bluuebunny/crossref_metadata_2025 huggingface dataset:
UNKNOWN PRIMARY INVESTIGATION SERVICE EVALUATION
Authors: Hazra Madhubrata , McGregor Mary , Brooks David
Published: February 2014

Background

In July 2010, NICE developed the guidelines for the diagnosis and management of Metastatic Malignant disease of Unknown Primary (MUO). At Chesterfield Royal Hospital (CRH) the Primary Investigation Service is lead by the Palliative Care team. It started in 2010 with the aim of investigating and supporting patients with MUO early and appropriately without unnecessary investigations or delays. Patients are referred as both in and out patients and discussed in an Unknown Primary MDT.

Aim

The aim of this evaluation is to review service development progress.

Method

Data were collected prospectively and compared over the last two financial years.

Results

87 patients were referred to the service in the last financial year, a 14% increase on the previous year. 7 patients were excluded as referrals were inappropriate. 55 patients were referred within 5 days of identification of MUO, 25 were referred after >5 days. Median time before inpatient referral was 4 days, for outpatients it was 8 days. 50% of patients had a performance status of 2 or greater at the time of referral.

Median time from referral to diagnosis was 10 days, (6 days for inpatients, 13 days for outpatients.) The median time from referral to definitive treatment decision was 15 days. Just over a third of patients had Oncological treatment, with 60% having chemotherapy and less than 40% radiotherapy as the initial mode of treatment.

Across both years the median survival from diagnosis was approximately four months, in the last year over a third died within a month.

Conclusion

This audit clearly highlights the fact that though it is a relatively new service in this hospital it is now well established and has gained wide acceptance. These patients have a very poor prognosis and Specialist Palliative Care involvement from the beginning was appropriate.
ELECTRONIC PATIENT RECORDS MUST TALK TO AN ELECTRONIC PALLIATIVE CARE COORDINATION SYSTEM (EPACCS) FOR EFFECTIVE ADVANCE CARE PLANNING (ACP)
Authors: Cawley Declan , Marshall Jane
Published: February 2014

Background

Advance Care Planning (ACP) is integral in facilitating end of life care (EOLC) preferences for patients. Evidence suggests that patients would prefer to die at home but recognise “the practical and emotional difficulties of exercising this choice”. Whatever the cause of death, patients may experience symptoms so drugs should be prescribed pre-emptively and available in the patient's home. Patient records need to have documentation supporting the preference(s) for death (PPOD), CPR status and available drugs for administration within the home but professionals need this information as suggested by having an electronic palliative care coordination system (EPaCCS).

Aim

To standardise the components of ACPs within an electronic patient record to facilitate effective data transfer to an EPaCCS.

Method

Baseline review of electronic patient records within a hospice setting, identifying components of ACPs and comparing what components are transferred to the EPaCCS.

Results

30 electronic patient records were randomly identified: the majority (73%) of patients had a cancer diagnosis (22/30), median age of 68 years. Interestingly 97% (29/30) of patients had reference to discussions about PPOD. 47% (14/30) had a documented preference for home, 23% (7/30) initially didn't want to discuss with only one (1/30) person on initial meeting having a preference for hospice. 13% (4/30) had documented changes in their PPOD. Within our local EPaCCS, only 37% (11/30) of patients were registered on this system; 55% (6/11) had their PPOD documented with the remainder (5/11) having had a recorded PPOD in their electronic patient record.

Conclusions

Documentation supporting the components of ACPs: PPOD, CPR status, pre-emptive drugs, is fundamental in facilitating the majority of individuals to die in their PPOD of home. However if data systems don't cross talk to each other, in a ‘push/pull’ system of data transfer, the success of implementing a loco-regional EPaCCS is questionable.
MEETING PALLIATIVE CARE NEEDS AT THE END OF LIFE IN PATIENTS WITH INTERSTITIAL LUNG DISEASE
Authors: George Mariam , Sharma Anisha , Powell Barbara , Bronnert Rosie
Published: February 2014

Background

British Thoracic Society (BTS 2008) and NICE (2013) Guidelines recommend integration of Palliative care with local services to enable access to best supportive care from diagnosis till death. In October 2012, a retrospective survey of medical records in the hospital trust evaluated palliative care needs and input of Specialist Palliative Care Team (SPCT) for patients with Interstitial Lung Disease (ILD). Subsequently, a pathway was developed to promote timely referral to the SPCT.

Aim

To conduct an audit on current practice of palliative care management of hospital ILD patients approaching end of life against NICE, BTS and National End of Life care Strategy guidelines.

Method

A three month (April-June 2013) retrospective audit of all in-patient deaths in a single tertiary cardio-respiratory hospital (415 bed capacity). Details of palliative care referrals and the management of such patients by the primary teams with emphasis on end of life pathways were reviewed.

Results

Fifty-two patients with diagnosis of ILD were admitted in the said period. Of the 10 patients who had died in this period, 8 had accessible medical records. 62% (5/8) patients had a referral made to the Specialist Palliative Care team. 60% (3/5) were for complex symptom control and 40% (2/5) for consideration for hospice transfer. Breathlessness, cough, fatigue, anxiety and depression were the common symptoms that required management. Six of the eight patients had their prognosis discussed –5/6 by the primary medical team and one by the SPCT. Preferred place of death was discussed and achieved in 80% (4/5) patients seen by the SPCT. DNACPR form was completed in 75% (6/8) patients.

Conclusion

Though good support exists for ILD patients in a tertiary care setting, there remains the scope for improvement through recognition of the services provided by the Specialist Palliative Care Team and more focused end of life care for such patients.
RESULTS OF A CONTROLLED EVALUATION OF A HOSPICE RAPID RESPONSE COMMUNITY SERVICE FOR END OF LIFE CARE
Authors: Butler Claire , Holdsworth Laura , Gage Heather , Coulton Simon , King Annette
Published: February 2014

Background

When faced with a life-limiting condition, most people would prefer to die at home but more than half continue to die in hospital. A 2011 systematic review concluded that there is only moderate evidence to show that home-based end of life teams reduce the likelihood of dying in hospital, though observational and descriptive studies suggest that home-based care with the capacity to respond rapidly to crises may improve the likelihood of dying at home.

Aims

The primary aim of the study was to assess the impact of a new rapid response service (in addition to usual hospice and community palliative care services) on patients dying in their preferred place of death (PPD). Secondary objectives were to evaluate carers' quality of life and the overall cost of providing end of life care.

Methods

Intervention:Hands-on care provided by trained Healthcare Assistants available day and night at 4 hours notice to support patients dying at home.

Design:Quasi-experimental, multi-centred, controlled evaluation with embedded cost analysis.

Results

953 patients died with a PPD recorded and 155 carers completed questionnaires.

The number of people achieving their PPD was not statistically significantly different in the intervention and control groups (about 60%). Patients in the intervention group were more likely to wish to die at home and significantly more patients in the intervention group died at home.

The carers of patients in the intervention group experienced more problems with their mental and emotional health than those in the control group.

The rapid response service did not significantly add to the costs of providing end of life care in the intervention group compared to the control group.

Conclusions

Access to the rapid response service did not significantly affect whether patients died where they preferred.
POST DISCHARGE TELEPHONE CALL TO PALLIATIVE PATIENTS
Authors: Reeve Ursula , Gale Sue
Published: February 2014

Background

The transition home for Specialist Palliative Care (SPC) patients is often complex; requiring multiple medications, equipment, healthcare agency support. Many patients go home to die which causes additional stress for patients/carers. Nationally, discharges are frequently unsatisfactory; a telephone survey of local outcomes was undertaken.

Aim

To identify any concerns/problems arising and improve the patient experience by providing SPC post-discharge support/advice.

Methods

A pro-forma comprising 11 questions was designed for call handling. All patients were called within 3 days of their discharge home. All patients were known to the experienced SPC nurses making the calls. Over an 8 weeks period 14 out of 45 discharges was audited.

Results

79% (11/14) were called within the timeframe. Respondents were patients (7), family (4), other (3). Two patients had died. All knew what their medications were for, how to take them and what their side effects were. Eleven had enough medications until they could arrange a repeat prescription, one had three days supply; pending dosset box. Thirteen (93%) were given the SPC 24-hour advice line number. District Nurses (DN) and personal carers had attended as arranged (21% and 57% respectively) and equipment supplied (29%); the remainder reporting that these were “not applicable”. Two ‘concerns’ were identified: one DN unaware injection required and another had taken patient's discharge summary.

Discussion

It is not known why a DN took the discharge summary or why another was unaware of the injection; this information had been sent to them. Most SPC patients have at least one DNs, professional carers and/or equipment therefore the response ‘not applicable’ may have occurred because the call was made before their arrive; this needs further exploration.

Conclusion

Patients were followed up in a timely manner and few concerns arose; those that did were resolved. The need for subsequent follow-up call/s is under review.
IMPROVING END OF LIFE CARE FOR PATIENTS WITH COPD AN EVALUATION OF A SERVICE INNOVATION USING THE “WOULD YOU BE SURPRISED? QUESTION
Authors: Quibell Rachel , McAleer Nina
Published: February 2014

Background

The National End of Life Strategy initiative “would you be surprised if this person died within the next 6–12 months?”1formed basis of a protocol to identify COPD patients with a prognosis of <12 months using a modified BODE score and clinical experience. GPs were notified to place patients on GP Palliative Care Registers. Discussions with patients were supported by communication prompts.

Method

Patients identified in a 14 month period had case note review. GPs were asked via letter about palliative care register and patient benefit.

Results

14 patients, 9 had died at the time of evaluation. 8 died in hospital, 1 at home. GP notification to death 2–16 months median 7 months, Mean 7 months. 8/9 had died within 12 months of notification.

5 patients alive had a range of 4–13 months since notification, mean 7 months, median 5 months.

Only (14%) patients had remained or remain alive for >12 months.

Admission rate pre and post notification remained the same

GP Responses

71% GPs responded

100% practices have GP Palliative Care Register

100% agreed information from secondary care helpful.

8/10 patients had been placed on GP register.

3/8 on register had been put on by GP prior to CHEST team notification

GP free text response was extremely positive.

“Anything that helps initiate the discussion is most welcome”

“Allows them to be discussed monthly so they are in our minds. Helpful”

With a simple protocol, decision aid (modified BODE) and communication prompts the CHEST team have developed a proactive approach to improving EOLC for patients with COPD

Prognostication was good. Fears concerning patient distress, lack of GP engagement and patients not receiving hospital care during exacerbations have not been borne out. GP comments suggest better community support. These numbers are very small, further work is necessary to identify more patients.
DEVELOPMENT OF AN INTEGRATED END OF LIFE CARE PATHWAY FOR PATIENTS WITH COPD
Authors: Berry Pauline , Jackson Christopher , Saba Tarek , Au GIllian , Martin Michelle , Bennie Marion , Tymon Lorraine , Whitfield Andrea
Published: February 2014

Introduction

Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease ultimately resulting in death, usually in a secondary care setting. Historically, many of these patients have never had the opportunity to discuss their End of Life (EoL) preferences, resulting in unexpected deaths that neither patient nor family are prepared for.

Problem

Patients with COPD are not prepared for the progressive nature of the disease and are dying without identifying their Preferred Place of Care.

Aim

Whilst developing a COPD pathway, an identifiable gap was evident relating to discussing EoL care. National guidelines recommended asking the Surprise Question to accompany the GSF prognostic indicators. However no local assessment tools were available to prompt EoL care discussion and planning for patients with COPD reaching their last year of life. The aim was to have a unified approach to this across primary and secondary care.

Method

A working group developed the Blackpool Teaching Hospital (BTH) End Stage COPD Assessment tool incorporating nationally recognised guidelines. This allows the initiation of a BTH Respiratory EoL Care Bundle at an appropriate stage in the disease trajectory and is closely linked to the time line of the North West EoL Care Model.

Results

The Respiratory team are now utilizing these documents to initiate early conversations, maximising treatment options and Advance Care Planning in a systematic manner. This information crosses the interface between primary and secondary care. Early results from the introduction of the COPD Assessment Tool will be presented.

Conclusion

The BTH End Stage COPD Assessment tool prompts clinicians to identify the last year of life for patients with COPD. Used as part of the integrated acute and community COPD pathway this will ensure that this important phase of the patient's illness is considered and will improve communication of their priorities for care across all care settings.
INTEGRATED PALLIATIVE CARE/ADVANCED RESPIRATORY DISEASE (ARD) CLINICS – A MULTI-CENTRE PILOT PROJECT
Authors: Curtis Claire , Challand Simon , Harrison Susan , Turner Marion , Bevan-Smith Elaine
Published: February 2014

Background

The symptom burden of ARD is similar to that of cancer, however patients with COPD are less likely to access Specialist Palliative Care (SPC) Services, and less likely to die at home. In Worcestershire there is a comprehensive COPD service providing an ARD pathway, but there exists a group of patients with ARD, who are too unwell to attend the pulmonary rehabilitation and fit to breathe groups, who need a differing level of support, but who are reluctant to attend generic hospice day care.

Aims

The monthly joint out-patient clinics aim to enhance end of life care for patients with ARD and their carers by:

▸ Providing specialist medical and nursing input from Respiratory and Palliative Medicine consultants, COPD CNS, and SPC day hospice team to minimise symptoms, and maximise activity and function.

▸ Improving joint working and increasing accessibility and acceptability of SPC services.

▸ Challenging and changing the culture and aims of care for ARD patients.

▸ Reducing un-planned hospital admissions.

▸ Offering ACP

Results

Monthly clinics were set up at two hospice sites, and have been running for 18 months.

Approx 50 patients have attended.

Unplanned hospital admissions have reduced, deaths at home have increased.

Patient and Carer satisfaction survey, HADS and distress thermometer have been used.

ACP has been undertaken using the Worcestershire advance statement document.

Conclusions

The clinics have evolved over the 18 months and benefits have occurred beyond just the scope of the patients who actually attend in person. There exists the ability to offer another treatment pathway, with culture change occurring because of this extra option for care. Teams have been empowered to engage in ACP, there has been enhanced carer support and improved joint working.
END OF LIFE CARE IN NEURODEGENERATIVE CONDITIONS: EVALUATION OF A SPECIALIST NEUROLOGY PALLIATIVE CARE SERVICE
Authors: Hussain Jamilla , Adams Debi , Campbell Colin
Published: February 2014

Background

The last year of life for people with advanced neurodegenerative conditions (ANC) is often unsatisfactory, characterised by multiple unplanned hospital admissions. Despite this few patients with ANC access palliative care services, with limited evidence of effective service models and when such individuals should be referred to palliative care.

Aims

1. To evaluate the Scarborough Palliative Neurology Service (PNS) model, led by specialist palliative neurology nurses, against the National End of Life Care Programme (NEoLCP) ANC recommendations. 2. To evaluate the validity of the seven NEOLCP triggers for palliative care referral.

Method

Retrospective observational study of 62 consecutive patients under a PNS. Principle component analysis (PCA) was performed to examine the relationship between triggers and survival.

Results

All patients had a key-worker who coordinated care. Capacity was assessed in 95% of cases, for who advance care planning and best interest decisions were documented in 95%. The terminal-phase was recognised in 72.6% and 100% of carers were offered bereavement support.

The median follow-up under the PNS was 336 days. The mean number of hospital admissions was 0.9 in the last year of life (compared to 3.5 nationally across diagnoses). Pneumonia was the cause of death in 56.5%. Thirty-one percent of patients died at home (nationally 14% of ANC patients die at home), 26% in hospital (46% nationally) and 24% in hospices (0.03% nationally).

Frequency of triggers increased as patients approached death. PCA found 4 components in combination explained 76.8% of the variance in survival. These representedrapid physical decline;significant complex symptoms-including pain; infection with cognitive impairment;andrisk of aspiration.

Conclusion

A model of service provision investing in specialist palliative neurology nurses is an effective model in delivering palliative care to this vulnerable patient group. The triggers for referral require further validation, although the derived PCA components do have face-validity.
BEREAVED GROUPWORK PILOT WITH CHILDREN AGED 7 TO 8 YEARS OLD
Authors: Jan Emma , Stafford Lynne , Holland Mary
Published: February 2014

CancerCare is a charity dedicated to helping local people whose lives are affected by cancer and other life limiting conditions. Services are free to anyone in North Lancashire and South Lakeland.

The Children and Young People's Service (CYPS) support 3 to18 year olds. In February 2013, CancerCare decided to undertake a pilot study to assess the feasibility of providing a therapeutic group for all bereaved children, not just cancer-related. The aims included:

▸

Normalising the children's experience of bereavement

▸

Decreasing their sense of isolation

▸

Allowing them to communicate their feelings around grief

▸

Sharing their experience of bereavement with others

▸

Receiving peer support

▸

Building emotional resilience

▸

Recognising support in their environments

▸

Working creatively and expressively to process their feelings around loss

▸

The pilot study was for children aged 7 to 8 years old.

Change was measured using feedback questionnaires and a pre/post intervention outcome tool, the Strengths and Difficulties Questionnaire completed by parents at the beginning and end of the groupwork. Children, who had high impact scores, indicating bereavement was greatly affecting their lives, showed a decrease in their scores at the end of the group; a shift towards greater emotional health. One child moved to a higher score at the end of the group; signifying an ‘unlocking’ of some aspects of grief the child was holding. The child was offered an onward referral for 1–2–1 therapy within CancerCare, following the end of groupwork.

In conclusion, the results demonstrate both children, and parents, found the group helpful and transformative. The pilot study identified a correlation between the original aims, and the outcomes experienced by children and parents.

The vision of Cancer Care is to build upon the success of the pilot study, offering further therapeutic bereavement groups to children in years 5–6 in the Autumn term followed by secondary schools in 2014.
AN AUDIT INTO ADVANCED CARE PLANNING FOR END OF LIFE CARE PATIENTS AT KINGSTON HOSPITAL
Authors: Merrick Sophie , Guilhem Emily , Kreeger Lulu
Published: February 2014

Background

The End-of-Life Care (EoLC) Strategy 2008 highlighted the importance of early identification of potential for dying and Advanced Care Planning (ACP).1 2 3Early awareness of poor prognosis helps patients and their relatives to understand their illness and make informed choices about their care; for instance whether to decline aggressive intervention and hospitalisation if it is unlikely to improve their quality of life.

Aims and Objectives

To prompt early communication within the MDT and with patients and their relatives about ACP for those deemed to be in their last year of life.

Method

Data from 40 discharged patients, who had been identified as likely being in their last year of life, was collected in each audit cycle.

Cycle 1 was a retrospective case notes analysis from one Care-of-the-Eldery (CoE) ward. Five key areas of ACP were reviewed: resuscitation status, prognosis, ceiling of care, readmission plans, patient/family awareness of condition and prognosis.

Prior to cycle 2, an ACP Summary proforma was implemented where discussions around the five key areas could be summarised. It was introduced at a CoE department meeting and teaching sessions were held for junior doctors.

Results

Tables 1 and 2 illustrate our findings.

Table 1

Documentation in Medical Notes

TargetCycle 1Cycle 2Resuscitation Status100%82%97%Prognosis95%55%95%Ceiling of Care95%41%100%Readmission Plans95%14%100%Patient/family awareness95%77%100%Table 2

Discharge Documentation

TargetCycle 1Cycle 2Resucitation Status100%6%89%Ceiling of Care100%56%100%Readmission Plans100%33%100%Patient/family awareness100%59%100%

Cycle 1

Documentation regarding prognosis and ceiling of care (escalation plans) was poor; often it was very difficult to find in the medical notes. On call teams had to make escalations plans for 4 patients. Patients and relatives were not always informed in a timely fashion leading to 3 complaints.

Cycle 2

Re-audit results following the implementation of the ACP Summary showed an improvement in all 5 key areas.

Conclusion

The ACP Summary ensured easily accessible information and prompted early discussions with patients, relatives and within the MDT. It improved communication with GPs on discharge.
AUDIT OF AVERAGE LENGTH OF STAY IN MARIE CURIE HOSPICE BELFAST
Authors: McCann Mary-Ann , Regan Joan , Doherty Jenny
Published: February 2014

Background

Average Length of stay (ALOS) is a widely used indicator of hospital and hospice performance and commonly viewed as a measure of efficiency. The standard for ALOS of patients in Marie Curie Hospice Belfast is ≤14 days.

Aims of this audit were

(1) to assess how often we meet the standard for ALOS in Marie Curie Hospice Belfast, (2) to identify the ALOS of patients admitted in a 6 month period and (3) the reasons why some patients stay is >14 days.

Results

48.3 % of patients had an ALOS ≤14 days. The ALOS between February and July 2012 was 19 days. 59.5% of patients died and 40.5% were discharged. The ALOS of patients who died was 18.9 days and for those who were discharged, it was 19.2 days. Patients with ALOS >14 days were older, more of them lived alone and fewer of them had a package of care in place. Symptom control was the commonest reasons for an ALOS >14 days, with an average symptom control admission lasting 35 days. Patients with brain tumours and prostate carcinoma had the longest ALOS at 47.5 days and 37.1 days respectively.

Conclusions

Symptom control was the most common reason for increased stay possibly reflecting the fragility and complexity of these inpatients and the potential for their condition to change. Identifying patients who may have a more complex discharge and beginning the discharge process at an earlier stage may help reduce the ALOS. The ALOS of patients who eventually died in hospice was 18.9 days. ALOS is a crude measurement of patient stay and occupancy and offers no information on quality of patient outcomes. One area for improvement is the development of a tool which incorporates ALOS, complexity and quality of care for patients.
VALE, VOLUNTEERS AT LIFE'S END: THE LOROS CARE HOMES PROJECT
Authors: Faull Christina , Faulkner Shani , Kavanagh Jo
Published: February 2014

Background

Supporting people in the last hours of their life has a particular importance: a human presence may reduce fear, and agitation and promote a peaceful dying; provision of a ‘sacred space’ performing rituals or an environment of valuing of the person's way of life and beliefs may be a consideration; and witnessing the passing from life to death.

Aim

LOROS developed a novel pilot service recruiting and training volunteers to work with care homes to compliment their care of dying residents. The aim was to explore the feasibility and evaluate its added value.

Service development

A three day training programme was developed for 9 volunteers : learning hand massage; a focus on common features of dying; features of dementia; and discussing the role and potential impacts on the volunteer. Volunteers developed ‘comfort packs’ containing readings, music, massage oil and religious icons. A regular support structure was developed.

Four care homes developed operational frameworks for contacting and integrating volunteers in to their team. Leaflets provided information to service users and processes were developed to discuss the service with residents and relatives.

Outcomes

Over seven months three of the four care homes utilized volunteers with 10 residents. Most residents who died did not need the additional support of a volunteer and some volunteers were not utilized. Where volunteers did provide support it was highly valued by staff and by relatives. Volunteers enjoyed the work and despite being needed infrequently there was no attrition.

Application to practice

Hospice trained and supported volunteers are welcomed by care homes as part of their care team for dying patients. The need for their service is infrequent and unpredictable and when it does occur it is immediate and intensive. These practical factors make it difficult service to provide.
MANAGEMENT OF DIABETES IN PALLIATIVE CARE
Authors: Dampetla Srilatha , Pawlak Tadeusz , Johnson Miriam , smrity smrity
Published: February 2014

Background

Of the half a million people who die in the United Kingdom each year, approximately 6–9% will have Diabetes Mellitus (DM). The 2011 position statement regarding diabetes management at the end of life released by the Association of British Clinical Diabetologists (ABCD) highlighted: avoidance of symptomatic hypo or hyperglycaemia; minimal blood glucose monitoring; review of oral hypoglycaemic agents; involvement of specialist diabetes team. Subsequent guidelines from the Joint British Diabetes Societies were published in July 2012.

Aim

To audit the diabetic care of patients with DM who died in a district hospital using ABCD statement as the audit standard.

Method

A retrospective case note audit of deaths between August 2011 and February 2012. The coding/ audit department identified patients coded to have DM at the time of death and/or DM was on the death certificate (parts I or II).

Results

Records were available 61/67 patients (mean age 82, range 42–97; men 31). Type 2 DM was present in 54 (89%) and co morbidities were common: cancer (33%); other serious medical problems (66%), most commonly cardiovascular conditions and infections.

The diabetes team saw 13% and 31% were placed on an integrated care pathway for dying although 51 (80%) patients had DNAR forms.

ABCD guidance adherence

Medication was reviewed/stopped in 25 (41%); blood glucose monitoring was stopped in 21 (34%) of those on the ICP for the dying. A total of 223 episodes of hypoglycaemic episodes were recorded of which only 33 episodes led to a change of medication.

Conclusion

Special attention should be paid towards end of life in diabetic patients. We demonstrated significant inadequate adherence to ABCD guidance. Particular issues that need urgent attention include: recognition of dying; hypoglycaemic episodes with inadequate response; involvement by specialist diabetes teams. A re-audit will be conducted following targeted education of clinical staff.
TRANSFORMING END OF LIFE CARE THROUGH CLINICAL TEMPLATE DESIGN AND TRAINING
Authors: Faull Christina , Prasad Rish , Griffiths Adam , Pearson Wendy , Wong Richard , Gray Sarah-Jane , Feathers Luke , Brown Jayne
Published: February 2014

National evidence suggests that whilst up to 67% patients wish to die in their own home, only 21% of patients actually do so. Recent Leicester City data reviewing emergency admissions and mortality suggests that recognising those patients who are not going to recover is inadequate in both primary and secondary care. Current systems and skills appear to be failing dying patients and their families, with local financial modelling also suggesting significant savings if appropriate care arrangements had been anticipated and implemented.

To improve care for this vulnerable patient group, a local enhanced service (LES) was commissioned and an innovative three strand approach developed in conjunction with local providers and experts.

Firstly, a clinical template for an Emergency Health Care Plan (EHCP) was created, using unique macros developed collaboratively with palliative care physicians, geriatricians and IT experts. This SystemOne template allows care plans for pre-defined conditions to be completed quickly and efficiently, providing outline plans for core clinical event scenarios which can be used to aid both completion and provide depth and breadth to the EHCP which is generated by the template. Secondly, locality mentors and practice end of life care champions were appointed with a training programme developed with the local Consultants in palliative medicine. Thirdly, extensive evaluation of the impact of the project on both patient and clinician needs, with baseline, peri- and end-point analysis planned and costed from the outset.

This abstract seeks to demonstrate the collaborative work behind the template, and the benefits of its use to practising clinicians, as already evidenced by its recent expansion to neighbouring CCGs.
PROVISION OF INFORMATION IN THE RESPIRATORY UNIT
Authors: Jackson Isobel , Davies Helen
Published: February 2014

Introduction

NICE guidance identifies the need to ensure effective communication of evidence-based information between patients and professionals to allow informed decision-making.

Aim

To assess patients' experiences of information provision within our Respiratory Unit and explore ideas for service improvement.

Methods

A questionnaire was distributed to 50 patients (20 lung cancer, 20 COPD, 10 ILD).

Results

Patients with COPD felt more short of breath (mean NRS score 6.9; lung cancer 4.05; ILD 3.3; ANOVA p=0.001) and were more troubled by it (p=0.002). Patients with COPD and lung cancer experienced episodes of panic more than patients with ILD (80% vs. 70% vs. 40% respectively). 45% of the lung cancer group expected their condition to improve, compared to 16% and 10% of patients with COPD and ILD respectively; however overall there was no significant difference between the groups' expectations of their disease prognosis (p=0.09). 40–58% of patients could not recall being told about their future disease course – 20% of each group reported being told they would ‘get worse’. Most patients received information from their GP and Hospital Consultant (although Clinical Nurse Specialists (CNS) rated highly in the lung cancer group 55% (15% COPD, 10% ILD)); few patients accessed the internet for this purpose (10-15%).

Patients were satisfied with their treatment however provision of more information about their disease and improved access to their GP and Hospital Consultant were identified as ways to improve care.

Discussion

Our patients' experiences mirror NICE guidance that communication improves care. Patients recognise Hospital Consultants as the main source of information yet identify a need for more information to optimise care. This remains an area we can influence. Increasing access to CNS support and judicious use of the internet could help to alleviate this deficit.
IMPLEMENTATION OF A PILOT MULTIDISCIPLINARY TEAM MEETING FOR SUPPORTIVE CARE IN ADVANCED LUNG DISEASE ( SCALD MDTM)
Authors: McTague Laura , Al-khairalla Mudher , McCook Ruth , Edwards Debbie , Warner Dawn
Published: February 2014

Background

Locally, only 12% of patients with advanced lung disease die at home. There is a significant rate of readmission to hospital in the last year of life. Most patients are housebound. Contact with Specialist Consultants and advance care planning is ad hoc.

The idea to develop the Multidisciplinary team meeting (MDTM) arose from the Acute Hospital Senior Clinicians EOLC development project and a local review of COPD services. The pilot took place within current local resources.

Aim

The Supportive Care in Advanced Lung Disease (SCALD) MDTM aimed to support clinical staff in identifying the last year of life. The MDTM would review appropriate investigations, discuss and communicate advance care planning and optimal symptom control to all involved.

Method

The MDTM included a respiratory consultant, specialist palliative care consultant and community respiratory nurse specialists. Patients gave verbal consent to the community respiratory nurses or referrer for the MDTM discussion to take place. The meeting was held at monthly intervals. A template was designed to record the MDTM and a letter was sent out the same day by the MDTM lead. The referrer returned to the patient to discuss the outcomes.

Results

A survey of 20 patients was carried out. The majority of patients had severe COPD, were housebound and on long term oxygen therapy. Advance care planning including plans for appropriate ceilings of care and preferred place of death were improved as a result of the MDTM. Other outcomes included specialist palliative care consultant home visits and respiratory consultant clinic review.

Discussion

The SCALD MDTM design and implementation resulted in improved advance care planning and Consultant contact. A larger pilot and research would give increased knowledge about the impact of this service design on the experience of advanced lung disease patients in the last year of life.
USING LITERATURE TO INFORM VIGNETTES DESIGNED TO EXPLORE THE PERCEPTIONS OF IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD) DEACTIVATION AT END OF LIFE
Authors: Hill Loreena , McIlfatrick Sonja , Taylor Brian , Fitzsimons Donna
Published: February 2014

Background

Rates of ICD implantation are increasing and while international documents guide professionals on the management of patients with an ICD, recent evidence illustrates disparity in the application of guidelines to practice. Furthermore limited research on patient preferences and lack of clarity on the ICD's role at end of life are compromising the provision of optimal care.

Aims

A systematic review of evidence published between 2008 and 2013.

Methods

A generic search strategy was developed, based on twelve key terms which were refined through an iterative process involving articles retrieved in a preliminary scoping review. Six electronic databases were selected and the search strategy adapted and applied. Studies were included if they met the inclusion criteria- Empirical studies published in English Language; primarily related to adults (above 18 years) with an implanted ICD; primarily related to the deactivation of ICDs at end of life. Citations and expert recommendation papers were checked for relevance. Quality of each study was assessed using the Hawkeret al., (2002) protocol and data were systematically extracted. Narrative synthesis led to the development of 3 key themes and identification of the salient factors or independent variables (IVs) in the ICD deactivation decision.

Results

Within the literature there is considerable variation in patients' preferences concerning ICD deactivation. These were grouped under three themes- preferences for the discussion, the ethical and legal considerations and facing the future. The validity of this evidence will be further refined through qualitative exploration involving patients, carers and professionals to determine the most appropriate IVs to generate vignettes for a UK wide professional factorial survey.

Conclusions

This innovative factorial survey design combines qualitative exploration and quantitative survey techniques. Greater understanding of decision-making in this complex setting will contribute to the development of appropriate educational support and improved care for ICD patients approaching end of life.
AN AUDIT OF REPORTED OPIATE ERRORS IN NORTHUMBRIA HEALTHCARE TRUST, 2012
Authors: Grogan Eleanor , Norris Laura , Parker Rebecca
Published: February 2014

Background

Opiates are frequently identified in medication incidents resulting in severe harm or death. The National Patient Safety Agency (NPSA) collects data pertaining to this and has made relevant recommendations.

Aims

To identify and systematically review errors in high risk opiate prescribing and/or administration in Northumbria Healthcare Trust, 2012, in order to inform patient safety recommendations locally.

Methods

The audit identified all errors reported via the trust's electronic incident management system, the associated case notes were reviewed and data analysed using descriptive statistics/thematic analysis.

Results

34 (of 45) sets of notes were available for review (75%). 5 drugs were involved, of these 3 accounted for 91% of all errors (Morphine, 50%; Oxycodone 23%; Fentanyl, 18%).

Administration errors accounted for 56% (n=19) of errors identified, prescribing 23% (n=8) and the remainder (21%;n=7) demonstrated errors in both domains.

Themes associated with administration errors were variable but included:

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6 incidents related to Fentanyl (failure to remove patch, patch re-applied at inappropriate interval, incorrect patch applied).

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6 incidents of an incorrect drug being given;4 of which involved Oxycodone liquid and Oxycontin M/R.

Other errors included administration without a signed prescription, incorrect doses, delays/omissions and inadvertent repetitions of doses.

Themes associated with prescribing errors included incomplete or illegible prescriptions, incorrect drug/dosing and failure to prescribe regular medications.

Conclusions

The audit is limited by sample size, reporting practice and an incomplete data set. However, the data obtained demonstrated similar themes to data collected by the NPSA. A proportionally high degree of errors occurred within the context of Fentanyl and Oxycodone prescribing/administration.

Specific interventions include:

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A trans-dermal patch administration and removal chart.

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An educational opiate ‘wall chart’ for healthcare staff.

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An alert sticker for high concentration opiate solutions.

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Recommendations may be applicable in other settings given the correlation the findings have with national data.
THE MODERN HOSPICE AND MEDICAL INTERVENTIONS
Authors: Gillon Suzie , Lowe Emma
Published: February 2014

Background

The modern hospice has to find a balance between providing traditional holistic palliative care, and up to date effective medical treatments and interventions. This has at times led to discussions that hospices are losing their unique identities and becoming akin to acute hospital wards.

InterventionNo of patients (%)Fluids21 (15)Oral antibiotics19 (14)Intravenous antibiotics11 (8)Blood transfusion3 (2)Bisphosphonate infusion2 (1)Paracentesis2 (1)Other8 (6)

Aims

We sought to objectively quantify medical interventions in a cohort of hospice inpatients from our 32-bedded city-based hospice, with around 600 admissions a year. Interventions included were: antibiotics (oral and parenteral); blood transfusions; bisphosphonate infusions; fluid infusions (intravenous (IV) and subcutaneous), and procedures such as paracentesis. We also noted the number of patients having blood tests at any time during admission.

Results

140 notes were available from 144 consecutive hospice admissions from Jan 1st2013. M=62, F=76. Mean age=72. Primary diagnosis: Malignancy=122 (87%). Mean length of stay=13.5 days (range 2 hours to 65 days). 84/140 (60%) of patients had at least one blood test during admission. 93/140 (66%) patients had no other interventions during their stay. 44 patients had interventions in the following categories:

‘Other’ comprised: albumin infusion (2); IV hydrocortisone (1); IV proton-pump inhibitors (3); transfer for coeliac plexus block (1) and transfer for management of neutropaenic sepsis (1).

Conclusions

Although hospice care is undoubtedly evolving, the majority of patients still do not undergo active or ‘invasive’ interventions. Regular review of this would allow discussion and goal-setting re future priorities for hospice care. It is important to create a balance between providing the best evidence-based care for patients while also not undertaking unnecessary interventions.
LONG-TERM OPIOIDS AND NALOXONE ADMINISTRATION IN A DISTRICT GENERAL HOSPITAL
Authors: Facey Caroline , Brooks David
Published: February 2014

Background

Respiratory depression is a known side effect of opioid medications. Naloxone is an opioid antagonist used in the reversal of opioid overdose. The use of naloxone in patients on long-term opioids can lead to refractory pain and opioid withdrawal.

Objectives

To determine the number of patients on long term opioids, admitted either electively or as an emergency, given naloxone in a district general hospital. To determine if naloxone use is in line with local guidance, which recommends naloxone should be administered to patients with respiratory depression, evidenced by a respiratory rate less than 8 and oxygen saturations less than 85%.

Method

A retrospective audit for all patients administered naloxone over a 12 month period (January–December 2012) at Chesterfield Royal Hospital.

Results

A total of 21 patients on long-term opioids were administered naloxone. Of the 21 patients in whom naloxone was administered, 2 patients had had an opioid dose increase during their hospital stay and 4 patients had been given additional opioid. Of the 21 patients, 1 patient given naloxone had documented evidence of respiratory depression. 7 of patients given naloxone had no documentation to support respiratory depression while 13 of the patients given naloxone had documentation that supported no respiratory depression.

Conclusion

Current practice compared to the local guideline is not satisfactory. Patients on long-term opioids, without respiratory depression, are being given naloxone, which could lead to refractory pain. The main areas identified for improvement are staff education and changes to the electronic prescribing system. This would include an opioid reversal bundle with recommended guidance for evidence of respiratory depression.
PLANNING FOR THE FUTURE WITH PATIENTS WHO HAVE ADVANCED HEART DISEASE: DESIGNING A RANDOMISED CLINICAL TRIAL OF ANTICIPATORY CARE
Authors: Highet Gill , Cudmore Sarah , Robertson Shirley , Murray Scott A , Boyd Kirsty , Denvir Martin A
Published: February 2014

Background

Many patients with advanced heart disease have a limited prognosis despite optimal medical, surgical and device therapy. These patients rarely receive coordinated, holistic care that acknowledges their individual needs and those of their informal carers.

Aims

This study assesses the feasibility of a randomised controlled trial of a complex intervention that incorporates ongoing, holistic care with anticipatory care planning for people with advanced heart disease.

Methods

We conducted 11 interviews with a diverse sample of healthcare professionals and 2 focus groups comprising 12 patients and 5 carers. Participants were given a previously developed “Future Care Plan” and details of the trial before the interviews/ focus groups. These acted as focal points for discussion. Data were transcribed and analysed using standard software to extract themes related to the rationale and design of a clinical trial of anticipatory care planning in advanced heart disease.

Results

Patients and carers highlighted fragmentation of services, difficulty in accessing specialist care and inadequate time for future planning and preparation as key barriers to holistic care. A patient-held plan was welcomed. Healthcare professionals identified challenges related to uncertainty of prognosis, explaining mortality-risk to patients, and switching from curative to palliative approaches. These data informed patient selection (a combination of prognostic tools and needs for additional supportive care), the intervention (cardiologist review and nurse-led support delivered though a patient-centred care plan), and clinical trial outcomes that are robust but measurable in a frail population.

Conclusions

Patients, carers and healthcare professionals share a number of common concerns in relation to providing high quality care for people with advanced heart disease. The findings of this exploratory study are informing the implementation of a phase II randomised clinical trial of an holistic, anticipatory care planning intervention for patients with advanced heart disease in line with good practice in end of life care.