives experience of death, dying and bereavement out with specialist palliative care environment

Projects included:

Âž memory making in the form of hand prints, hair and jewellery in organza bags

Âž brightest star bereavement boxes

Âž death certification checklist

Âž raising awareness of resources and processes

Âž care after death boxes.

Next steps: Secure funding to embed projects in daily practice, continuing partnership working

04. Approaches to delivering palliative care in nursing care homes in the UK: a systematic scoping review

Author(s)

Finucane A, Hockley J and Kohli-Lynch N

The UK population is ageing with more elderly people living and dying in nursing care homes, making these important settings for palliative care interventions. Multimorbidity and dementia are common and many residents will have high symptom burden and complex care needs. A scoping review was undertaken to map palliative care interventions in nursing homes in the UK. This involved systematically searching six databases from January 2000 to February 2016. 17 articles were identified. These consisted of 7 evaluations studies, 7 descriptive or observational studies and 3 implementation studies. The studies focused on palliative care pathways, advance care planning, staffing issues and healthcare links across settings. The majority of studies were focused on staff views with few focussing on residents’ experiences. However overall there was a paucity of research on palliative care interventions in UK nursing homes. An increased emphasis on developing and evaluating palliative care interventions that are informed by the needs and preferences of resident’s and family’s experiences is recommended.

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