Improving documentation of Treatment Escalation Plans within 72 hours of admission to East Lothian Community Hospital

Introduction:

East Lothian Community Hospital (ELCH) comprises of 95 medical beds for older patients undergoing rehabilitation following acute admission or discharge planning. Ideally, transfers from acute hospitals should have Treatment Escalation Plans (TEPs) in place, however only 67% of patients had a TEP documented electronically within three days of ELCH admission. Overnight and weekend cover is provided through nurse practitioners or Hospital at Night (off-site), therefore documented individualised plans by senior decision makers in the event of clinical deterioration is vital.

Objective:

95% of patients admitted to ELCH would have a provisional TEP documented electronically within 72 hours of admission by February 2023.

Methods:

Using quality improvement methodology, two Plan-Do-Study-Act cycles were completed. Firstly, a questionnaire was sent to junior doctors and nurse practitioners responsible for admitting patients to understand barriers to completing TEPs. Data was collected from electronic records on admission date, first documentation of provisional TEP (by a junior doctor or nurse practitioner) and admitting ward. The first cycle of change focused on increased awareness through posters reminding clinicians to consider TEP on admission. The second cycle of change involved two education sessions, highlighting the importance of TEP and how to approach difficult conversations.

Results:

28.5% of junior clinicians did not feel comfortable discussing TEPs on admission, with barriers being time constraints, level of responsibility and concern about making incorrect decisions. The first cycle (increased awareness) showed an improvement in documented provisional TEPs within 72 hours of admission from 67% to 79%. The second cycle (two education sessions) saw a further improvement to 94%.

Conclusions:

Basic interventions to increase awareness and education to address concerns surrounding TEP discussions were very effective. Future cycles are planned with new junior doctors to sustain the improvement. Next steps are to clarify the role of other medical practitioners in completing provisional TEPs.