bluuebunny/crossref_metadata_2025_split huggingface dataset:
Introduction of county-wide electronic palliative care notes system improves quality and efficiency
Authors: Heron Nicola 
Published: March 2012

BackgroundA partnership of the five different Specialist Palliative Care service providers in Worcestershire came together to implement a county-wide clinical notes system for specialist palliative care patients. The SystmOne electronic clinical management system was introduced in August 2009 across all settings from acute hospital to independent sector hospice and NHS community palliative care providers.Aims of this surveyTo demonstrate improvements in clinical care and efficiency through sector wide access to a single set of electronic palliative care notes.MethodsReferrals to a hospital palliative care team over 1 month analysed in SystmOne to document patient pathways and access to multiple services and providers. Estimates of time saved by reduced telephone calls and faxes between agencies were also made.ResultsSeventy-two episodes of patient care were analysed. 27 (37.5%) were already known to palliative care services within Worcestershire, therefore clinical information, some advance care planning information and psychosocial details were available to the acute hospital palliative care team at the time of their initial assessment. Thirty-seven (51%) were discharged from the acute hospital and received on-going support from palliative care teams within the county (18 different teams in total), all of whom were able to access the clinical information contributed to the electronic record during the inpatient admission. During this 30 day period, the authors estimate that 17.3 h were saved by communicating/referring via SystemOne. The authors include a case study which demonstrates improved quality of patient care.ConclusionCounty-wide access to a single electronic palliative care record has improved efficiency and quality of information and patient care.
Location, location, location
Authors: Whyte Graham , Groves Karen , Finnegan Clare , Lancs West , Leonard Niall , Scott Helen 
Published: March 2012

BackgroundThe End of Life Care Strategy (2008) highlighted the need to raise the quality of care provided to dying people in care homes and this is supported by The Route to Success in End of Life Care – Achieving Quality in Care Homes. (2010) Previous work done locally had suggested there were a large number of attendances at Accident and Emergency (A+E) by care home residents and in order to understand whether any of these were avoidable and form conclusions as to how support for staff caring for these patients could be improved, a greater understanding of what happened at the care home prior to transfer to hospital was felt to be needed.AimTo conduct a prospective audit of all A+E and Emergency Admission Unit (EAU) attendances by care home patients at the end of life.MethodologyCare home patients presenting to A+E and EAU were identified on a daily basis over a 2 month period. Baseline data was collected from the time of arrival to A+E or MAU. Telephone consultations then took place with the care homes in question to obtain information about what happened to the patient leading to the resultant transfer to hospital.ResultsResults demonstrated the extent of coordinated care, review by community clinicians prior to transfer and also the use of end of life tools such as the GSF.ConclusionService improvement initiatives have been targeted to reduce hospitalisation by admission avoidance, further develop the use of end of life tools in care homes, increase the confidence and expertise of care home staff, with the ultimate aim of improving the experience, co-ordination and quality of care that care home residents receive at the end of life.
Development of a non-pharmacological breathlessness management pathway
Authors: Acreman Susan , Baker Kate , Clifton Sian 
Published: March 2012

AimBreathlessness is one the most common problems experienced in cancer; evidence suggests that up to 79% will encounter this distressing symptom, which can undermine functional ability and compromise independence. Evidence suggests that while there are breathlessness management programmes, few exist specifically for cancer and none provided care and advice cross the eight domains which are physical, psychological, practical, nutritional, social, spiritual, financial and information.MethodA survey of breathlessness programmes for people with cancer across South East Wales revealed inadequate provision, with current services unable to meet the demand. Additionally, they did not cover the eight domains of care necessary for the provision of holistic care. An evidence based non-pharmacological breathlessness management programme was developed as well as a workforce education programme to ensure the right level of skills and competence of those delivering the pathway.ResultsFourty people were referred and 22 were seen. The most common presenting tumour sites were breast (N=12), lung (N=9), pancreas (N=3) and ovary (N=3). Of the patients who entered the pathway, 19 (83%) self-managed successfully and 3 (17%) required referral for specialist care such as nutrition, occupational therapy and physiotherapy.Conclusions and discussionWhile dyspnoea is not routinely assessed and is an expected burden for many people with cancer, simple self-management techniques used as this pathway can empower such people to cope a little better with the distress and life limiting effects of their dyspnoea. As this is a patient led intervention, they determine what level of advice and information they want and thus they are able to control this as well as the level of professional intervention accessed. Finally, though the pathway was developed primarily for people with cancer, it has been shown that it can be effortlessly transferred to other conditions where breathing may be compromised.
Management of hypercalcaemia at hospice setting
Authors: Hanchanale Sarika , Jordan Alice 
Published: March 2012

ObjectiveHypercalcaemia of malignancy is a palliative care emergency that needs early intervention. Bisphosphonate therapy improves the morbidity of acute hypercalcaemia, reduce bone pain and pathological fractures. North of England Cancer Network Palliative Care Guidelines suggests early admission, rehydration followed by bisphosphonate therapy (if appropriate). We assessed the hypercalcaemia management at hospice setting and adherence to regional guidelines.Materials and methodsRetrospective data of all patients admitted with hypercalcaemia at Hartlepool hospice (January 2010–December 2010) was collected with regard to baseline demographics, calcium level, management and follow-up planning. Further analysis was done to assess whether regional guidelines were followed.ResultsA total of 22 patients were admitted with hypercalcaemia during the study period. Median age (range) was 68 (52–84) years and Male to female ratio was 1:1. The top five common cancers were lung (5), breast (5), prostate (3), bowel (3) and head and neck (2). Patients with mild (2.6–3.0 mmol/l), moderate (3.0–3.5 mmol/l) and severe (>3.5 mmol/l) hypercalcaemia were 18, 3 and 1 respectively. Most common presenting symptom was pain (36%) and nausea (36%). Symptomatic hypercalcaemia was treated in 88% of patients. Intravenous fluid therapy was given in 65% of patients with symptoms. Bisphosphonate therapy was given in 88% of patients with symptoms and after intravenous fluids in 27% of patients. Symptomatic improvement is noted in 56% of patients. Post-treatment calcium level was checked in 70% of patients. Recommendations were intravenous fluid therapy with 1–2 l normal saline to be given before Zolendronic acid (if not contraindicated). Repeat calcium levels at 5 days and 3 weeks. Furthermore, strict documentation of all events including symptomatic improvement was recommended.ConclusionHypercalcaemia in palliative care setting is a common problem and must be treated according to the standard regional guidelines. Follow-up audit has been planned after implementation of recommendations.
Audit of venous thromboembolism risk for patients admitted to a palliative care inpatient unit
Authors: McKenna Maria , Porteous Anna , Andrew Inga , Robson Peter , Lee Mark 
Published: March 2012

BackgroundA venous thromboembolism (VTE) risk assessment tool has been developed locally, in line with NICE guidelines, based upon the National Risk Assessment Model (DoH 2010). This single page document identifies key risk factors for VTE and contraindications to anticoagulation.AimsUndertake a baseline audit of the new VTE risk assessment tool within a palliative care setting. Methods: Retrospective case note review of consecutive hospice admissions over a 3 month period, following introduction of the VTE risk assessment.ResultsForms – 58 patients were admitted during this period, 88% percent had a fully completed VTE risk assessment. Primary prophylaxis – 5 patients (9%) received primary prophylaxis with Low Molecular Weight Heparin (LMWH). The most common thrombotic risks, other than temporarily reduced mobility, were age>60y (64%) and abdominal/pelvic pathology (26%). Twenty-six patients (45%) had a contraindication to anticoagulation, the most frequent being active bleeding (16%) and cerebral tumour (12%). Secondary prophylaxis – Eight (14%) were already anticoagulated for thromboembolic disease, five with LMWH, two with warfarin and one was switched from warfarin to LMWH on admission. Malignant versus non-malignant disease – 51 patients (88%) had a malignancy. None of the seven patients without cancer received primary or secondary prophylaxis. 11% of patients with malignancy were dehydrated, 9% were obese and 16% had a history of VTE. These risk factors were not present in the non-malignant group.DiscussionOur rates of prescribing primary prophylaxis are higher than previously published data, despite similar contraindication rates. Interestingly, certain risk factors (dehydration, obesity, history of VTE) were more prevalent in the malignant patient group, despite not being cancer specific. This work reiterates that malignancy is a greater risk factor for VTE than immobility.ConclusionUse of local, concise VTE risk assessment forms has led to high rates of compliance with guidance. Data collection is on-going.
An audit on ‘death rattle’ (noisy breathing at the end of life), and usage of antisecretory medicat
Authors: Thirukumaran Thiru , Subramaniam Sivakumar , Cawley Declan , Fisher Simon 
Published: March 2012

‘Noisy breathing’ also known as death rattle, is common in end of life care situations and can be distressing for the family given it's unpleasant resonance. A recent Cochrane review by Weeet al(2009 review) concluded that there is no evidence to show any intervention was superior to placebo; it is very difficult to subsequently manage.AimTo evaluate current practice against national guidelines on the use of antisecretory medications in end of life care.MethodologyRetrospective, case notes review of all the patients died in the author's unit (Jan 2011–May 2011).ResultsSeventy-two patients were identified with 65 patients having antisecretory drugs prescribed and 36 patients requiring medications. 49/65 had complied with the recommended guidance with only 29/36 having a documentation of a response. 7/36 patients with no documentation of assessment. 24/29 patients had documented benefit from the antisecretory drug and a syringe driver started in 24/36 cases. Apart from drugs evidence of other modalities used was lacking: 3/36 patients evidence of re-positioning only. Documentation of communication with family was only in 4/36. 22/36 patients died within 48 h from 1st dose of antisecretory given and 16/24 patients died within 24 h of the syringe driver starting.ConclusionIn a majority of patients medications used appropriately and response assessment completed. However, documentation of communication with family and other approaches needs to be improved. Interestingly when antisecretory drugs were used death ensued within 48 hrs for the majority. Education of all staff members is extremely important along with regular audit.
Measuring the effectiveness of a fatigue and breathlessness group for palliative patients
Authors: Brookes Katie , Edwards Anne , Marshall Samantha , Williams Sarah 
Published: March 2012

BackgroundIt has long been known that fatigue and breathlessness for patients with a life limiting illness is prevalent and is frequently rated as having a greater impact on quality of life than pain (Hoekstraet al2007). It has also been shown that often it is not addressed adequately, (Coakleyet al2002). Patients believe that the symptoms are an inevitable part of their disease and patient, carers and some health professionals misguidedly use rest as a coping strategy. In 2007, in order to address these issues in a group setting, the first Fatigue and Breathlessness course commenced at St Peter's Hospice, Bristol. Topics covered on the course are fatigue, breathlessness, benefits of exercise, energy conservation, sleep, anxiety management and nutrition. Patients themselves set goals, and are encouraged to practise what they have learnt in the group at home. One of the biggest challenges has been how to measure the effectiveness of the programme. As highlighted by Pearsonet al(2007) ‘this poses significant problems in palliative care due to the declining function of clients that confounds the apparent effectiveness of the intervention’. An assessment tool has now been introduced which asks patients to measure their symptoms using a visual analogue scale (VAS), alongside a questionnaire which gives a qualitative assessment of abilities and focuses on goal achievement.AimTo measure the effectiveness of the course using pre and post VAS scores and qualitative assessment tools such as goal setting and questionnaires.ConclusionGoal setting and patient feedback proved to be the most effective tools in providing measurable and meaningful outcomes. This demonstrated a high patient satisfaction rate and improvement in quality of life. We can now provide evidence for the effectiveness of the course in a palliative setting.
Audit of the use of corticosteroids in advanced malignancy: maximising benefit and minimising harm
Authors: Hayle Catherine , Capewell Claire , Morris Debra , Brooks Lindy , Fletcher Andrew , Lowe Joanne , Sanders Dave , Harrison Sophie 
Published: March 2012

BackgroundCorticosteroids are used within specialist palliative care for a variety of indications, from wellbeing to medical emergencies such as spinal cord compression. For benefits to outweigh toxicity, it has been suggested that they should be used according to defined guidelines.AimThe NorthWest Audit Group aimed to review the practice of organisations across the Northwest of England regarding corticosteroid use.MethodThis multi-centre, cross-regional, retrospective case-note audit used a standardised data collection tool to gather information on patients with advanced malignancy, known to specialist palliative care. A multi-professional steering group developed standards of good practice against which the first 2 weeks of steroid therapy was audited.ResultsData were collected on 181 patients from 22 sites including hospital, hospice and community settings. Specialist palliative care professionals were involved in the commencement of steroids in 63%. The indication was documented in 82%, with most commonly cited reasons being anorexia, pain, fatigue and raised intracranial pressure. Previous steroid use was documented in 18%. When patients were prescribed medications that interact with corticosteroids, 4/21 (19%) had evidence of this being taken into consideration. Instructions for blood sugar monitoring were present in 24%. Where there was concurrent aspirin or NSAID use, gastro-protection was prescribed in 36/41 cases (87%). For patients remaining in the same care setting, there was evidence of a dose review in 79%. For those who were discharged from the service, there was a plan for future monitoring in 58%.ConclusionThis audit was well received with a very positive return. It demonstrated scope for improvement in current practice. Issues highlighted include the need for improvement in documentation of previous steroid use, instructions for blood sugar monitoring and review of drug interactions. Communication is vital when a patient is transferred between services so that monitoring of safety and efficacy is on-going.
Experience of tolvaptan on patients with end stage heart failure
Authors: Broughton Caroline , Murray Andrew , Morley-Davies Adrian , Satchithananda Durwarakan Kirupanantha , Hookey Claire 
Published: March 2012

IntroductionHyponatraemia is common in end stage heart failure (ESHF). It is associated with poorer outcomes and limits the use of increasing doses of loop diuretics to alleviate congestive symptoms. Inability to reduce symptoms from hospitalised patients with ESHF can be the difference between patients dying in hospital or being discharged into the community. Tolvaptan is a vasopressin antagonist with diuretic effect with minimal effect on sodium levels. We present our current clinical experience with tolvaptan in palliative care patients with ESHF, hyponatraemia and congestive symptoms.MethodHyponatraemic patients with ESHF and intractable symptoms (either unresponsive to or conventionally unsuitable for further escalation of loop diuretic therapy) were considered for tolvaptan by their managing cardiologist. Seven patients were selected, 1 died on the day tolvaptan was started, notes were unavailable in 1 case.ResultsWe report on 5 patients – 4 had tolvaptan started in hospital. Demographics: 4 male, mean age 71.8 years, mean number of co-morbidities was 5.6. Mean duration of treatment was 9.6 days. There were no adverse events or side effects. Loop diuretic doses were continued unchanged in 4 and increased in 1. Sodium Creatinine Weight in mmol/l in μmol/l in kg Before tolvaptan mean (SD) 122(4) 108(57) 81.1 (13.6) After tolvaptan mean (SD) 128 (4) 103 (48) 77.6 (12.4) All hospitalised patients were subsequently discharged. One patient died 3 months after treatment. The total cost of tolvaptan was £4300.80. This appears marginal compared to the total cost of hospitalisation (cumulative in patient stay of 169 days).ConclusionTolvaptan is safe, well tolerated and reduces congestion without significantly worsening either hyponatraemia or (in our patients) renal function. It can aid discharge from hospital to facilitate patient's palliative care choices. Tolvaptan adds to strategies for symptom relief in ESHF by palliative care specialists and cardiologists alike.
Regional audit on the symptomatic management of nausea & vomiting in the medical management of malignant bowel obstruction
Authors: O'Brien Elizabeth , Edwards Laura , Sutherland Aaron , Mitchell Kath , Concannon Maxine , Murray Yvonne , Sanders Dave , Waterman David , Twomey Feargal , Harrison Sophie 
Published: March 2012

BackgroundMalignant bowel obstruction is a recognised complication of advanced malignancy. Surgery is not always suitable therefore antiemetics are the mainstay of symptomatic management. There is little evidence for any specific antiemetic. NWAG was initiated to co-ordinate audits across palliative care settings within the north-west.AimsTo review the assessment and management of nausea and vomiting in medically managed malignant bowel obstruction. To audit against six standards set following a literature review.MethodRetrospective, multi-centre review of case notes.ResultsThirteen organisations returned 101 data collection sheets (5 hospices 8 hospitals). Ninety-nine of these were used (41 from hospices and 58 from hospitals). The presence or absence of nausea, vomiting and colic was documented at initial assessment in 80%, 91%, 80% respectively (n=99). Antiemetics were prescribed via non-oral routes in patients with nausea and/or vomiting regularly in 90% (n=252) and PRN in 97% (n=236). Regular or continuous medications via non-oral routes were prescribed within 48 h of a documented episode of nausea and/or vomiting secondary to malignant bowel obstruction in 68%. Consideration was given to reviewing management of nausea and vomiting in patients requiring two or more PRN medications for nausea and vomiting in the preceding 24 h. Day 2 82% (n=22), Day 4 88% (n=19). Metoclopramide was stopped if colic was present in 27% (n=11). 6. The co-prescription of cyclizine and metoclopramide should not occur – regular 100% (n=99) Regular +PRN 93% (n=99)ConclusionRegular assessment of symptoms is crucial in patients with medically managed bowel obstruction. Frequency and route of administration should be considered. Regular review is required to establish effectiveness of management and the need for change. PRN and regular medication combinations need assessment.
‘Dead-tired’ – a novel MDT approach to fatigue management for patients with advanced disease
Authors: Bowler Emily , Malik Farida 
Published: March 2012

IntroductionFatigue is a common and distressing symptom for patients with malignant and non-malignant disease.1 The importance of specific training programmes for managing fatigue have been cited.2 The authors describe an innovative multi-professional fatigue clinic for patients with advanced disease.MethodsA palliative care occupational therapist/physiotherapist-led fatigue clinic was developed in the day therapy unit in St Wilfrid's Hospice, Eastbourne. The clinic involves 4 weekly sessions; topics include breathing techniques, graded exercise, energy conservation (pacing, prioritising), energy restoration (nutrition, sleep, relaxation) and a complimentary therapy led session. Data collected as part of the service included patient self-reported fatigue (brief fatigue inventory (BFI)) collected at start, 4 weeks & 5-week follow-up) and demographics. Patients also completed a fatigue diary and service evaluation. Descriptive statistics were used to describe service findings. A paired t test was used to describe difference in global BFI score at start and at 4 weeks.ResultsTwenty-seven patients were referred to the clinic (25 internal hospice referrals) 18 started the service. Nine patients were unable to start (seven unwell, one died, one declined). Results are available on 17 patients (mean age 64.6 years (SD 10.7), 71% female,) 16/17 had a cancer diagnosis (5/16 had breast cancer, 5/16 colo-rectal cancer). Mean global BFI at start=69.1 (range 48–85) and at 4 weeks=54.9 (range 40–72). Mean improvement in global BFI score=14.2, t=3.3, p=0.02, n=10. Patients positively evaluated the service. Further data for 5-week follow-up, to follow.ConclusionFindings suggest the fatigue clinic appears beneficial in managing patient fatigue. Early referral is recommended, so patients are seen before their disease has progressed too far.