Abstract
Introduction: Treatment Escalation Plans (TEPs) are helpful tools that reduce un-necessary treatment burden, improve patient experience and follow the principles of realistic medicine. This is relevant in orthopaedics where a high percentage of the patients are frail, co-morbid, and would benefit from clear and realistic care plans. We aim to improve TEP completion to >50% of orthopaedic patients, over the age of 65yrs old, in three trauma wards at the Royal Infirmary of Edinburgh by August 2023.
Methods: We sampled three patient notes on each ward twice weekly from May – August 2023, noting whether TEPs were present, if it was consultant endorsed or provisional, and what key sections were completed (resuscitation, treatment goals and communication). To be included, the patient had to ≥65 and under orthopaedics. Process mapping demonstrated 2 key targets- admission clerk-in and registrar review. PDSA 1 involved creating a prompt for documenting TEPs on FY1 clerk-in which was added to the admission proforma folder and displayed as posters. PDSA 2 was a teaching session designed for orthopaedic registrars and other team members about TEP conversations.
Results: Pre-intervention data, demonstrated a median of 28% of orthopaedic patients ≥65yo have a TEP. Of the completed TEPs: 88% solely consisted of a resuscitation decision; 33% had treatment goals, 33% communication; and 0% of TEPs were endorsed. After PDSA 2; median TEP completion increased to 33%. Of the completed TEPs; none had only a resus decision, 100% have treatment goals; 100% communication, and 83% are endorsed.
Conclusions: Our studies have demonstrated that education and proforma changes have increased TEP documentation rate, although not to our projected target. However importantly, the percentage of TEPs that contain goals, document communication and consultant endorsement has improved significantly. This project is ongoing with with planned further PDSA cycles.
Comments
Well done
We introduced our TEP over the pandemic and is implemented trust wide
Do you have a proforma?
Happy to chart through
bw
Harnish Patel see poster 1882
Well done
We introduced our TEP over the pandemic and is implemented trust wide
Do you have a proforma?
Happy to chart through
bw
Harnish Patel see poster 1882
Thank you for your question!
In NHS Lothian, we have a TEP proforma which is built into our electronic note system. It has a section on goals of treatment, and then three different options for ceilings of treatment (full escalation, selected appropriate escalation, comfort supportive care only). If you tick for selected appropriate escalation, you are given further options about locations of treatment - ward level, transfer to other medical/surgical area, transfer to critical care. There are also options about investigations/interventions/treatments which you can select yes or no for- palliative care, invasive procedures, imaging other than x-rays, IV access (now or renewed), IV or S/C fluids, oral antibiotics, IV antibiotics, blood transfusion, venepucture, ABG. There is a section on feeding- is NG tube appropriate? Has the decision been made for oral (at risk of aspiration). There is then a free form box to write anything else that would be appropriate or would be inappropriate. There is a section on CPR status and capacity, and a section to document who this has been discussed with (patient/NOK/Crit Care consultant) and the understanding of the patient and their family on their condition. Lastly, you document who has filled in the TEP, and if it is provisional (created by a junior pending senior review) or endorsed (approved by a senior).
I've attached a link to the NHS Lothian teaching page on TEPs, the "How to Use the TEP training video" by Dr Robin Taylor gives an overview of the TEP used in Lothian.(https://www.med.scot.nhs.uk/resources/resources/treatment-escalation-plans)
Would be great to talk through; are you at the conference in person?
Jess Turnbull