bluuebunny/crossref_metadata_2025_split huggingface dataset:
CAUSES OF SLEEP DISTURBANCE IN A SPECIALIST PALLIATIVE CARE UNIT
Authors: Glynn Jayne , Gale Sue , Tank Shila 
Published: February 2014

BackgroundSleep disturbance is a common and distressing problem in patients who are terminally ill and may intensify symptoms such as pain, depression, and/or anxiety. Staff in a Specialist Palliative Care inpatient unit felt that they were inadvertently and partly responsible for unnecessarily disturbing patients during the night, however, the frequency and precise nature of what caused patients to wake was unknown. A survey was undertaken to identify causes of disturbance and explore ways of reducing them.MethodsData were collected on all direct patient contact between 10pm and 6am. Data including time of disturbance, mode of seeking attention, and the primary reason for nurse assistance were recorded along with secondary data relating to additional needs and outcomes.Results301 disturbances occurred in 27 nights. 86% (60/70) of inpatients had at least one need (range 1–4). Most needs were between 22:01–24:00 hrs (29%) followed by 00:01–02:00 hrs (25%) and 02:01–04:00 hrs (23%). Patients used their call bell (58%), called out (18%) or were observed by a healthcare professional. Primary reason for seeking help related to elimination (31%), symptomatic (26%), wanted food/drink (13%), repositioning (10%), confused/talking in their sleep (6%), others (15%). Of the 10 symptoms reported pain was the most common followed by breathlessness, insomnia, cough/hiccups. Patients frequently articulated additional needs once their primary need had been met, for example, wanted analgesia, then asked for hot drink, assistance to the toilet, fan, etc. These subsequent needs resulted in 500 activities being carried out. Nurses and/or their activities were not reported as a cause for waking patients, however, when meeting an individual's needs other patients opportunistically expressed help/needs.ConclusionNursing activities do not appear to disturb patients. Ways of reducing nocturia in this client group are limited, however, more could be done to explore symptom management, such as prophylactic medication use. Pre-bedtime snacks should be provided and encouraged.
ESTABLISHING AN IMPROVING CARE GROUP IN HOSPICE: TRANSLATING RESEARCH INTO PRACTICE
Authors: Wijenayake Erandi , Hookey Claire 
Published: February 2014

BackgroundIntegrating research into daily practice is a challenge. Keeping up-to-date with the latest research and guidelines can help clinicians improve quality and safety of care. Following the Palliative Care Congress in 2012, an 'Improving Care Group' (ICG) was set up at Douglas Macmillan Hospice in Stoke-on-Trent.AimsThe ICG aims to improve care through utilising evidence based research. It is a multidisciplinary group with medical, nursing, physiotherapy, social work and psychology representatives.MethodsThe group identified several areas for which to examine the evidence base. Task groups were established for:ExerciseHolistic Assessment ToolsSex and SexualityFan Therapy for BreathlessnessClinical Ethics CommitteesEach task group reported back to the ICG and an action plan was agreed.ResultsLiterature review in some areas reinforced existing practice. For example, no evidence of benefit for use of holistic assessment tools within specialist palliative care was identified. However, the ICG identified that within the current holistic assessment, sex and sexuality were not well explored leading to a further task group.Examples of changes implemented by the ICG include:Training for hospice staff in assessment of needs and concerns around sex and sexuality.Development of patient information leaflets on sex and intimacy.Increased focus on exercise particularly for day therapy unit patients, including the “Tour of Stoke-on-Trent challenge”.A pilot of fan therapy for breathlessness.Teaching on management of breathlessness for hospice staff.Teaching on clinical ethics for hospice staff and identification of a group interested in becoming a hospice clinical ethics committee.ConclusionsThe Improving Care Group has provided a vehicle for enabling staff from different backgrounds and departments to work together to integrate research into practice, across all areas of the hospice.
EVALUATING THE IMPACT OF DAY THERAPY USING ST CHRISTOPHER'S HOSPICE INDEX OF PATIENT PRIORITIES (SKIPP)
Authors: Rayment Clare , Gordon Jean , Lepp Lydia 
Published: February 2014

AimsTo evaluate patients' perceived global impact of day therapy and the impact of day therapy on patients' quality of life (QOL) and concerns using SKIPP.MethodsSKIPP was completed at a patients' second attendance and thereafter 6 weekly for all new patients attending day therapy at Marie Curie Hospice, Bradford between January and July 2013.Results43 new attendees: 39 completed SKIPP. 24 completed one SKIPP, 15 two and 5, three. 28 patients continue to attend, 7 have died and 4 were discharged. SKIPP was completed by patients alone or with staff. Data was missing for SKIPP one for 9 patients. Average QOL, on a 1–7 (excellent) score, at SKIPP one was 3, SKIPP two, 5, and SKIPP three, 6. At SKIPP one, 77% of patients felt day therapy had improved things for them: 8% felt it had not helped much and 5% didn't know. At SKIPP two these figures had changed to 87% felt day therapy had helped: 13% not at all. At SKIPP three, 4 patients felt it had helped to a very great extent, 1 not at all. At SKIPP two, 10 felt that day therapy had made their concern better, 3 had no change and 2 felt it was a little worse. At SKIPP three, 3 patients felt their concern was better, 1 much worse and data was missing for 1 patient.ConclusionsSKIPP demonstrates that average QOL improves during day therapy attendance and most patients' think day therapy is helping them overall. However, a third of patients' main concern remained the same or a little worse at SKIPP 2. Only a small number completed a second SKIPP and this will influence the results. SKIPP appears to be useful in demonstrating the benefits of day therapy for some aspects of patient care.
PRIOR AND PROPER PREPARATION: FUNDAMENTAL STEPS WHEN IMPLEMENTING THE GOLD STANDARDS FRAMEWORK (GSF) IN A TERTIARY CANCER CENTRE
Authors: Griffiths Ann , Coackley Alison , Noble Agnes , Howarth Susan , Hampton-Matthews Julian , Foulkes Margaret , Lee Heather 
Published: February 2014

BackgroundThe GSF was developed in 2000 to improve palliative care in primary care. National dissemination was facilitated through a cascade approach with a Central Team supporting local facilitators. GSF has been shown to improve:-1. Quality of care2. Co-ordination and communication3. Patient outcomes and cost effectiveness.Acute hospitals have been described as the missing link in providing seamless, co-ordinated high quality end of life care. At present there has been no experience of implementing GSF into a tertiary cancer centre. Identification of patients in the last 12 months of life was recognised to be challenging for staff.AimTo analyse the knowledge and skills of health care professionals working in a tertiary cancer centre in identification of patients in the last twelve months of life and the use of advance care planning tools.MethodThree questionnaires were distributed to health care professionals1. A base line survey assessing the knowledge and skills of health care professionals recognising patients in the last twelve months2. An organisational questionnaire assessing the knowledge of the senior managers3. An after death analysis for deaths within the CentreResultsThe baseline questionnaire was distributed to 152 staff. The response rate was 76%. The organisational questionnaire was distributed to 3 wards and the Head of Nursing. The Response rate was 100%.The After Death Analysis examined 86 deaths in the TrustComplete results from the three questionnaires will be presented with details of the subsequent action planConclusionInterim results from the surveys have demonstrated that healthcare professionals require further training in the identification of patients at the end of life and the use of advance care planning tools. A comprehensive education package delivered over 6 months will aim to address the needs of staff.
ANTIBIOTIC STEWARDSHIP IN PALLIATIVE CARE — DEVELOPMENT OF ANTIBIOTIC PRESCRIBING GUIDELINES FOR A HOSPICE INPATIENT UNIT
Authors: Donald Leila , Lindsay Fiona 
Published: February 2014

BackgroundThe incidence of infections in palliative care patients is high due to immunocompromise from underlying disease processes and treatments including chemotherapy and steroids. An earlier audit of hospice notes revealed poor documentation of antibiotic prescribing and poor adherence to hospital antimicrobial guidelines.AimsTo promote antibiotic stewardship through the development of local antimicrobial guidelines specific to palliative care and inpatient hospice setting. To provide a simple, pragmatic approach and promote the safe, effective and economic use of antibiotics in palliative care patients.MethodsA literature search of Embase, Medline, the Cochrane Library and NHS evidence using the search terms ‘palliative care’ or ‘palliative therapy’ and ‘antibacterial agents’ or ‘antibiotic agent’ was completed National antibiotic guidance (BNF), published antibiotic guidance specific to palliative care (palliativedrugs.com) and local antimicrobial guidelines (PCT and Hospital) were also reviewed in development of the hospice antibiotic prescribing guidelines. The guidelines were discussed with the hospice pharmacist and presented to the medical and nursing staff, providing peer review and education.ResultsThe literature search identified 10 articles meeting the search criteria but the focus was on antibiotic use in the last few days of life and was unsuitable. No definitive guidelines for antibiotic prescribing in palliative care were identified. The developed hospice antibiotic prescribing guidelines provide guidance for first and second line treatment of 12 specific infections of the lower respiratory tract, urinary tract, skin and soft tissue and other miscellaneous infections including clostridium difficile and intrabdominal sepsis. Clear documentation is emphasised with requisite information stipulated. The guidelines were introduced in May 2013.ConclusionsThe innovative multi-disciplinary approach used to develop the antibiotic guidelines will encourage consistent prescribing and documentation to produce safe, effective and economic antibiotic use in hospice inpatients. The rigorous development process allows the guidelines to be transferable to other specialist palliative care inpatient settings.
THINK DELIRIUM! AN AUDIT OF ASSESSMENT OF COGNITION DURING ADMISSION TO A SCOTTISH PALLIATIVE CARE UNIT
Authors: Pinnell Kathryn 
Published: February 2014

BackgroundDelirium is prevalent in the palliative care patient group. It is associated with high morbidity and mortality rates and causes distress for patients and carers. Delirium may be reversible. Assessment and management of delirium are a priority of Healthcare Improvement Scotland.MethodA retrospective casenote review of 100 consecutive admissions to a Scottish specialist palliative care unit (SPCU) was undertaken.AimsThe audit aimed to establish whether we assess and document cognition on admission, or within 48 hours, to a SPCU. If there was a documented indicator of cognitive impairment and/or delirium, the audit reviewed whether delirium was screened for and if causes of delirium are considered and treated appropriately.ResultsSeven of 100 patients admitted had a cognitive assessment performed on admission or within 48 hours. In three cognitive assessment was documented as inappropriate or unable to be done. 34 patients had a documented indicator of cognitive impairment and/or delirium on admission. 14.7% (n=5) had a cognitive assessment on admission or within the first 48 hours. None had a documented screen for delirium however 3% (n=1) had a diagnosis of delirium. 9% (n=3) had a diagnosis explaining static cognitive impairment so weren't included in further analysis. 68 % (n= 21) of the 31 patients had the clinically most obvious cause at time of admission addressed, most commonly infection or opioid toxicity, 16% (n=5) had no possible cause documented or addressed and in 16% (n=5) 3–5 possible causes were considered. None had a full assessment of all possible causes of delirium.ConclusionAssessment of cognition and delirium screens are not done routinely on admission to our SPCU. There is scope to improve this with further education. In addition a tool will be developed and implemented to aid screening for delirium and assessment of possible causes. Re-audit is planned after implementation.
A scoping exercise to explore the current perceptions and attitudes of UK paramedics towards their role in the management of End of Life Care patients, in the pre-hospital setting
Authors: Kirk Andrew , Crompton Phil , Jack Barbara , Knighting Katherine , Kirt Jennifer 
Published: February 2014

BackgroundStudies have highlighted that clinicians may not feel prepared to deal with end of life care patients as historically their training has been focussed on acute medical and trauma management. This has been shown to cause conflict with paramedic perceptions of their role. Although research exists that explores the attitudes and experiences of health and social care professionals who deal with palliative care patients on a routine basis, there is little evidence that explores the attitudes and perceptions of end of life care within the emergency pre-hospital setting.Aim of the studyTo gain an understanding of UK paramedics perceptions and attitudes towards dealing with End of Life Care patients and carers/relatives.MethodsAn online survey was distributed to all paramedics in the North West of England. The survey contained open and closed questions to enable collection of both qualitative and quantitative data to address the aims of the study. Demographic data including NHS band, personal experience and education & training was gathered in order to contextualise the data.ResultsNHS band and educational background are the main influences on the participants views of End of Life provision provided by paramedics. Length of service as a paramedic and experience appear to be factors that affect confidence when dealing with these incidents in practice. The majority of participants rated that communication about End of Life Care between services is poor. Most participants would like EOL training to be mandatory and would prefer face to face training to self-directed learning packages.ConclusionsCommunication between services is viewed as poor whilst staff backgrounds influences their views. Whilst the majority of paramedics feel that End of Life Care it is a key part of their role, there is a need for wider training to address differences in staff awareness, knowledge and confidence.
A REGIONAL RE-AUDIT OF THE SYMPTOMATIC MANAGEMENT OF NAUSEA & VOMITING IN THE MEDICAL MANAGEMENT OF MALIGNANT BOWEL OBSTRUCTION
Authors: Jackson Timothy , Waterman David , Ahamed Ashique , Lennon Rebecca , Suman Julie , Murray Yvonne , Brady Denise , Harrison Sophie 
Published: February 2014

BackgroundThe medical management of symptoms associated with malignant bowel obstruction remains a clinical challenge in palliative care. Where surgical intervention is not appropriate, thorough clinical assessment should guide treatments for nausea and vomiting. In 2011, the North West Palliative Care Regional Audit Group (NWAG) coordinated a multi-centre review revealing variations in prescribing practice and adherence to guidelines. In response, participating organisations were asked to develop action plans.AimTo re-audit the assessment and medical management of nausea and vomiting in malignant bowel obstruction against updated evidence-based standards, and compare results with the 2011 NWAG audit.MethodA regional, multi-centre, retrospective case note audit was undertaken for patients with malignant bowel obstruction. 8 audit standards were produced following an updated literature review. Data was submitted electronically and analysed centrally by NWAG for participating organisations.ResultsThirteen organisations returned 101 data collection forms (6 hospices, 7 hospitals), an identical number to the original audit. Presence or absence of nausea, vomiting and colic was documented at initial assessment in 77%, 94% 68% respectively (n=101) compared with 80%, 91%, 80% in the original audit. Antiemetics were prescribed via non-oral routes in patients with nausea and/or vomiting in 87% (originally 97%). Where nausea and/or vomiting occurred due to bowel obstruction, regular or continuous non-oral medications were subsequently prescribed within 48hrs in 64% of cases (originally 68%). During an initial 4 day assessment period, if patients required two or more PRN medications for nausea and vomiting in 24 hours, medications were reviewed in 91%. Metoclopramide, if prescribed, was discontinued if colic occurred in 67% of cases. Metoclopramide and cyclizine were prescribed concurrently in 9%.ConclusionWhilst this re-audit demonstrates some variation from the original audit, practice was consistent in many areas. Findings support the need for regular and comprehensive clinical assessment in order to maintain effective symptom control.
KETAMINE USE IN PALLIATIVE CARE WITHIN THE NORTH TRENT CANCER NETWORK (NTCN)
Authors: Fingas Samuel , Ahamed Ashique , Ahmedzai Sam H 
Published: February 2014

BackgroundKetamine is a potent analgesic with potentially serious adverse effects (eg dysphoria, bladder dysfunction), being used in palliative medicine. Its evidence base is limited and a recent RCT using the SC route in cancer pain failed to show efficacy. Neither route nor dosing are standardised, which raises questions for clinical governance in palliative care services.AimsTo characterise ketamine use in palliative medicine within NTCN, with specific reference to variations in route and dosing.MethodA short online questionnaire was developed using SurveyMonkey, to capture NTCN palliative medicine consultants' current practices, preferences and opinions. Reminders were used to ensure compliance.ResultsResponse rate 15/15 (100%). All had prescribed ketamine in their current post: 100% via SC route, 93% oral, 27% IV. Preference for different routes of administration varied. Ketamine is initiated in outpatient clinics/ day units, and in patients' homes. IV ketamine is only prescribed in hospital/hospice. 86% of consultants discharge patients on ketamine into the community. An estimated 255 patients received ketamine in the previous 12 months. Concomitant opioid reduction varied greatly between physicians. 12/15 physicians switch ketamine routes from SC to PO during treatment. PO and SC ketamine are being used indefinitely. IV treatment is only used as ‘burst’ treatment. 87% give PRN ketamine. Test dose administration varies greatly (53% SC and 100% IV). 5/15 wanted training on IV ketamine. Barriers to ketamine use include cost, community support, and lack of IV pumps. 93% do not use a standardised recording tool. Most organisations do not have a written protocol.ConclusionThere is significant variation in practice of ketamine use. Despite recent adverse evidence, SC ketamine is most commonly prescribed. Many patients are treated indefinitely and are at risk of side effects. Further studies are needed to establish national usage and to identify priorities for research.
DRUGS AT THE END OF LIFE: AN APPROPRIATE CONCERN?
Authors: Pickard Jonathan , Smailes Rosanna , McKenna Maria 
Published: February 2014

BackgroundThe Independent Review of the Liverpool Care Pathway (LCP) described concerns about use of opioid and sedative drugs at the end of life. Baroness Neuberger reiterated the importance of appropriate use of medications to achieve a peaceful death. One concern was that a continuous subcutaneous infusion (CSCI) was started when dying was diagnosed or the LCP commenced, regardless of symptoms.AimTo investigate the use of medications at the end of life.MethodA retrospective audit of deaths within one hospital was undertaken in July 2013.ResultsOf 44 hospital deaths over a one-month period, 82% (n=36) were deemed expected. 56% (20/36 patients) were prescribed anticipatory medications for symptoms of pain, agitation, nausea, vomiting and secretions by the appropriate route and frequency. 100% of anticipatory PRN prescriptions were correctly dosed and 83% were appropriately prescribed parenterally.72% of patients utilised anticipatory as required (PRN) medication. A CSCI was used in 42% (15/36) of cases. They most commonly contained an opioid to manage pain (93%) and/or a benzodiazepine for agitation (73%), but also included anti-emetic (20%) and anti-secretory drugs (13%). The rationale for CSCI commencement was clearly apparent in 7/15 cases; most commonly it was due to frequent use of PRN drugs (n=6) or as a switch from a regular oral opioid (n=1). A CSCI was used for a mean of 3.9 days.One limitation of these findings is the reliance on written documentation within the patients' medical notes.Conclusion and RecommendationsThis audit demonstrated that the majority of patients do not receive medication via a CSCI at the end of life, but that most are administered PRN medication for their comfort. The rationale for starting a CSCI should be clearly documented, specifically recording indication for use and communication with patient, family and carers.
PREDICTING WHEN THE LCP MIGHT NOT BE USED?: AN AUDIT OF COMMUNICATION WITH SECONDARY, CONTENT ANALYSIS OF LANGUAGE
Authors: Arolker Milind , Ford Margaret , Marshall Susan 
Published: February 2014

BackgroundBradford Teaching Hospitals NHS Foundation Trust (BTHFT) provides acute care services and comprises around 1200 beds. Although it participates in the National Care of the Dying Audit (NCDAH), this recurring process previously examined documentation just within the Liverpool Care Pathway (LCP) document. Following adverse media interest in the LCP, we carried out a retrospective casenote audit of deaths examining all documentation surrounding the death of the patients; data was collected from medical, nursing and, if used, LCP documentation regarding communication for patients and relatives about dying in general. When differences in the documented language emerged between notes of patients whose deaths were, and patients whose deaths were not supported by LCP-use, we carried out a secondary, content analysis of random subsets of each of these two groups of notes.AimsTo assess whether relatives were informed that the patient is dying and to compare differences in documentation language when the LCP was and was not used.ResultsOf 96 adult deaths during October 2012, 83 case notes were available for analysis. After excluding 27 (33%) sudden or unexpected deaths, the remaining 56 (67%) expected deaths split into two sets: 41 (73%) supported by LCP, and 15 (27%) not supported. In both sets, the relatives had been informed that the patient was dying: LCP, 100%; and non-LCP, 93%. However, content analysis revealed that hedged language (terms such as ‘unlikely to survive’, ‘looks to be dying’, ‘un-survivable’) was more frequently documented in deaths unsupported by the LCP, compared to those supported by the LCP, where terms used in the medical notes connoted a greater degree of certainty, e.g. ‘is dying’, ‘not responding to treatment.’ConclusionBTHFT' staff document communication about dying well, despite contrary, adverse media reporting. Content analysis results suggest that hedged documentation language is associated with lower likelihood of integrated care pathway use for dying patients.