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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.

Enhanced End of Life Care in Ayrshire Nursing Home

The Abbotsford Nursing Home in Ardrossan has been providing meaningful and sensitive care for its residents for almost 30 years in North Ayrshire.

Recently, we have developed a new service, Enhanced End of Life Care, for when a person is no longer able to be supported at home (for instance, due to carer fatigue), or the person has been admitted to hospital but would prefer his/her place of care to be closer to home, family and friends.

In a close working partnership with District Nursing, G.P.'s, NHS Specialist Palliative Nurses and The Ayrshire Hospice Specialist Palliative Care Community Nurses, we respond to provide a comprehensive form of palliative care in an informal, relaxed environment. Our holistic approach includes pain and symptom management and nursing care in a dedicated en-suite bedroom

facility, as well as accommodating the person's spiritual, emotional and/or social support needs.

Our Enhanced End of Life Care service has been developed with strong support from Specialist Palliative Nursing teams at The Ayrshire Hospice and the NHS, local District Nursing teams and Macmillan Cancer Support. This collaboration is providing support and assistance both operationally and with additional knowledge and skills development for our team in Abbotsford.

It is free to the service user and is funded through the Scottish Government's Integrated Care Fund. We were awarded this funding by the North Ayrshire Health & Social Care Partnership and it is currently for one dedicated en-suite room facility. This initiative will enable local people in the advanced stage of their illness to be cared for twenty four hours a day in closer proximity to their family, friends and within their community. The service can be offered to people who would

prefer this choice and where their life expectancy is limited. However, should the person's symptoms stabilise, it is anticipated that a return to home will be a positive outcome, allowing the service to become available for another individual and his/her circle of friends and family.

If you would like more information on this new, innovative service, please contact Louise Pettigrew, Registered Manager, or her Depute, Georgette Langan, on 01294 602915 or by email.

By Nigel Wanless, Abbotsford Nursing Home

Macmillan Pharmacy Service Annual report

The Macmillan Pharmacy Service has published its Annual Report for 2014-15.

The service has now been rolled out across all Health and Social Care Partnerships within Greater Glasgow and Clyde. The expansion began in August 2013, following successful evaluation of the Macmillan Pharmacy Facilitator pilot project (2009-2013), by the University of Strathclyde.

The overarching aim of the service is to support community pharmacy and the wider primary care health and social care team to advance person-centered, sustainable, high quality, safe and timely pharmaceutical palliative care (PC) services as close to home as possible for patients, carers and families.

The idea is to shift the balance of care away from the acute sector to a more financially sustainable community based services that will better serve the growing ageing population, reduce pressure on out-of-hours services and avoid emergency hospital admissions.

The annual report is available for download here: Macmillan Pharmacy Service Annual Report.

Poster abstracts of the month: February

The SPPC Annual Conference in 2015 featured 38 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:

Improving Discussion and Documentation of CPR and Escalation Status in the ECC

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.

Poster abstracts of the month: January

The SPPC Annual Conference in 2015 featured 38 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:

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.

Poster abstracts of the month: December

The SPPC Annual Conference in 2015 featured 38 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:

Art and Hospice Care - Building a Strategic Relationship

Avoiding Harm at the End of Life: How good are we?

Beer Mat Chat – Love, Loss and Lager

Community Referrals : ensuring an appropriate and timely response through the use of a telephone triage tool

Don't forget about me: Developing a person centred approach to caring for people with dementia with a hospice setting

Art and Hospice Care - Building a Strategic Relationship

Author(s): Dr Erna Haraldsdottir; Lesley Christie

Background: Art Strategy was developed in a hospice, in collaboration with an artist organisation and with funding from Creative Scotland.

The process of writing the strategy:

  • Five months consultation period with the hospice staff, volunteers and patients, artists, cultural organisation and potential funders.
  • A number of workshops and consultation approaches with staff patients and volunteers.
  • Short art based workshops for patients.
  • Implementation of the Art Strategy:
  • The strategy proposes a programme of activities that will offer appropriate therapeutic engagement for patients, families and staff as well as bringing in the wider community into the hospice building and grounds.
  • Eleven proposed projects have been identified within the themes of:
  • oSensitive spaces, exhibition spaces, partnership residence projects, the social programme, staff project, research project and emergent artist mentoring scheme.

What we will achieve with the strategy:

  • Permanent public art elements for sensitive spaces enhancing a therapeutic environment
  • Space within the hospice exhibiting patients’ and artists’ work
  • Event programme attracting the public into the hospice.
  • Therapeutic art as part of hospice activities for staff, patients and families.
  • Long term partnership with arts organisations and link with the local professional creative community.

Avoiding Harm at the End of Life: How good are we?

Author(s): P Brooks Young; S Keir et al

Aim: When someone is dying, there is no room for less than perfect care for the person involved and their family. It is critical that staff have the knowledge-base and skills to reliably deliver high-standard person-centred care. Within a larger piece of work supporting the delivery of key aspects of palliative care, we wanted create a system that would enable us to know how well we were achieving this.

Methodology: A tool was developed across 11 in-patient areas to define four key process indicators of high quality end of life care: communication, symptom management, essential care and review. This was implemented across the Medicine of the Elderly department. Five sets of case notes are randomly selected and reviewed each month.

Results: Case note review took less than 10 minutes each. This was aided by the introduction of a new care-rounding document that incorporated key aspects of essential care. Review data was used at the well attended multi-professional morbidity & Mortality (M&M) meeting to remind all members of the team of key aspects of care and to support continuous quality improvement.

Conclusion: This tool provides a route to assure our delivery of palliative and end of life care It also provides a way of monitoring the impact of other quality improvement measures being tested including patient / family experience.

Beer Mat Chat – Love, Loss and Lager

Author(s): Mark A Hazelwood; Rebecca M Patterson

Background: Storytelling/remembrance can the reduce isolation of recently (and less recently) bereaved people, and strengthen community resilience [1]. Traditional rituals and approaches which supported storytelling/remembrance are declining in Scotland. Pubs are hubs of social interaction and storytelling, especially for men.

Aim: To explore the acceptability of beer mats in pubs as a prompt to storytelling and remembrance of people who have died, and to promote To Absent Friends, a peoples’ festival of storytelling and remembrance.

Method: Five mats were designed – each had a carefully selected quotation or piece of trivia relating to loss or remembrance, plus a weblink to 20,000 mats were made available to order.

Feedback regarding acceptability was elicited through conversation with bar tenders, direct observation and a questionnaire dispatched with some orders. A press release was issued.

Results: The mats were generally viewed as being acceptable. A local brewer distributed c 15,000 mats to pubs across Edinburgh. The main Edinburgh newspaper ran a prominent article about the mats, the To Absent Friends Festival and the value of greater openness about death and dying.

Conclusion: Beer mats appear to be an acceptable way of introducing reflection on loss, grief and mortality into pubs. More research is needed to establish the effectiveness of the mats in prompting storytelling and remembrance.

Community Referrals : ensuring an appropriate and timely response through the use of a telephone triage tool

Author(s): Milton L; Barker L

Background: The Marie Curie community palliative care teams in Edinburgh and West Lothian receive over 800 new referrals per year. Crucial for any service is the process around the screening of referrals; important both in clinical terms and to ensure efficiency of the service.

Method: The teams in Edinburgh and West Lothian developed a new approach to respond to referrals, with a triage telephone call being made to the patient by an experienced clinical nurse specialist to assess:

  • the appropriateness of the referral,
  • the urgency and complexity of the patient’s situation,
  • which location would be appropriate for the first assessment.

Results: Referrals to the service over a six month period were analysed (n=406). 7% of referrals were assessed as not being appropriate (n=28). The triage process identified the complexity, urgency and condition of the remaining 378 patients; 55% of patients were seen within 5 days. 10% of patients were seen as an out-patient in the hospice; 90% were seen at home.

Conclusions: Telephone triage is an effective method of determining the appropriateness of referral and location for the first assessment, allowing care to be prioritised. It also demonstrated the team offer a responsive service to complex and urgent patients.

Don't forget about me: Developing a person centred approach to caring for people with dementia with a hospice setting

Author(s): Kim Donaldson; Fiona Cruickshank

The number and care of people living with dementia is of growing global concern. Predications suggest that in Scotland the numbers will have doubled by 2031. As palliative care strives to care for all, regardless of diagnosis, culture or background there is a need for hospices to meet the challenge of caring for those living with and dying from dementia.

St Columba’s Hospice set up a working group with the aim to develop a person centred care plan for patients with dementia and/or other cognitive impairment. The care plan guides professionals to consider how to best communicate with the person, the impact the environment has upon them, meaningful activities, tools to support symptom management and liaising with external professions. The use of the care plan in practice has been supported by additional information resources and education. An initial informal evaluation has taken place and adaptations made.

This poster aims to illustrate the development of a care plan to support professionals to make all interactions with people living with dementia meaningful.

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