Abstract
Advance care plans (ACP) in secondary care: What are the patient outcomes following discharge from hospital with an ACP?
Introduction: Treatment escalation plans are discussed in hospital but not always communicated to community care on discharge, leading to avoidable admissions to hospital and hospital deaths which may be not what the patient wants. The project aimed to review what happened to patients discharged from hospital with an ACP over a 12 month period.
Method: Older person service (OPS) inpatients were identified for ACP discussions, using Clinical frailty score, presence of life limiting conditions, co-morbidities, significant decline. Over a 12 month period 155 ACP's were completed using the ACP document on the Trust electronic record (EPR), including the level of appropriate care and preference for location of on-going care. On discharge copies of the ACP were sent with the patient, to their GP and to the ambulance service. EPR was used reviewed patients up to 12 months post discharge.
Results: Of patients with an ACP; the wish of all patients was to remain out of hospital and be cared for in the community; 63% were discharged to care home setting; 19% were readmitted as inpatients (v’s 43.7% Trust OPS/no ACP readmissions); 8% of patients died before discharge; 92% of patients who died after discharged, died out of hospital (v’s 47.5% Trust OPS/no ACP deaths); 25% were still alive at 12 months. The process of completing the ACP and communicating the ACP was found to be long and not user friendly with multiple steps and needed refining
Conclusion: ACP's offer support to facilitate patient's wishes. The use of ACP's in secondary care benefits patients on discharge, it reduces readmissions and in-hospital deaths. The current ACP document is lengthy and requires simplifying. This has led to a work group to redevelop the ACP into a more user friendly/shareable document, which will encourage on-going use of ACP's and can be adopted throughout the Trust
Comments
An important topic. Thank you for sharing the initial positive results. Do come back with the results of the next stage when you have a more user-friendly ACP form being implemented.
Thank you, Sarah. I too will be looking forward to the next stage when we use the new document.
Interesting work and encouraging that the discussions and planning group less often died in hospital
Would you be willing to share your care planning tool? Did you embed the information in the discharge summary or was it a separate stand alone document? We have a short electronic document we use through our digital letters but it goes separately to the summary which is not always effective..
Hi Claire
Unfortunately the care planning tool which we used is no longer in use or available, which is a real shame. The advance care plan was high- lighted on the discharge summary but we were not able to embed it. A copy was sent home with the patient, a copy was emailed to the GP and ambulance service/OOH. A digital copy did remain on the patients electronic hospital record, which most surgeries and community hubs have access to. The updated advance care plan is a work in progress and we have been looking to see how this can be shared in the community in a more effective manner.
Thank you for taking the time to view my poster.