bluuebunny/crossref_metadata_2025_split huggingface dataset:
Merseyside and Cheshire palliative care network audit and guidelines for managing breathlessness
Authors: Jeffries Clare , Oates Susan , Ledson Martin , Bonwick Helen , Marley Kate 
Published: March 2012

BackgroundMerseyside and Cheshire Palliative Care Network (MCPCN) Audit Group was established in 1995. It is a multi-professional group composed of individuals working in palliative care across eight integrated care networks (ICN) in community, hospital and hospice settings. Its objective is to develop standards and guidelines through audit, literature review, expert opinion and group consensus to support healthcare professionals working in palliative care in the region. Breathlessness is a common symptom encountered in palliative care in patients with both malignant and non-malignant conditions.AimsTo audit the networks performance against previously developed MCPCN standards on managing breathlessness in advanced disease and revise these standards and guidelines.MethodPreviously developed guidelines and standards were reviewed. Literature reviews on pharmacological and non-pharmacological treatments for breathlessness in advanced disease were undertaken. Clinical nurse specialists and doctors working in palliative care across the region were sent an e-mail with a web link to an audit proforma to complete for patients they managed with breathlessness over a 3 month period. Literature review, audit findings and review by external expert was presented to the MCPCN and consensus guidelines and standards reached.ResultsThe treatment of 106 patients from hospital, hospice and community settings across 7 of 8 ICN was audited.ConclusionUpdated MCPCN guidelines on the use of pharmacological (opioids, benzodiazepines, corticosteroids, nebulised medication, oxygen) and non-pharmacological interventions were developed with evidence and recommendations graded. Revised MCPCN standards include: •Reversible causes should be identified and treated where appropriate. •Consider a trial of relaxation therapy and/or anxiolytics in patients with anxiety and breathlessness. •All patients should have access to non-pharmacological interventions. •Diamorphine and morphine are opioids of choice in patients unable to swallow unless already taking an alternative strong opioid. •Oxygen should be prescribed. •Pulse oximetry should be used; prescribe oxygen only if the patient is hypoxic.
An audit of blood transfusion in palliative care
Authors: Snell Kalyani , Churm Deepta , Hughes Andrew 
Published: March 2012

BackgroundIn a palliative care setting, to whom should we offer blood transfusion and when should we stop? Is there consensus regarding the best care for our patients? Transfusion should be based on an assessment of symptom management and patient wish. The British Committee for Standards in Haematology (BCSH) guidelines' acknowledge complexity and suggest the decision to transfuse is largely based on the clinical situation. Gleeson (1995) demonstrated that cancer patients showed a significant improvement in strength and well-being with blood transfusion (pretransfusion Hb ranging from 4.9–10.7 g/dl). No previously published audit has looked at regional practice among both haematologists and palliative care physicians.AimsTo provide a snapshot of blood transfusion practice in the palliative care setting within the Northern Region (UK). Is current practice in keeping with guidelines?MethodsAn anonymised questionnaire was sent to regional haematology (N=33) and palliative care (N=55) physicians. The questionnaire was based on a fictional scenario involving a lady with metastatic breast cancer and symptoms of anaemia (fatigue and dyspnoea). The respondents were asked to indicate whether transfusion would be offered in differing clinical circumstances.Results98% of respondents offered transfusion if the symptomatic patient had a Hb of 8 g/dl. 73% offered transfusion with an Hb of 10.5 g/dl. 3% would offer transfusion with an Hb of 8 g/dl, but no symptomatic benefit with previous transfusions. There was general consensus between palliative care and haematology for these decisions. 42% would transfuse a patient with a prognosis of days to weeks, an Hb of 8 g/dl and previous symptomatic improvement with blood transfusion. A greater proportion of haematologists would transfuse in this circumstance.ConclusionThere is general consensus to use blood transfusion for symptom control in a palliative care setting. Differing opinion arises when progonosis is shorter. Current practice is in keeping with BCSH guidelines.
Symptoms and quality of life in children with incurable central nervous system (CNS) tumours
Authors: Brook Lynda , Walker David , Grundy Richard 
Published: March 2012

BackgroundSymptoms in children with incurable central nervous system (CNS) tumours are frequently managed with corticosteroids but 33% of children prescribed corticosteroids experience adverse effects and the overall effect on quality life is unclear.AimsTo determine the views of parents of children with incurable CNS tumours about symptoms, quality of life (QOL) and the benefits and problems associated with steroids.MethodsSemistructured interviews with the principal care giver of six children who died from a CNS tumour. Parents were asked to describe their child's symptoms, QOL and benefits or adverse effects of treatments used to control symptoms. Verbatim transcripts were analysed using Thematic analysis.ResultsSix key themes were identified: getting the diagnosis, treatment decisions, side effects of illness and treatment, adapting to the illness, facing death and professional support. The decision to stop curative treatment was influenced a number of factors including lack of efficacy or worry about the effects of the treatment on QOL. Children varied in the side effects that they had from the illness and its treatment. Sometimes, side effects from treatment were hidden by the effects of the disease, or were perceived as minor. Steroids were often perceived to have minor or positive side effects. Despite the need for parents to maintain a sense of normality for the child, both they and the child were often acutely aware of the limitations brought by the disease, especially when compared with other children. A rapid deterioration in the child's condition often alerted parents to end of life. Older children were usually aware that they were dying, even when parents tried to keep it from them, and they made plans for after their death.ConclusionsQOL is an important influence for treatment decisions in children with CNS tumours during palliative care. Symptoms and adverse effects of treatment appear less important than maintaining normal day-to-day activities.
Audit of the use of ‘just-in case’ boxes as part of a local enhanced service agreement for end of life care
Authors: Westwood Debbie , Bagshaw Kerry , Curtis Claire , Blaine Felix 
Published: March 2012

BackgroundThe local enhanced service for end of life care (EOL) was started by Worcestershire Primary Care Trust in 2009, with the aim of developing good practice and improving EOL care. GPs were asked to sign up to and fully adopt the Gold Standards Framework (GSF). Access to palliative care medications and proactive management of symptom control are key components of GSF, and to support this ‘just-in case’ boxes were launched in April 2010. It was anticipated that the use of the boxes would avoid the distress caused by poor access to medications in out of hours, by anticipating symptom control needs and enabling availability of key medications in the patient's home.OutcomesTo assess the success of this initiative a 6 month audit was undertaken between May and October 2010.ResultsA total of 66 boxes were placed in patients' homes. Fifteen of those boxes were not used. No patients were transferred into the acute trust (one patient was transferred to a care home), meaning that 65 people remained in their own home at time of death, with 48 of those patients' end of life care being supported by provision of anticipatory medication. Only 6% of the responses reported any resistance to use of the boxes, either by the patient or their family. Provision of the boxes improved symptom control in 55% of the cases, and 89% of the boxes were reported as containing the most appropriate drugs. We estimate an approximate cost saving of, at least, £69,140 was made. This was calculated by multiplying the number of times the provision of the just-in case box prevented use of a further healthcare service by the average cost for that specific episode of care. This can be compared favourably to the cost of providing the drugs, being £3,346.
Prescribing of breakthrough opioid analgesia in acute hospitals – a multi site audit
Authors: Wilkinson Anna , Alloway Lara 
Published: March 2012

BackgroundAll patients prescribed long acting opioids should also be prescribed short acting opioid analgesia for breakthrough pain. This audit was piloted in a single site. Prescribing practice was poor so an implementation plan agreed trust wide. One year later audit data showed a significant improvement. Another year later improvement was maintained but not increased. One barrier was rotation of staff between trusts once educated. The authors were awarded funding from HQIP to develop a multi site audit as part of a quality improvement programme.StandardsNational guidelines state that the short acting opioid dose should be one sixth of the total daily dose and no dose ranges prescribed. Opioids for breakthrough analgesia should be available as required, with a time limit between doses specified. This was agreed as hourly or two hourly. Targets: 90% of prescription doses to follow national guidelines 100% of prescription frequencies to follow guidelines 100% of prescriptions for a single dose, not a range.MethodologyService improvement methodology is being used for the whole audit process. Quantitative data on prescribing practice has been collected on 717 prescriptions from across 8 acute trusts. All healthcare professionals in each trust were sent a survey to help determine the underlying causes of poor prescribing practice. An audit lead in each trust recruited an improvement team to attend a 1 day service improvement workshop focused on data analysis, determining root causes, applying a priorities framework to these and establishing detailed action plans to address one priority issue in each trust. Action learning sets will be offered to site leads for 1 year followed by reaudit.ResultsData will be presented demonstrating poor prescribing practice, varying significantly between trusts. Survey data will also be presented.ConclusionCommon errors in opioid prescribing practice will be shared with underlying causes and implementation plans.
Revolving scheme/cash round scheme at hospice Africa Uganda
Authors: Irumba Lisa Christine , Evelyn Octivia 
Published: March 2012

IntroductionHospice Africa Uganda (HAU) was started as a catalyst to encourage the spread of palliative care for cancer patients and later also those with HIV/AIDS to improve their quality of life and reduce suffering. In addition, HAU is a model for African countries in clinical palliative care. It operates in a 20km radius from the site. Offers a daily out-patients, home visits, outreach clinic and a community day care.Problem StatementDuring that challenging time when the patients are very sick and there is no food in a home, especially when the sick are the bread winners, HAU provides some nutritional support, transport refunds and provision of basic needs. With that, patients are comfortable enough and in future when they get stronger and stable they want to continue getting that support, therefore getting very dependent.Project DescriptionPatients attending day care through group therapy identified the need to start up small businesses through monthly cash round to help them meet their needs for example, school fees, and they could do this through small businesses for example, selling tomatoes, small poultry farm, mat making, charcoal selling. Patients have to be co-managed by HAU and palliative care community volunteers for easy follow up.ConclusionDiscussions are still going on how best this activity can be continued. There is now less dependence of patients who have the small businesses.
Auditing referrals in an acute hospital to determine ward capability in common symptom management
Authors: Harris Andrea , Wheelhouse Alison , Hunter Noeleen , Walker Jane , Nicholson Alexander 
Published: March 2012

BackgroundGeneral Palliative Care should be provided by the usual professional carers of the patient and family irrespective of specific roles. Where more complex needs are identified, the Specialist Palliative Care Team (SPCT) is available to offer support and advice. Palliative Care Guidelines have been published to support symptom management throughout the hospital trust and awareness of these is raised during doctor induction and education sessions. A perception by the SPCT was that referred patients often have had neither a basic assessment of symptoms nor a trial of first line symptom management. Seeking evidence to support or refute this perception and to determine more accurately where teaching priorities lie, an audit of referrals and referred patients' prior management was undertaken.Methods50 consecutive referrals and notes were audited against agreed criteria to determine what measures had already been implemented in four areas of physical symptom management (pain, nausea & vomiting, constipation and end of life symptom management) prior to the host team involving the SPCT. The measures expected to have been implemented by the generalist team were drawn directly from symptom control guidelines. Problems identified by SPCT were also compared with reason for referral.ResultsIn each of the four domains there was poor correlation between reason(s) for referral and problems identified on assessment. For example nausea and vomiting was a problem in 34% of cases but constituted only 4% of referrals. Likewise initial basic symptom management expectations were not fulfilled in any domain.ConclusionSPCT perceptions were confirmed. Acute hospital generalist staff are not equipped with the core knowledge to initiate symptom assessment and introduce basic palliative care symptom measures. The SPCT will develop and deliver targeted ‘micro-teaching’ sessions on the four areas of expectation to bring all wards to a basic level of competency. Re-audit will follow.
Implementation of a locality based Gold Standards Framework Register
Authors: Sadler Hilary 
Published: March 2012

BackgroundIt was identified that when community nurses were called out to palliative care patients, particularly on evenings and weekends they felt that communication regarding the status of the patient could be improved. It was acknowledged that a quick reference register of all palliative care patients would be useful to enhance continuity and bring nurses up to date quickly and efficiently.AimsThe initiative was important in order that patients were empowered to remain in their preferred place of care, plan for the future and be able to make informed decisions about where and how they wanted to be cared for.MethodPatients preferred place of care was documented and actual place of care and death was monitored by the Macmillan clinical nurses specialist and via the Gold standards register to identify if patients were being cared for in a place of their choice and to ensure unnecessary hospital admissions were avoided. Feedback was also monitored from the community nurses and a confidence survey was carried out retrospectively to see if community nurses skills and awareness had improved. Changes included incorporating the Macmillan Clinical Nurse Specialist into a weekly designated ‘slot’ within the community nurse meetings. At this time the Macmillan CNS: Hands over the current status of those patients on the caseload Discusses any new referrals Informs staff regarding plan of care for particular patients and potential risk factors for the patient such as those at risk of spinal cord compression, poor renal function and risk of hypercalcaemia Discusses any queries or concerns that the community nurse may have.ConclusionA confidence survey indicated that the community nurses were more aware of PPC and ACP. It also indicated and increased palliative care knowledge base.
Changing hospital culture: the role of an acute palliative care unit
Authors: Paterson Fiona , Buchanan Deans , MacIvor Frances , Lundie Susan , Levack Pamela , Baker Lee 
Published: March 2012

ObjectiveTo create a culture in an acute hospital where palliative care is more understood. At a strategic level hospitals accept the need to provide palliative care which is integrated with other hospital activity. It is however, often difficult at ward level to achieve this, especially in addition to ‘active’ medical treatment. Our advisory palliative care service began in 1998. We now report the benefits of a pilot (2009–10) Acute Palliative Care Unit (APCU) which has now achieved NHS funding. Pilot Acute Palliative Care Unit: Three single rooms in an acute surgical ward •7.6 seconded nurses some with Specialist Palliative Care experience •1.0 Consultant for the APCU and Ninewells advisory service •0.6 Consultant to run an education programme.AdmissionsPatients seen by the advisory service with the most complex symptoms or needs.DataProspective collection: daily ESAS and distress scores; percentage of patients seeing appropriate disciplines within 2 working days; family meeting; discharge outcome; satisfaction (patient, family and staff).Results100 patients were admitted in the first 11 months. Pain was reduced from a median of 7 (IQR 5–10) on admission to 3.5 (IQR 1–5) within 48 h; distress from 7 (IQR 1–10) to 0 (IQR 0–5) within 48 h. There was no significant increase in any symptom (paired t test or Wilcoxon Matched-Pairs Signed Ranks Test). Median length of stay was 5 days (IQR 3–10) and mortality (23%) was low for a palliative care setting. 77% of patients were discharged directly from the unit: 32% home; 26% hospice or community hospital; and 19% to their original ward for active treatment or further consideration of active treatment.DiscussionSeeing specialist palliative care practiced effectively in an acute surgical ward initially intrigued medical and nursing staff but it also encouraged an understanding of each others' disciplines and promoted collaborative working.
A report on physiotherapy services for children and young people
Authors: Davies Joanna , Miller Michael 
Published: March 2012

IntroductionThere is a recognised difference in the centralised children's services compared with the more localised adult services for those with neuromuscular diseases. At the young people's unit at Martin House transition is a difficult time with uncertainties about the availability and working practices of physiotherapy services for adults. With funding from the DoH as part of the £30million the physiotherapy services in Yorkshire and Humber were reviewed.MethodContacts were made from a number of sources, starting with known children's services and an email questionnaire was sent. There was a small circulation of questions to users of the service.ResultsThere was excellent completion circulated after contact had been established by the researcher. • The paediatric service in the region is well coordinated with close links with respective neuromuscular teams. • The challenge of identifying the different adult services highlighted the possible difficulties faced by people with a neuromuscular condition. • There is variety in the provision and accessibility of adult services offered around the region. • There is a limited review/monitoring service in place for adults with only 42% of teams offering this. • 54% of adult teams are unable to provide on-going physiotherapy. They are usually goal- orientated and based on self-management which isn't always appropriate in a progressive deteriorating condition. • The lack of access to specialist physiotherapy in adult services is a problem for both community and hospice physiotherapists and patients. • Provision of Hydrotherapy is an on-going issue.Recommendations• Consideration of a review/monitoring service for adults is needed. • Consideration of a transition service is needed. • There is a need to provide more access to specialist neuromuscular physiotherapists in adult services. • A maintained and accessible database of adult services for these patients should be made available to assist referrers.
Lessons from liaison: achieving preferred place of death for patients in a tertiary cancer centre
Authors: Coackley Ann Griffiths Alison , Noble Agnes , Howarth Susan 
Published: March 2012

BackgroundThe National Institute of Clinical Excellence emphasise that, ‘People with incurable illness should be able to make choices about care at the end of their life and this includes a choice about where they die.’ The logistics of arranging a rapid discharge for a dying patient from a tertiary cancer centre serving over 2 million population can seem to be an overwhelming challenge for staff. A multi professional working group based at Clatterbridge Centre for Oncology developed and implemented a Rapid Discharge Pathway following close liaison with services and personnel across the Network.Aims of StudyTo evaluate the effectiveness of the Rapid Discharge Pathway for the Dying Patient o To resolve emerging challenges associated with emergency discharges at the end of life to a large geographical area.MethodA retrospective audit was completed over a pilot period reviewing medical case notes and pathway documentation.DiscussionSeven patients requested a rapid discharge at end of life with an age range of 23–71 years. Six were successful and one was cancelled due to a rapid deterioration in condition. The study demonstrated the effectiveness of a procedure to ensure discharge medicines were rapidly available and appropriate equipment was in place. There was good communication with families and other healthcare professionals. Challenges included ambulance availability and out of hours discharges. Innovative ways to resolve difficulties are described and the possibility of escorted discharges is explored.
Acute palliative care in the assessment areas
Authors: Raj Julie , Parr Paula , Hugel Heino , Maher Bridget 
Published: March 2012

AimTo describe the benefits of early review by the Hospital Palliative Care Team (HPCT) for acutely admitted palliative patients.BackgroundOver an 18 month period, the HPCT at a large University Hospital have attended the Medical Admissions Unit on a daily basis to pick up known patients and new referrals to the service, in order to provide early symptom control advice, to advise on appropriate treatment plans, and to begin early discharge planning for potentially complex patients. They have attended post-take ward rounds and introduced targeted palliative care teaching sessions within the Acute Assessment Areas. An electronic flagging system to alert both the admitting team and the HPCT of a patient's palliative status has also been trialled.MethodsA retrospective audit of a 1 month period prior to implementation of this service was compared to the results of a similar audit performed 18 months following implementation.ResultsPrior to implementation, only 5% of patients referred to the team were identified in the Assessment Areas. The median total length of stay was 10 days, and on average patients were referred on day 5, half way through their admission. Following implementation, on average 25% of all referrals came from the assessment wards, all of whom were seen within 24 h of admission. Total new referrals to the team have increased by over 50%, suggesting the intervention helped to identify patients who would otherwise not have been referred. (Graphical representation of these results).ConclusionThe service is felt to be of benefit by both the staff in the Assessment Areas and the HPCT, improving early access to services and advice for palliative patients, and improving clinical relationships. Further work is on-going to quantify any improvement in discharge outcomes for patients, including place of discharge and average length of hospital stay.