Sharing Current Scottish Practice

Authors: Moray Kyle ; Jenny Smith ; Amy Armstrong ; Louise Ratcliffe ; Jenna Schafers

Background: Escalation planning and CPR decisions not always considered early enough in patient journey, potentially leading to suboptimal care.

Aim:To assess the standard of documentation in inpatient notes across the ECC wards relating to the discussion of resuscitation and escalation status.

Results: 46 patients’ notes reviewed. 9/46 had DNACPR form of which 6/9 had documented discussion with family. 4/46 patient's had documentation of escalation status. 7/9 forms countersigned by consultant & 3/9 had review date completed.

Summary: If decision for DNACPR has been made then in general all completed and discussed correctly. Poor documentation of any advance planning or DNACPR discussions.

Future - Introduce a Treatment Escalation Plan proforma to the ECC to prompt and aid discussions about escalation and CPR. This work is ongoing.

Key Information Summary Access and Anticipatory Care Planning in Secondary Care: A Quality Improvement Project

Authors: Dr Charlie Hall; Dr Juliet Spiller

The electronic Key Information Summary (KIS) is a vital way of conveying Anticipatory Care Information from Primary to Secondary care. For patients with Anticipatory Care plans, Special Notes and electronic Palliative Care Summaries are now available to hospital teams readily via the KIS.

Using the PDSA approach we undertook audits and interviews to assess: KIS prevalence among patients admitted to a Medical Admissions Unit (MAU) and content of the KIS. We assessed levels of clinician access to the KIS, their opinions of the usefulness and also barriers to accessing the KIS. Evidence of Goals of Care (GOC) discussions with patients at risk of deterioration or dying were also assessed.

The majority of hospital clinicians thought the KIS was useful but many did not know how to access it. Interventions were subsequently trialled including: Education and awareness, trial of an 'Anticipatory Care Planning tab' and introduction of the SPICTTM tool to MAU admissions booklets.

Re-audit showed a significant increase in access to the KIS on admission, but mixed results regarding the use of the new admission documentation and GOC discussions. Further PDSA cycles to test sustainable interventions throughout NHS Lothian are discussed and recommendations made.

Establishing a Culture of Improvement in a Scottish Hospice

Sime C; Milligan S; Bett P; McConnell S; Pyper C; Mills A; Rooney K

The Scottish Government’s 2020 Vision for healthcare in Scotland is to provide safe, high quality care, whatever the setting. National quality improvement programmes have been developed to deliver these ambitions, resulting in an upwelling of improvement activity across NHS Scotland.

However, the spread of improvement methodologies through the Scottish hospice sector has been considerably less dramatic. Indeed, there appears to be relatively little uptake of improvement as a specific model for achieving quality and effectiveness, in spite of its adoption elsewhere.

Ardgowan Hospice has committed itself to utilising the model of improvement in order to continuously address the safety, effectiveness and person-centredness of its services. A Continuous Improvement Team was created to facilitate improvement projects, in conjunction with the creation of two new posts within the organisation to support data management and improvement activity. Key areas identified for improvement were referral pathways into the hospice, and referral-to-bed times. This is a joint project with the University of West of Scotland. Internal improvement projects are establishing and embedding the ‘what matters to you’ model; a quality of sleep study and the introduction of outcome measures, including the Integrated Palliative Outcome Scale (iPOS) and carers assessment tool.

Goals of Care within a Structured Response Tool

Sarah Gossner; Gordon Mills; Tracy Burton

A project has been undertaken to design and test a Structured Response Tool (SRT) to support the recognition and escalation of, and response to deteriorating patients in acute care in NHS Lothian. Its development was driven by a combination of the National Point of Care Priorities (Scottish Government 2013; HIS 2013) and local findings from the Deteriorating Patient Collaborative and the Advance Nurse Practitioner (ANP) scoping project.

Throughout the local Deteriorating Patient Collaborative there has been a focus on anticipatory care planning within Goals of Care.

In addition to this the Information Reconciliation project has informed the development of the SRT to support the clinical teams to ensure a bespoke Structured Response is achieved for all deteriorating patients.

There has been multi-disciplinary acknowledgement that a SRT can support the recognition and appropriate response to deterioration. This presentation will discuss the impact of the SRT on the consideration of Goals of Care and inclusion of previous ACP for patients who may be at risk of further deterioration and dying. Moving forward we will assess whether the SRT acts as a forcing function to improved engagement with patients and families.

How Palliative care nurses make meaning of loss and death when delivering end of life care to patients and their families

Geraldine Finnan

If palliative and end of life care is to be delivered in an effective manner then understanding of patient’s needs, improved education and training for health care providers and more resources are required (NHSScotland 2014). The nurse as an individual with personal attitudes, beliefs and values must also be considered. According to Peters et al (2013) following their literature review of death anxiety faced by nurses, in the course of their care delivery many nurses face death and dying patients and their attitude to death is made up of a complex combination of past and present experiences, cultural, societal and philosophical views. A study conducted by Gerow et al ( 2010 ) found that nurses experience grief for their patients in a very different manner to that experienced by family members .The need to remain strong and offer support on one hand whilst managing their own emotions following the death of a patient with whom they may have formed a connection can be very difficult and Remen (2006) states that

‘The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet’.

Implementation of a Falls Prevention and Management programme in a Hospice In-Patient unit

Jean Gow (Specialist Physiotherapist in Palliative care); Elaine McManus (Practice Educator)

Evidencing Best Practice and Documentation

Falls prevention and management is a key aspect of patient safety and an important quality indicator. This can be challenging in a specialist palliative care setting where the pace of decline and fluctuating levels of independence is a common feature. The aim of care is to deliver safe professional practice whilst promoting patient choice, independence and dignity.

Aim: To evidence best practice

Method: Based on the latest guidance from National Institute of Excellence we developed 1) a falls risk-assessment tool; 2) a care plan for falls prevention and management and 3) ten quality standards.

A practice focused approach was used to engage staff in the importance of the guidance and the use of the tools pre and post implementation. The tools were integrated into the e-Health recording system (Crosscare) and compliance with the standards were audited one year after implementation (February 2015).

Results: The audit identified good compliance against the standards and also identified areas for improvement.

Next steps: Devolve ownership of programme to IPU nursing staff; explore best practice in managing specific risk factors ie delirium/cognitive deficits using a person-centred approach; link the process to outcomes.

Implementing the adapted ‘6 steps’ approach – An end of life care project for local care homes

Jackie Higgins; Margaret Ramsay

Background and Aims: This collaborative project was funded by Falkirk, Stirling and Clackmannanshire Change Fund ‘Reshaping Care For Older People’ The overall aim was to design, develop and deliver a palliative care/end of life care education package targeted at nursing and local authority care homes in Forth Valley. This project focused on supporting organisational change and the development of staff knowledge and skills related to EOL care.

Project Outline: This innovative project involved classroom teaching and ongoing support from the project’s Palliative Care Facilitator (PCF) within the participants care home setting. This approach supported transfer of learning from the classroom to the workplace. Participants were also encouraged to complete a project related to end of life care.

Evaluation: Participants completed pre and post participation questionnaires to demonstrate impact of learning and individual self-confidence ratings related to specific end of life domains.

Results: Participants demonstrated increased confidence related to communication about end of life issues with residents, families and other health care professionals. Participants also identified areas where they could implement change.

Discussion: This project enabled staff to increase their confidence in talking about and planning for end of life care within their care homes. The PCF supported participants to put their learning into practice and undertake changes in practice within their own settings.