bluuebunny/crossref_metadata_2025_split huggingface dataset:
Documentation of cardiopulmonary resuscitation decisions at a busy hospice inpatient unit
Authors: Kay Samantha , Babburi Aruna , Castanheira Trisha , Plenderleith Steve 
Published: March 2012

BackgroundIn response to the guidelines issued by the Resuscitation Council relating to making decisions about cardiopulmonary resuscitation (CPR), the National Council for Hospice and Specialist Palliative Care Services and the Association for Palliative Medicine of Great Britain and Ireland produced joint guidance for palliative care. This included the recommendation that written information be made available to patients about the hospice CPR policy, how decisions are made about CPR and the facilities available at the unit.AimsTo identify whether all patients had received the hospice CPR information policy and whether the resuscitation component of the admission clerking had been fully completed. To identify how many CPR decisions are being discussed with the patient and in those situations where it is the clinician making the decision, whether reasons are documented in the medical notes explaining this decision.MethodsThe medical notes of all inpatients at Birmingham St Mary's Hospice were analysed prospectively over a 2 week period, when bed occupancy was greater than 60 per cent.ResultsAll patients received a patient information booklet regarding the hospice resuscitation policy and there was high compliance (94%) of accurate documentation around CPR decisions. However, 82% of these decisions had been made by the clinician without discussion with the patient and only two patients (12%) had actually clearly had a discussion with the admitting doctor and had chosen themselves not be for resuscitation.ConclusionIf a patient is in the terminal phase of their illness, CPR is likely to be futile and the patient has no realistic choice to make. However, this audit highlighted the need for more discussions with patients around their CPR status and documentation of this in the medical notes, even if this is to make patients aware that decisions are being made on their behalf and invite discussions if desired.
Multi-disciplinary team assessment of prognosis in palliative care
Authors: Grogan Eleanor , John Justina 
Published: March 2012

BackgroundPredicting patient prognosis is a challenging clinical decision and some studies report that clinicians often overestimate patient survival1. One important aspect of predicting prognosis is ensuring that patients are allocated the appropriate resources as part of their management, including continuing healthcare placement if appropriate. A continuing healthcare placement is funded via NHS resources and has set criteria including that all patients referred should have an expected prognosis of less than 3 months. Patients with a longer expected survival do not usually receive full NHS funding if transferred to a care placement.AimsAudit of patients transferred from an NHS inpatient specialist palliative care unit (PCU) to a continuing healthcare funded placement to assess whether (1) prognosis was accurately predicted using multidisciplinary team expertise on the PCU and therefore (2) NHS funding was correctly allocated to these patients.Conclusion86% patients transferred from the NHS inpatient specialist palliative care unit (PCU) to a continuing healthcare placement lived for less than 3 months. Some of these had a survival significantly shorter than the predicted 3 months but it was difficult to determine from the medical notes if, on retrospect, this would have been expected. This in turn raises the issue of whether it may have been in the best interest of some of these patients to have remained on the PCU.
The importance of high facilitation when implementing end of life care tools in care homes
Authors: Hockley Jo , Holman Deborah 
Published: March 2012

BackgroundCare homes are increasingly places where older people live and die. The end of life care programme promotes the use of end of life care tools in care homes; however, changing the relatively weak culture of care homes where there is high turnover of staff, a majority of untrained carers, and a lack of multi-disciplinary working, is complex. The Care Home Project Team at St Christopher's Hospice, London became a Regional Centre for the delivery of the GSFCH programme in October 2008. Since this time 132 care homes have completed this programme of which 53 nursing homes are from our own locality.MethodsFour FTE palliative care nurse specialists facilitate the implementation of end of life care tools across five PCTs (population 1 386 076). The team uses high facilitation to empower nursing home staff and visit their specified nursing homes 2/3 times a month to role model monthly coding meetings, advance care plan discussions, LCP training etc. Emphasis is given to supporting staff with monthly reflective-debriefing sessions following a death. Managers collected preprogramme data on all deaths in order to compare to subsequent years.ResultsSince 2008, inappropriate hospital deaths have been reduced by 16%. In 2008, 57% residents across 19 nursing homes died in the homes compared to 73% residents across 53 nursing homes in 2010. Sixty per cent of nursing homes (32/53) have gained accreditation compared to a national average of 10%. Commissioners now fund all members of the Care Home Project Team.ConclusionHigh facilitation of evidence-based tools in end of life care can develop a palliative care culture in nursing homes. However, sustainability is not without cost. Our sustainability programme consists of nursing home cluster groups within each PCT. Each cluster covers 3 levels: new staff; 4-day training package for regular nurses/carers; action learning for managers.
Macmillan end of life discharge pilot project at the James Cook university hospital (JCUH)
Authors: Taylor Yvonne , Walker Jane , Hunter Noeleen , Harris Andrea , Nicholson Alexander 
Published: March 2012

BackgroundCurrent end of life initiatives emphasise the importance of achieving the preferred place of care for patients approaching end of life. National survey data suggest 50–60% patients would prefer a home death but data for South Tees indicates that only 22% of patients achieve this (2007–2009). A new service was therefore developed to offer consultation and support to effect a safe, coordinated and patient-focused discharge to every patient on the end of life care pathway (EOLCP) whose preferred place of care was not JCUH.AimsTo increase the awareness, expertise and confidence of the host clinical teams in discharging these complex patients.MethodsFunding was secured from Macmillan Cancer Support to employ a Discharge Sister with administrative support. During a 3-month development phase, project promotion and stakeholder liaison (within and beyond the acute hospital) was prioritised. Thereafter every ward was contacted every day to offer the service to patients on the EOLCP. Discharge packs comprising discharge prescription, medication administration charts, patient/carer information and discharge checklist were designed for every community care location served by JCUH as a tertiary centre.ResultsIn the first 12 months, 111 dying patients were discharged home via the project. Awareness and confidence of the discharge logistics process continue to increase among ward staff but negotiating the plan seems to require the greater experience of the Macmillan discharge sister and specialist palliative care team (SPCT) colleagues.ConclusionA bespoke discharge pathway and experienced facilitation secures rapid discharge of a complex vulnerable patient group. Although there are no previous data for comparison the ‘clinical memory’ of the SPCT (who previously supported these discharges in an ad hoc fashion) suggests significantly increased activity. The authors conclude that more patients are achieving their preferred place of death. The work continues and is subject to independent evaluation.
Waste not want not: LEANer thinking in specialist palliative care units
Authors: Lew Eva , Gupta Srirupa , Hare Caroline , Flynn Jackie , Cobbin Mark , Glover Jan 
Published: March 2012

BackgroundThe ability of specialist palliative care units to provide high-quality, patient-centred and cost-effective services within the current economic climate is crucial for both commissioning of services and patient satisfaction.1 Lessons in improving productivity and quality, while minimising cost, can be learned from adopting ‘LEAN’ thinking.2 In essence, ‘LEAN’ is an improvement approach which seeks to improve patient flows and eliminate inefficiencies or wastes which are non-value added for the patient, while being open and flexible to change.3Methods/AimsFarleigh Hospice engaged external consultants to facilitate a 3 day LEAN workshop to examine the patient pathway from ‘referral to bereavement.’4 Only ‘frontline’ staff participated, for example, Macmillan Nurses/Day Hospice, Triage/Discharge, Administrators/Receptionists, Doctors, Physiotherapists/Occupational Therapists, Psychosocial Team, Bereavement and Carers' Services. Using process mapping investigation, participants visually analysed current pathway steps in 5 areas: referral; initial assessment; intervention; discharge; and, bereavement. Non-value adding activities within the current process were identified. Subsequently, a redesigned ‘future state’ for services was envisioned resulting in immediate (‘Just Do It’ projects) and future strategic improvement projects. All redesigned processes were measured for quality, cost and speed of delivery response. Participants committed to long-term project review and progress monitored within further facilitated sessions.ConclusionDespite the on-going process, benefits already include: • Empowered enthusiastic staff with increased likelihood of sustained improvement • Less resistance to change • Improved acceptability of innovation • Improved team working across and within departments • Increased time for patient contact Recommendations: ‘LEAN’ is an effective productivity/quality improvement tool which can be successfully applied within SPC units.
An audit of the prescribing, administering and monitoring of oxygen therapy within a hospice
Authors: Foster Gillian 
Published: March 2012

BackgroundFollowing the publication of the Executive Summary of the British Thoracic Society Guideline for Emergency Oxygen Use in Adult Patients 2008, a local hospice guideline for the prescribing and use of oxygen had been developed for that setting and patient population. Consequently new charts for prescribing, administering and monitoring of oxygen therapy were produced for the in-patient unit.AimsThe charts were audited to ensure that oxygen was prescribed and administered safely and appropriately and that inappropriate monitoring of oxygen saturation levels for patients approaching end-of-life was avoided.ConclusionFifteen oxygen charts were audited in each audit cycle. Medical staff usually judged appropriately when a patient should or shouldn't have a target oxygen saturation indicating that no unnecessary and inappropriate requests for monitoring were taking place. However on the few occasions when this was indicated it was not usually measured. A small number of patients were having oxygen saturations measured by nursing staff when not clinically indicated. Greater attention was needed in considering oxygen as a drug that was required to be prescribed and its administration recorded. The results were disseminated through the clinical team and the charts amended to highlight who was responsible for completing each section of the chart. An additional prompt in the main drug chart was added. The audit was repeated after a period of 6 months. There was a significant improvement in signing and dating an oxygen prescription from 60 to 100% of charts suggesting that oxygen was now being regarded as a drug by clinical staff. Nursing staff were now usually only checking oxygen saturations if indicated – enhancing patient safety yet avoiding unnecessary and inappropriate checks. There was a large improvement in nursing staff recording the delivery system and flow rate for oxygen at drug rounds (19–61%).
Use of Oxycodone and association with renal function
Authors: Ackroyd Rajeena , Aman Sanisah 
Published: March 2012

BackgroundOxycodone is a semisynthetic opioid, generally prescribed in patients who do not tolerate morphine. There has recently been concern that oxycodone is being used more frequently which would have cost implications. Regional guidelines suggest that oxycodone should be considered when patients have a GFR of less than 50.AimsThe aims of the audit were to see when oxycodone is prescribed by the specialist palliative care team and is oxycodone prescribed more frequently in patients with impaired renal functionMethodRetrospective audit of specialist palliative care notes of all deaths between November–December 2010 (inclusive).ResultsSixty patient's notes were analysed The average eGFR for all patients (n=60) on referral was 70 17 (28%) patients had an eGFR of less than 60 (CKD stage 3–5) on referral. Thirty-three patients were on opioids on referral and 20 patients were commenced on them. Ten patients were either commenced or switched to oxycodone 2 patients were commenced oxycodone due to a previous rash with morphine (eGFR 30.7) and due to concern regarding renal function (eGFR 49.6), 8 patients were switched to oxycodone: the commonest reasons being renal impairment and drowsiness. The average eGFR for all patients on oxycodone (n=10) was 51. For the patients who remained on morphine (n=40) the average eGFR was 72ConclusionThe majority of patients tolerate morphine reinforcing that it should be the first choice in the majority of patients. There is limited evidence for the use of oxycodone in renal impairment. For patients who do have renal impairment, particularly with eGFR less than 50 it may be appropriate to consider oxycodone when fentanyl or methadone are not suitable. Further evidence on its use in renal impairment would be useful.
Anticoagulation in the Hospice Setting
Authors: Steel Kim , Leith Marion , Brooks Lindy , Butcher Lowrie , Hill Jenny , Waterman David , Lomax Philip 
Published: March 2012

BackgroundIn March 2007, NPSA issued a safety alert regarding the oral anticoagulant warfarin. In palliative care the focus of care is on quality of life and the burdens and benefits of medications require consideration. Following the NPSA alert St Ann's Hospice undertook an audit to examine its practice. The first audit was undertaken from February 2008–August 2008; this audit was then extended to August 2008–August 2010.MethodPatients were identified through an INR history obtained from the local laboratories. A retrospective case note audit was undertaken. The standards incorporated in the NPSA audit were used. These consider four key areas: (1) admission history, (2) dosing warfarin, (3) monitoring and prescribing and (4) safe discharge of patientsResultsTwenty-five cases were considered. The majority were anticoagulated for either VTE (14/25) or atrial fibrillation (8/25). 7/25 patients suffered adverse events of which bleeding accounted for 5/25. 16/25 had their warfarin stopped during their admission (2 at the point of admission); 6/16 were commenced on low molecular weight heparin. 47% of INRs were in the therapeutic range. When a dose was altered INRs were checked on average 4-5 days postchange. 8 patients were discharged from the hospice on warfarin, 2/8 had INRs within the therapeutic range and poor communication of follow up, target INR and last INR to the community was found.ConclusionIn palliative care the benefits and burdens of all medicines needs to be considered. The benefits of anticoagulation in patients with advanced disease are unknown but this audit shows there can be significant risks. To minimise these risks requires a robust approach. In response to this audit the hospice instituted a compulsory e-learning for prescribers, a new oral anticoagulant policy and, due to the infrequency of patients on warfarin, a pharmacy system to highlight patients.
Parental perceptions of end-of-life care on paediatric intensive care units in Brazil
Authors: Lago Patricia , Halal Gilda , Piva Jefferson , Nilson Christine , Halal Michael 
Published: March 2012

ObjectiveAssess the perception of parents of patients who died in a Pediatric Intensive Care Unit (PICU) about the care given by health staff in the moments preceding death.MethodsExploratory-descriptive study with a qualitative approach.SettingsTwo PICU (Hospital Sao Lucas, and Hospital de Clinicas de Porto Alegre).Subjects15 parents of children who died from April to September 2008. Data collection was performed through three steps: (A) The researchers contacted the parents through a phone call, (B) At the hospital, the doctors who assisted the children clarified doubts about the therapy offered, results of exams and decisions regarding end of life, (C) Semistructured interview, recorded in audio, was carried out by researchers (not participated of the care of children). Data analysis was performed using the technique of thematic content analysis.ResultsThe analysis resulted in four categories: (A) the moment of death in the PICU; (B) talking with the attending physicians – possibility of understanding; (C) parental involvement in decision making in the PICU; (D) parental participation in research – moments of unburdening and the possibility of satisfaction. The results show that parents lack a peaceful environment where they can adequately carry out the goodbyes at the time of death of their children. They emphasised the solidarity provided by the nursing staff at this point and the poor involvement of the medical team. The opportunity to revisit the process of their children's death was considered positive. Parents felt that they did not have an effective participation in the end of life decisions.ConclusionResearch shows that the difficulty of communication between health staff and parents is a factor that impacts negatively on the decision taking and grieving processes. Moreover, it stresses the importance for the parents to reassess the moment of the children's death with health professionals.
Fulfilling a vision – a new model for therapy services at a hospice in west Sussex
Authors: Biggerstaff Barbara 
Published: March 2012

BackgroundPalliative rehabilitation encompasses a number of therapeutic interventions that help patients adapt to the functional changes imposed by their illness with an aim at improving quality of life. The provision of therapy services has long been seen as an essential part of holistic hospice care. This abstract lends further support to this view by highlighting an innovation in the delivery of therapy services undertaken by a hospice in West Sussex. The hospice's overarching vision was to provide all patients under its care with the opportunity to receive a specialist, responsive and equitable occupational therapy and physiotherapy service. Prompted by an extensive service expansion and a paucity of qualified therapists in post, the hospice embraced a different model to help achieve this.AimsKey aims of the new model were: (1) formulation of a separate therapy team with a team leader at the helm to develop and run this new service (2) promotion of close partnership working with generalist community therapy teams with a focus on education (3) development of an outpatient service across both hospices sites including creative use of self-help groups (4) collaborative working with primary care, demonstrated in the running of a Breathe Easy clinic outreached to a local GP practice.ConclusionTeam members were recruited and a time line for service activity was drawn. Clear therapy pathways, including criteria for referral and evaluation were also compiled for inpatient, day hospice and community services. Challenges were ensuring that only those patients with specialist therapy needs accessed the service and with referrers embracing the benefits of patients being seen as an outpatient as opposed to home. This evolving service has proved to be very popular and in the future it will need to be responsive to anticipated changes initiated by GP commissioning and increasing patient need.
Metastatic spinal cord compression in Newcastle upon Tyne NHS Foundation Trust
Authors: Gunn Hannah 
Published: March 2012

BackgroundNICE guidelines regarding the diagnosis and management of metastatic spinal cord compression (MSCC) were issued in November 2008.1 These guidelines were incorporated into the process of National Cancer Peer Review Programme for Acute Oncology in 2011.2AimsProspective data collection regarding number of patients, as well as source and time of referral of patients in NuTHFT with suspected MSCC over a 6 week period. The subsequent audit will look at standard of management of suspected MSCC patients in NuTHFT against national guidelines.MethodMSCC audit group established from leads of department in oncology, neurosurgery, spinal orthopaedics and palliative care.SurveyAn online form on the NuTHFT intranet for the initial survey. which was completed by clinicains across involved specialites. Data was then analysed and cross-referenced with various other sources of data collection. Audit: The patients identified by the survey were used as a cohort to audit current NuTHFT practices against national guidelines for management of suspected MSCC.ResultsSurvey55 patients were identified by the survey. Pain and neurological deficit were of equal prevalence as presenting feature. 45% of referrals came from hospitals other than NuTHFT, 31% were from within NuTHFT and 14% were from primary care. 47% were referred during working hours and 42% were referred out of hours. 70% of patients identified through varies sources were recorded on the online survey.AuditData will be presented Conclusion: Management of MSCC poses a management challenge given the diversity of specialities involved and the complexity of the co-ordination of management of such patients. Use of an online form can centralise data collection and provide significant amounts of data.
‘Spot’ audit of strong opioid prescribing at Musgrove park hospital, Taunton
Authors: Michaels Katherine , Jayaraman Smita , Lagan Sarah 
Published: March 2012

This audit examined compliance with best practice within a busy district general hospital (750 beds) on 1 day. Audit Measures: • First line strong opioid, morphine-exceptions, renal impairment, documented sensitivity • PRN prescribing, 1/6 of the regular dose and same compound (where applicable), dosing interval ‘up to hourly’ and specified indication of use- exception, renal impairment • Regular laxatives • Antiemetic prescription at least PRN • Prescription compliant with Trust policy Adult inpatients prescribed regular strong opioid analgesia, irrespective of route, were included in the audit. An audit proforma was completed with reference to the patient's medical records and prescription chart.Results• 100% compliance, adherence to local Trust prescribing policy • Only 4% (29/750) of adult inpatients on the audit day were prescribed regular strong opioids, in all cases for pain relief. This figure was lower than expected and begs the question, is pain poorly assessed/poorly managed within the acute hospital environment? • 68% compliance overall with prescribing morphine first-line, 78% for those prescriptions started within the hospital • Higher ratio of prescriptions for patients with non-malignant disease- increased patch prescribing (buprenorphine, fentanyl) in this patient group • 21% (6) had no breakthrough analgesia prescribed, 65% of prescriptions met the standard, those that did not had too low a PRN dose prescribed • Mean, median and mode doses (equivalent morphine doses) 132, 60, 60mgs respectively • 89% of patients with impaired renal function had an appropriate 2nd line strong opioid prescribed but poor compliance with PRN prescribing in this patient group • Regular laxatives were prescribed in 48% patients while antiemetics were prescribed in 72% As a result of this audit practical prescribing guidance cards are being issued to all junior doctors with the plan to re-audit in 1 year's time.