Anticipatory Care Planning

Introduction

In today's healthcare practice, many patients live longer with multiple health issues, often in a frail or terminally ill state. Their quality of life doesn't necessarily improve. These patients require optimal supportive care that respects their dignity. Advanced Care Plans (ACPs) are crucial here, facilitating person-centered discussions about future care preferences while the patients have the mental capacity for meaningful participation. We aim in this study to assess how many patients in General Internal Medicine department would benefit from ACP and compare that to our current practice in implementing ACPs

Method

This cross-sectional retrospective study was done in 2 instances, 1 month apart from 29/03/23 to 01/05/23. The Sample size was 300 patients. The eligibility criteria were life expectancy of 12 months or less, age of 80 years and above, Clinical Frailty Scale (CFS) 8 or more, advanced dementia, and end-stage disease.

Result

33 patients (11%) met the eligibility criteria for ACP. 8 patients (24.2%) were above the age of 85. 25 patients (75.8%) had a Clinical Frailty Scale score higher than 7. 12 patients (36%) had terminal cancer. ACP was done for only 6% of the cases that meet the eligibility criteria. Within three months, 90% of these cases passed away. It is important to mention that in 57.6% of the cases, ACP was discussed with the patient and the next of kin (NOK) but was not formally documented.

Conclusion

Our findings revealed that only 6% of the eligible cases had evidence of ACP. This aligns with the study “advanced care planning in patients referred to the hospital for acute medical care: Results of a National Day of Care survey” which showed 4.8% had an ACP. The absence of ACP in the vast majority of re-admitted patients represents a significant missed opportunity to improve care.

Introduction

In today's healthcare practice, many patients live longer with multiple health issues, often in a frail or terminally ill state. Their quality of life doesn't necessarily improve. These patients require optimal supportive care that respects their dignity. Advanced Care Plans (ACPs) are crucial here, facilitating person-centered discussions about future care preferences while the patients have the mental capacity for meaningful participation. We aim in this study to assess how many patients in General Internal Medicine department would benefit from ACP and compare that to our current practice in implementing ACPs

Method

This cross-sectional retrospective study was done in 2 instances, 1 month apart from 29/03/23 to 01/05/23. The Sample size was 300 patients. The eligibility criteria were life expectancy of 12 months or less, age of 80 years and above, Clinical Frailty Scale (CFS) 8 or more, advanced dementia, and end-stage disease.

Result

33 patients (11%) met the eligibility criteria for ACP. 8 patients (24.2%) were above the age of 85. 25 patients (75.8%) had a Clinical Frailty Scale score higher than 7. 12 patients (36%) had terminal cancer. ACP was done for only 6% of the cases that meet the eligibility criteria. Within three months, 90% of these cases passed away. It is important to mention that in 57.6% of the cases, ACP was discussed with the patient and the next of kin (NOK) but was not formally documented.

Conclusion

Our findings revealed that only 6% of the eligible cases had evidence of ACP. This aligns with the study “advanced care planning in patients referred to the hospital for acute medical care: Results of a National Day of Care survey” which showed 4.8% had an ACP. The absence of ACP in the vast majority of re-admitted patients represents a significant missed opportunity to improve care.

Background

Advanced care planning (ACP) allows patients to discuss their wishes for future care. In London, the Universal Care Plan (UCP) allows ACPs to be shared digitally between healthcare professionals in the community and secondary care. Inpatient admission provides an opportunity for ACP discussions, and documentation via a UCP on discharge.

Methods

We audited pre-existing UCPs in all patients admitted to an inpatient geriatric ward between May and October 2024.

We then conducted 3 PDSA cycles to promote ACP discussions during admission, and documentation via new or updated UCPs.

- PDSA cycle 1: template created for consultant ward rounds to prompt identification of whether patients might be appropriate for ACP.

- PDSA cycle 2, visal prompt created as a reminder to use the template.

- PDSA cycle 3, teaching session delivered to rotating doctors to highlight the template and UCP forms.

We also followed up patients to identify how frequently patients were readmitted or died.

Findings

We found that a minority of patients were admitted with a UCP in place.

After PDSA cycle 1, 21% of patients were discharged with a UCP. After PDSA cycle 2, this number increased to 47% .

After PDSA cycle 3, over half of patients were discharged with a UCP in place. 

Within 3 months of discharge, 28% of patients were readmitted and 10% of patients died.

Conclusions

The template created a structure to promote the use of ACP, and the number of patients discharged with a UCP increased following our interventions . However, there remains a high burden of readmission to hospital.

 1. Introduction. Advance care planning (ACP) allows patients to prepare for their future and articulate their care preferences. Despite it being a major policy focus there are significant barriers that affect ACP delivery, including paperwork burden and information sharing difficulties. Electronic Health Records (EHRs) are fundamental to how ACP conversations are recorded and communicated. We present data from inpatient geriatric medicine unit during a change in trust-wide EHR (namely, EPIC) and a contemporaneous ACP educational drive.

2. Methods. Clinical notes for all patients on three geriatric wards were analysed on a single day in July 2023 and April 2024. EPIC was rolled out in October 2023.Demographics including age, admission and discharge destination, clinical frailty score (CFS) and social circumstances were retrieved and notes were reviewed for ACP decisions. Teaching took the form of regular small group seminars for ward teams, and departmental sessions to build confidence and optimise ACP documentation using the new software.

3. Results. 83 and 85 patients were identified in July 23 and April 24 respectively. Demographic data were similar between groups including mean age (82; 84), CFS of ≥6 (67%; 61%). In July cohort, one patient had an ACP . In April, 20 patients had an ACP and 8 patients had a Universal Care Plan.

4. Conclusion(s). Significant improvements were noted in ACP delivery and documentation. Following the launch of EPIC alongside targeted teaching to staff members, the proportion of patients with an ACP increased by 23% and UCP by 10% over a 9-month period. EPIC includes improved ability to search for relevant information and dedicated space to document ACP plans, both of which may have contributed to these results. Future work aims to expand this learning into GSTT community services and across other trusts, capitalising on the potential of improved EHR technology in the NHS. 

Introduction: Advance care planning (ACP) supports individuals to express their values and goals regarding future care, playing a crucial role in patient-centred approach. The Gold Standard Framework (GSF) recommends offering ACP to those with declining health, functional deterioration, or major health transitions. Prior to this project, Harrogate District Foundation Trust (HDFT) had not evaluated ACP quality for >2 years, relying solely on DNACPR forms and patient notes.  This QIP assessed the impact of implementing the nationally recommended ReSPECT documentation on ACP quality.

Objective:
To evaluate the extent of ACP in frail patients at HDFT and evaluate whether ReSPECT documentation improved these discussions.

Methods:
In cycle 1, a retrospective review of patient notes from June-December 2023 was conducted to assess the depth of ACP, including DNACPR decisions, treatment ceilings, readmission plans and preferences for place of death and care. The Supportive Palliative Indicator Care Tool (SPICT) identified patients suitable for ACP, with those scoring ≥3 (1 point/life-limiting category) classified as most vulnerable. Cycle 2 followed the implementation of ReSPECT documentation in January 2024 and the quality of ACP was reassessed.

Results:
In Cycle 1, only 11% of SPICT-appropriate patients had ACP beyond resuscitation and treatment ceilings, leaving an 89% opportunity for improvement. After ReSPECT implementation, there was an almost 4-fold increase (41%) in more comprehensive ACP.

Conclusion:
The introduction of ReSPECT significantly improved the depth of ACP. However, further improvement is needed. Next steps include implementing a communication skills workshop to enhance healthcare professionals’ confidence in facilitating ACP discussions.

Introduction:

Advance care planning is a process that allows individuals to make decisions about their future healthcare, including end-of-life care, by discussing and documenting their preferences, values, and goals with healthcare providers and loved ones.These are especially critical for patients with serious, life-limiting conditions or for frail older adults who may face unexpected health crises.It is a commonly recognised barrier to care planning however that senior doctors often do not have the time to complete it for all patient’s who require them and that junior doctors lack confidence in having these discussions, this Quality Improvement Project aims at to increase the use of Advance care planning in the form of Emergency health care plan (EHCP) by empowering junior doctors to competently lead these discussions by introducing focused teaching on the topic to regular teaching.

Method:

Our objective was to organize teaching sessions for all junior doctors and LED doctors across University Hospitals of Leicester to educate them identifying suitable candidates and competently leading the discussion. So far we have delivered these sessions during Geriatric departmental teaching, IMT teaching and trust grade teaching and have gathered feedback to assess the teaching. We have also been collecting information on the total number of EHCPs completed by the trust over various periods, following the introduction of focused Advance Care Planning training into regular junior doctor teaching

Result:

After completing the original round of teaching, we found an overall improvement in the confidence that individuals had in both holding conversations about EHCPs and documenting the forms. 63.2% of participants now felt confident in conducting conversations, with 78.9% feeling confident to complete the EHCP form itself in the electronic system. As of now, we have not demonstrated an improvement in the number of EHCPs completed, with an initial result of 39 over the three months before teaching, compared to 36 after teaching. It was also noted that almost all EHCPs were completed in the context of advanced frailty and were not utilized for younger patients with terminal conditions.

Conclusion :

This initiative has been shown to increase junior doctors' confidence in leading ACP discussions, highlighting the need for such training to promote patient-centered care. Expanding this educational effort to include additional training for foundation-level doctors and GP trainees may further enhance advance care planning practices in hospitals. However, it is interesting to note that despite the perceived increase in confidence, the total number of completed plans does not appear to have improved. This may be partly due to our not yet targeting all relevant groups; future rounds of the project should explore the ongoing barriers to completion.

Background: This project is based in the geriatric department of Wye Valley NHS trust which serves Herefordshire and mid-Powys.

Introduction : In frail, older patients, cardiopulmonary(CPR) resuscitation has low rates of success. Lack of appropriately completed ReSPECT forms leads to futile attempts of CPR, repeated readmissions and patient harm. This project aims to improve patient centred advance care planning (ACP), and the quality of their documentation in the ‘clinician recommendations’ section in ReSPECT forms through development of new educational tools.

Methods: The Supportive and Palliative Care Indicator Tool (SPICT) was used to identify patients benefitting from ACP in the department. Data was collected on how many patients had ReSPECT forms and how well they were completed against standards adapted from the Resuscitation Council guidelines. Plan-Do-Study-Act(PDSA) cycle 1 was completed developing an aide-memoire (ReSPECT tool), and an interactive workshop. PDSA cycle 2 lead to design of the project poster titled ‘Revamp your ReSPECT discussions’ which was displayed on the wards, and shared on social media. PDSA cycle 3 was conducted to measure response and aid direction. Results: PDSA 1 showed 71% patients meeting SPICT criteria had ReSPECT forms. This improved to 82% by PDSA 3. PDSA cycle 1 revealed that only 32% of ReSPECT forms were completed to audit standards, by PDSA 3 this improved to 43%. The project received engagement from the wider healthcare community on Twitter/X where the project poster garnered over 36,600 views and has been shared in the trusts latest issue of safety bites.

Conclusions: Our work led to an improvement in the quality of documentation and illustrated a novel approach to communicating the standards expected when delivering patient-centred ACP. The interest received via social media highlighted the importance of sharing this experience. We plan on building on this success through wider communication of the standards.

Introduction

Advance care planning (ACP) offers people the opportunity to plan their future care whilst they have capacity to do so and is supported by national guidance. Decisions regarding future care are more likely to be individualised and holistic when patients and their significant others are involved. This QI project aimed to address this by increasing the frequency of ACP discussions being offered and recorded on gerontology wards in an acute London Trust.

Method

A multi-professional steering group was established to improve ACP using PDSA methodology. A new ACP toolkit, training programme and electronic flowsheet (within the hospital’s patient record system) were implemented. ACP documentation quality was audited on gerontology wards pre and post implementation (over one to four months respectively). Data was compared using Pearson’s Chi-squared test.

Results

ACP flowsheets were completed by junior and senior doctors, and clinical nurse specialists in frailty and palliative medicine. The initial audit found disparity between documented topics of ACP conversations, with cardiopulmonary resuscitation recommendations being most discussed. Post implementation, 24 ACP flowsheets were reviewed, showing that more ACP topics were documented where these conversations were had; preferred place of death increased from 24% to 60% (p 0.011); treatment escalation plan increased from 41% to 75% (p 0.014); preferred place of care increased from 59% to 71% (p 0.066). Topics not showing significant improvement in documentation (despite inclusion in the flowsheet) were spiritual needs, information needs and prognostic discussion, broader social needs and what was most important to the patient.

Conclusion

The implementation of an electronic ACP flowsheet improved documented ACP conversations in some topics, guiding healthcare professionals to deliver care that aligns with peoples’ wishes and preferences. Documented conversations became easier to access, review and audit. Work is still needed to promote ACP conversations being centralised around what matters most to patients.

Introduction

Over 500,000 fragility fractures occur in the UK each year (1). NICE guidelines state that all women aged ≥65 and all men aged ≥75 should be considered for a fracture risk assessment. It was recognised that locally these guidelines were not being met. The aim of this quality improvement project was to improve the number of patients being assessed for osteoporosis across two medical wards.

Method

This quality improvement project followed two “Plan Do Study Act” (PDSA) cycles. The first cycle involved teaching sessions for junior doctors on using the FRAX tool – a tool recommended by NICE guidelines to estimate 10-year predicted absolute fracture risk. Posters and visual reminders were placed around the wards. The second cycle involved creating a sticker which was placed in patients’ medical records prompting doctors to calculate FRAX scores and document the results. Patients deemed inappropriate for bone protection and patients already receiving bone protection prior to admission were excluded.

Results

A baseline set of data showed that 0% of patients had undergone fracture risk assessment, therefore resulting in no patients being prescribed bone protection or being referred to osteoporosis clinic. Repeat assessment after the first intervention showed 29.7% of patients had undergone fracture risk assessment, 13.5% were prescribed bone protection and 16.2% referred to osteoporosis clinic. After the second intervention, 80% of patients had undergone fracture risk assessment, 10% were prescribed bone protection and 55% referred to osteoporosis clinic.

Conclusion

Use of the FRAX tool was moderately increased by the targeted training of junior doctors and markedly increased by using a visual memorandum in the patient records. This led to an increase in treatment for osteoporosis, reducing patients’ future risk of fragility fractures.

References

1. National Osteoporosis Society. Susan's story: Osteoporosis 2017. https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2017/02/rightcare-susans-story-full-narrative.pdf

Introduction

In-hospital CPR has survival rates of 15-20% [BMA Decisions on CPR, 3rd edition, 2016], further reduced with frailty and multimorbidity. Successful CPR is associated with significant morbidity and prolonged suffering. Do not attempt resuscitation (DNACPR) is an advanced medical decision, aimed at preventing harm where CPR is considered futile.[GMC Guidance.p128-145]

Aims

To reduce the burden of inappropriate CPR within surgical specialties using the following standards:

1. DNACPR status reviewed on admission, and all decisions implemented within 24hours of clerking.

2. DNACPR decisions implemented prior to surgery.

3. To assess clinician perceptions regarding DNACPR decisions.

Methods

This second cycle follows the intervention of a poster and departmental education in January 2020. A survey was sent to clinicians of all grades in Trauma and Orthopaedics (T&O) and General Surgery in January 2023. Data on implementation of DNACPR decisions was retrospectively collected over January and February 2023 for all T&O emergency and elective admissions >60-years-old.

Results

26 survey responses were obtained with all participants having had DNACPR discussions. 80.7% self-reported as confident/very confident in having these discussions. Out of 264 patients included, 80 discussions took place, of which 64 (80%) were implemented. 69% were implemented within 24hours of clerking, a 23% increase from cycle 1. 90% of community DNACPRs (9/10) were applied within 24hours, however the one remaining patient received inappropriate CPR. Of the 47 patients with DNACPR who had surgery, 87% were implemented prior to surgery, a 12% increase from cycle 1.

Conclusion

Improvement was demonstrated on both standards between cycles. This QI focused on implementation of DNACPR following discussions, however, did not consider patients in whom DNACPR may have been appropriate but not discussed. Further areas to explore include appropriateness of CPR/ DNACPR decisions in advance of surgical interventions and the understanding behind limitations of treatment offered separate to CPR.