Using PCOC tools for transition of care
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1 University of Wollongong Research Online Australian Health Services Research Institute Faculty of Business 2013 Using PCOC tools for transition of care Claire Johnson University of Western Australia Tanya Pidgeon University of Western Australia Publication Details C. Johnson & T. Pidgeon, "Using PCOC tools for transition of care", 12th Australian Palliative Care Conference. (2013) Research Online is the open access institutional repository for the University of Wollongong. For further information contact the UOW Library:
2 Using PCOC tools for transition of care Abstract PCOC is a quality initiative developed specifically to "support continuous improvement in the quality and effectiveness of palliative care service delivery across Australia". Keywords pcoc, transition, care, tools Publication Details C. Johnson & T. Pidgeon, "Using PCOC tools for transition of care", 12th Australian Palliative Care Conference. (2013) This conference paper is available at Research Online:
3 Using PCOC Tools for transition of care Claire Johnson, Tanya Pidgeon
4 What is PCOC? PCOC is a quality initiative developed specifically to "support continuous improvement in the quality and effectiveness of palliative care service delivery across Australia". Established in 2005 quality improvement initiative Measures patient outcomes in palliative care Specifically targeted at specialist PC services National approach Benchmarks added in 2008
5 PCOC Assessment Tools Phase 1 Stage of illness patient and family RUG-ADL 2 Functioning, dependency and resources AKPS 3 PCPSS 4 Performance and prognostication Distress patient and family, includes psych/spiritual SAS 5 Distress 7 symptoms, patient perspective Reports also gather other patient and episode of care information such Diagnosis, age, gender and LOS 1 Eagar et al 2004; 2 Fries et al 1994; 3 Abernethy et al 2005; 4 Eagar et al 2004; 5 Kristjanson et al 1999
6 PCOC- Additional benefits Assessment tools drive the focus of care/care planning Improved symptom management Acknowledgment of the carer/family as part of the unit of care Provision of a common language Consistent, clinical picture of the individual patient A seamless service between home, hospital and inpatient palliative care Enhanced communication between patients, families and clinicians Consistent, formal documentation of assessment Assessment across domains provides referral triggers
7 PCOC- Features Standardised, centrally managed, and locally delivered training by PCOC quality improvement facilitators means a consistent approach to: The use of the tools Assessment of patients Language Documentation Reporting Benchmarking/monitoring service performance Interpretation of reports
8 Case study Introducing Bob Callis Age: 55 years Diagnosis: Adv. lung Ca with bony metastasis Diagnosed: April 19, 2012 Medical Hx: Smoker for 15 years, ceased 20yrs ago, nil other sig. hx Social Hx: Lives with wife Maisie (Bob s carer) and their 2 teenage children Maisie believes Bob is getting worse so she contacts the community PC service and requests a visit. Maisie reports that she is feeling fatigued & unwell.
9 Inter-jurisdictional Communication PC Phase: 2 (Unstable) AKPS: 50 RUG ADL: 13/18 (needs help with bed mobility, toileting, transfers & eating). PCPSS: Pain = 3, Other symptoms = 3, Psych/spiritual = 3, Family/carer = 3. (3 = severe) SAS: Difficulty Sleeping = 8, Appetite problems = 2 Nausea = 8, Bowels = 9, Breathing = 7, Fatigue = 7 and Pain = 9. (patient rated scores, out of 10)
10 Within-service communication Picture of board and clinical handover sheet
11 Name/Age/Diagnosis Presenting Problems Family Care Needs Pump/Pain Control 1 Omar Little 59 Hepatocellular Ca Muscular Atrophy Hep C+ive Pain Anxiety Oesophageal varices Reduced mobility Emotional issues F= Jim F= Russell Phase SMOKER- Nico patch For DC RUG-ADL 12 DOA 8/2 home Mobility Diet Bladder/bowel DR THOMAS Crisis order Deidre Bunion 60 Intranasal melanoma 12 Cerebral, Maxillary spread 2 Name/Age/ Hx MS, HTN, Epistaxis Diagnosis Mathilda Da Silva 81 Bob Callis 3 55 PACEMAKER MRSA+ive Ca Ovary, PVD, CML HEPARIN BD Hx Melanoma 97, Amputation L)toe Yuji Matsumoto 76 Advanced Mesothelioma 11 4 CLEXANE Hx Asbestosis, HTN lung Ca with NIDDM bony Bob Callis 55 metastasis 5 6 Advanced lung Ca with bony metastasis Walter White 57 Glioblastoma 11 Hx Gout Presenting Problems NIDDM SAS (PSS) Pain-9 (3) Nausea-8 SOB-7 Anorexia-2 Insomnia-8 Constipation-9 Fatigue-7 Deteriorating mobility/functioning Family/carer (3) Psych/sp (3) NIDDM Mouth care Sacral wound Herpes simplex Swollen eye Boil labia AB s Pain Confused SOB Dry mouth Dressing s feet MRSA PRECATUTIONS C DIFF Pain chest wall Cough Drowsy Difficult swallow Poor appetite Dyspnoea O2 Pain Nausea SOB Anorexia Insomnia Constipation Fatigue Deteriorating mobility/functioning Expressive Dysphasia Emotional labile Seizures Headaches Social issues Falls Confused P= Ken D= Flo S= Mark S= Ron D= Carol S= John S= Max NOK= NH W=Maisie P=Skyler D= Holly F= Jesse Phase For NH placement RUG-ADL 18 DOA 20/1 - RPH Mobility Diet Bladder/bowels IDC Para regime Phase (P) RUG-ADL 18 DOA 24/1 SCGH Mobility (Falls risk, Fall 2/2) Diet Bladder/bowels IDC Phase 2 RUG-ADL 10 DOA 18/2 home Mobility Ambulating with frame occasionally requires assistance Diet Independent in care Bladder/bowels Constipation, last BO 5/7 Phase? for NH RUG-ADL 18 DOA 11/2 home (SCHCS) Mobility (Falls risk HiLo bed) Diet Bladder/bowels IDC DR THOMAS Crisis order Fentanyl patch 7am med Family Care Needs Dr/Symptom *Chaplain Control W= Maisie Phase:2 RUG-ADL: 13 DOA :18/2 home Phase (P) for NH placement RUG-ADL 12 Mobility: DOA Ambulating 4/2 home (SCHCS) with frame Mobility occasionally Diet Bladder/bowels requires assistance Diet : Independent in care Bladder/bowels: Constipation, last BO 5/7 DR ONG IT/CADD SC Pump DR THOMAS 6 fractions of radiotherapy DR ONG Pain chart Fentanyl patch Targin BD SC pump O2 therapy via nasal cannula DR THOMAS 6 fractions of radiotherapy SC pump O2 therapy via nasal cannula DR THOMAS Crisis order 7 Lien Nguyen 74 Ca Breast 03 Lung, Brain, Skeletal mets Hx SEIZURES, L) Mastectomy, Hypothyroidism, NIDDM SEIZURES 4/1 Pain SOB/Cough UTI AB s Decreased mobility Dressing L) Chest Lymphoedema L) arm S= Matt D= Kelly Phase RUG-ADL 17 DOA 15/2 home (SCHCS) Mobility Diet Bladder/bowels DR ONG Crisis order Oxycontin BD 7am med
12 Reassessment and care planning Several days later Phase: 3 (Deteriorating) AKPS: 40 RUG ADL: 10/18 (little more mobile) PCPSS: Pain= 2, Other symptoms = 3, Family/carer = 3 Psych/spiritual = 2 (2 = moderate) SAS: Difficulty Sleeping = 2, Appetite = 2, Nausea = 2, Bowels = 1, Breathing = 6, Fatigue = 1, and Pain = 1
13 Summary- key message Why does this work? Assessment Language Reporting Used by every one in the same way Not just data collection
14 Kathy Eager - Chief Investigator, University of Wollongong David Currow - Chief Investigator, Flinders University Patsy Yates - Chief Investigator, University of Technology Queensland Tanya Pidgeon - WA Quality Improvement Facilitator Funded under the National Palliative Care Program and is supported by the Australian Government Department of Health and Ageing
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Patient Name Election Date Assessment Date. Vital Signs T Pulse (Resting) Resp BP Weight: MAC
INITIAL ASSESSMENT NURSING Patient Name Election Date Assessment Date MR# Date of Birth Age Vital Signs T Pulse (Resting) Resp BP Weight: MAC Pain Assessment Intensity: none = 0 1 2 3 4 5 6 7 8 9 10 =
Administrative Approval: Vice President of Professional Services
Title: Psychosocial Distress Screening Policy Aspect of Care/Service: Continuum of Cancer Care Submitted by: Senior Oncology Nurse Navigator Committee Review: Clinical Practice (preliminary review 1/9/14)
FOCUS CHARTING. The Focus Charting System is the accepted documentation system at Windsor Regional Hospital.
FOCUS CHARTING The Focus Charting System is the accepted documentation system at Windsor Regional Hospital. Advantages of Focus Charting Flexible enough to adapt to any clinical practice setting and promotes