PICD an integrated end of life care pathway Dr Michael Franco Palliative Medicine Physician & Medical Oncologist, Southern Health, Christine Mooney,, Palliative Care Nurse Consultant; Gabrielle O ConnorO Connor,, Palliative Care Nurse Consultant (Manager); A/Prof Kate Jackson,, Director Supportive and Palliative Care; Dr Leeroy William,, Palliative Medicine Specialist; Ben Evans,, Palliative Care Consult Nurse; Kaye Walsh,, Palliative Care Consult Nurse; Pam Hosking,, Palliative Care Consult Nurse; Peter Poon,, Palliative Medicine Specialist
A very wise man once said I still don't know what I was waiting for, And my time was running wild. A million dead-end streets, Every time I thought I'd got it made, It seemed the taste was not so sweet Ch-ch-ch-ch-Changes Turn and face the strain Ch-ch-Changes Just gonna have to be a different man Time may change me But I can't trace time
Created in 2007 Aim was to create an End of Life Pathway for non-palliative care specialist staff to use at Southern Health Four main campuses Over 1000 beds Used the Liverpool Care Pathway as a starting point Aimed for brevity To be fully integrated into patient s history and used at the bedside as the nursing care plan
With support and input of senior medical and nursing staff of General Medicine Initial project funding through a training and development grant from the Department of Health Funding used for a project officer One of Southern Health s existing Palliative Care Nurse Consultants Already well known to the staff on wards and understanding of the Southern Health system Funded for 0.5EFT to audit, then implement and trial PICD
Initially to four general medical wards Project manager: Performed an audit of all deaths for two months prior to implement Ran education sessions to a total of over 200 staff members Provided ongoing support to each of the wards during trial of PICD Performed a second audit after the first two months of PICD Great results!! Examples (pre vs post-picd): Pastoral Care involvement 0% vs 70% Social Worker involvement 40% vs 75% Medications appropriately ceased and prn charted 70% vs 100%
No more funding for project manager Repeat audit at 12 months Not Great Results!! A significant amount of the initial gains were given back: Examples (pre vs 2 months post-implementation vs 24 months postimplement): Pastoral Care involvement 0% vs 70% vs 48% Social Worker involvement 40% vs 75% vs 61% Medications appropriately ceased and prn charted 70% vs 100% vs 93%
Twelve months of intensive, aggressive education and training was not long enough to ingrain cultural and system change On review with the wards, it was found that it was the lack of an ongoing education and mentoring that was the key component in losing the initial gains Ideas for improvement Rotating junior medical staff New nursing staff Refresher courses for permanent staff
Some more funding gained from the Department of Health used to reinstitute Project Officer Project Officer concentrated on education sessions and promotion of use of PICD rather than getting involved at the level of individual patient Improved results on repeat auditing Renewed enthusiasm from Health Service, other wards, doctors and nurses Rollout to other sites, in particular Oncology
Easier than other wards Experienced in working in a multidisciplinary team Used to having family meetings and discussions regarding prognosis, limitation of treatment, death and the dying process Gains made on the pre vs post audits smaller, as baseline statistics good already E.g. Discussion goals of care: 87% pre- & post-implementation Worked as an affirmation of current practices more than changing patient care
PICD instituted: Stroke Unit Dandenong Hospital General Medical Wards Interest from ED and ICU
More enthusiasm! Small palliative care consult service stretched thinner and thinner for resources with increasing demand for PICD
Involving Medical Unit Heads and Nurse Unit Managers empowering them to take responsibility for PICD in their unit Nurse Champions Large nursing education program Repeated education programs to rotating junior medical staff Developing a DVD to enable online training with our unit doing the initial training and then providing subsequent advice and support
PICD used on 650 patients so far in the acute hospital setting Hospital Executive instituting a policy for end-of-life care Therefore, PICD has high level support and is mandated for use with all dying patients across Southern Health Available on hospital intranet and on wards Some extra resources may become available
The successful implementation of a pathway requires very different strategies and foci in the initial stage vs the ongoing sustenance of the protocol
Hands on involvement at a ward level is the key component of initial success of instituting the rollout of a new pathway Builds a grass roots knowledge base to handle the basics of using the pathway Allows development of enthusiasm in staff Leads naturally to the emergence of ward champions Ward Champions Benefits for the champions: Professional development Valuable additions to their CV Job satisfaction Benefits for the protocol Provision of the hands-on support to free up the time of the project manager No funding needed
Education and mentoring, rather than involvement at the ward level is the key component of ongoing success of instituting the rollout of a new pathway Get support on three levels Executive level Unit level Ward level Funding helps!
It is easier to establish an end-of-life pathway in wards that are experienced in dealing with these issues Inpatient Oncology Unit? Inpatient Palliative Care Units We did not encounter the problem of: We re already doing this well we don t need new unnecessary paperwork to tell us how to do it
Many thanks for your attention