RUH End of Life Care Working Group Annual Report April 2013 March 2014 Agenda Item: 11 Page 1 of 11
Contents 1. Introduction page 3 2. End of Life Care Working Group page 3 3. End of Life Care Work Plan page 3 4. CQUINs page 6 5. Integrated Care Pathway page 8 6. Ambassadors a collaborative for end of life care page 8 7. Support and education for staff page 8 8. Information for public and staff page 9 9. The National Care of the Dying Audit page 9 10. Partnership working with Dorothy House page 10 11. Future developments page 10 Agenda Item: 11 Page 2 of 11
1. Introduction There has been significant focus over the last year at the RUH, to support the delivery of high quality, timely, effective, individualised services for patients with end of life care needs, support for their families and support for staff to provide these services. This service improvement work continues, to support staff in providing compassionate, holistic, patient centred care. This report gives an overview of the end of life care service improvement work at the RUH for 2013/14. 2. End of Life Care Working Group The working group has met quarterly, with representation from: Executive Lead (Chair) Senior palliative care nurse/end of life care facilitator Senior palliative care nurse specialist Matron oncology Head of Patient Experience Senior chaplain Medical and nursing representative from medicine and surgery Consultant in Palliative Medicine, RUH and Dorothy House (Vice Chair) Paediatric Nurse Heart Failure Nurse Specialist Patient /family representative Dorothy House nurse specialist/lead Representative from Sirona Representative from Wiltshire Representative from Mendip Discharge liaison nurse lead on continuing health care Representative from Patient Affairs The objectives of the working group have included agreeing an annual work plan for end of life care. The work plan aligns to the themes within the national End of Life Care Strategy. 3. End of Life Care Work Plan Work Stream 1 and 2 - Discussions as the end of life approaches, regular re-assessment and care planning Promoted early identification of patients with end of life care needs, through by implementation of The Conversation Project (see CQUIN section). Completion of the Kings Fund Point of care project. Electronic Palliative Care Co-ordination System (EPaCCs) linked to Millenium (see CQUIN section) Agenda Item: 11 Page 3 of 11
Collaborative working between the RUH and Sirona to support improvements in heart failure service. This included a process mapping event and a pilot of MDT meetings with the RUH heart failure team, Sirona heart failure nurses and the RUH palliative care team. Embedding of The Conversation Project on existing wards and extending implementation to other wards. Future use and development of an electronic end of life patient record in collaboration with community CCG s. Work Stream 3 - Co-ordination and experience of care Promotion of end of life care across the Trust with Dying Matters Awareness week May 2013. Development of the Ambassadors for end of life care adopting a collaborative approach to initiate good practice and change. Collaborative working with BaNES, RUH hospital consultants and Dorothy House with evening meetings held to look at the coordination of care, June 2013. To develop processes to facilitate timely, safe discharge process for patients who are dying. To further support the transition of care and transfer of information between the RUH and the community services. To work with the RUH and CCG s to develop a Ceiling of Treatment form that is acceptable and appropriate to all areas Work Stream 4 - Delivery of high quality care of the dying in acute hospitals. CQC inspection December 2013 The CQC stated that: Patients received safe and effective end of life care. Their care needs were being met and the service was integrated with GPs and community services, which supported effective discharge arrangements and care at home. Most patients and their families were positive about the care and support they received, and said they were treated with dignity and respect from reception staff Agenda Item: 11 Page 4 of 11
through to consultants. Staff had appropriate training and supported patients to be fully involved in their care and decisions. The service was well-led and staff were dedicated to improving standards of end of life care across the hospital Two multi-professional workshops held to develop best practice for the movement of the dying patient to guide staff on decisionmaking about moving patients from one area to another and use of side rooms. The final guidance was added as an appendix to the bed management policy. A plan to ensure those dying patients being discharged from the RUH had appropriate Just in case medications was developed in liaison with the pharmacy department and the CCGs. Reviewed complaints with the RUH Lead for Complaints and Head of Patient Experience to look at themes and information relating to end of life care, inform how to improve provision of care. The RUH completed the National Care of the Dying Audit for Hospitals, with the report expected May 2014. Further development and implementation of the Just in Case medication documentation and guidance to support a pilot on some wards. 2014/15 Review the Integrated Care Pathway documentation. Following publication of the National Care of the Dying Audit for Hospitals, in May, the recommendations will be used to inform the work plan for 2013/14. Work stream 5 Care after death A post bereavement audit was developed and implemented as part of the CQUIN (see CQUIN section for outcomes form the audit) A checklist of actions to support dignity in care after death has been developed and cascaded to wards. Closer working with Patient Affairs Team to support shared learning in bereavement. Partnership working with the Facilities Team to contribute to the development of the interior design and Agenda Item: 11 Page 5 of 11
garden area for the new mortuary build. The development of a Feedback Service for bereaved family members of patients that have died at the RUH. Using information from the Feedback Service to inform ongoing service improvement and learning in end of life care. Work Stream 6 Education for EOLC Closer working with the Education Department to include end of life care as part of the induction programme. This is now included in the Patient at risk day for registered nurses, HCA s and therapists. Development of regular study days for the Ambassadors for end of life care, to support mentorship, reflective learning and sharing of best practice. To explore the potential for e learning resources to supported ongoing access to information and learning in end of life care. Development of e learning resources to support RUH staff. Working in partnership with Dorothy House Education Department to support opportunities for learning for staff across different settings. 4. CQUINs The CQUINs for end of life care for 2013/14 included: 7.1 Early identification of patients that are at end of life through access to Adastra (EPaCCs). EPaCCs linked to Millennium system, via RUH dashboard. Palliative care team and designated staff trained to access and update information on EPaCCs. Audit completed - 101 entries checked for patients admitted to the RUH. Only 38 records on EPaCCs included up to date clinical and advance care planning information including Do Not Attempt Cardiopulmonary Resuscitation (DNAR) status, preferred place of care/death and history of support within community before admission. Agenda Item: 11 Page 6 of 11
The majority of entries within EPaCCs were found to be out of date or incomplete clinical information recorded. The audit identified inappropriate resuscitation status and lack of advance care planning information. Information from the audit was fed back to BaNES and Wiltshire CCG end of life care strategy groups to inform future end of life care locality register development. 7.2 Development and implementation of a robust EOLC pathway- The Conversation Project Project promoted early identification of patients with end of life care needs and promoted conversations with patients and their families.6 wards enrolled and implementing The Conversation Project Pulteney, Haygarth, Waterhouse, ACE, ASU and Respiratory. Palliative care team attend weekly MDT/white board meetings on each ward. Audit completed of 172 patient records through the year. Quarter 4 audit (88 patient records) identified: Evidence of discussion with patient 97% Clear documented plan 97% Evidence of discussion with family 97% Evidence of advance care planning 39% Plan to do presentations for sisters and matrons meetings. Plan to present at Grand Round meeting in June. Plan to present patient story to Trust board. Continue to embed The Conversation Project on existing wards and extend to other wards. 7.3 (a) Supporting sessions develop and implement a sustainable programme of support sessions for staff to discuss issues around patient s death and EOLC Staff have access to the palliative care team for support with reflective review sessions on the wards. Guidance on these sessions provided to all the wards. Working with The Kings Fund a facilitated a session was Agenda Item: 11 Page 7 of 11
provided to introduce and explore the concept of Schwartz Rounds. To review the uptake of the reflective review sessions and develop processes for ongoing experiential learning for staff supporting patients with end of life care needs. 7.3 (b) Junior doctors survey survey junior doctors on rotation on the pilot and roll out wards for the EOLC pathway to ensure they are receiving suitable involvement, confidence and knowledge in EOLC identification and planning Junior doctors are supported by the medical team from Dorothy House with The Conversation Project, through training sessions, shadowing and reflective review sessions. A survey was completed of junior doctors at the beginning and end of each 4 month rotation. learning from this included: Junior doctors felt more confident in initiating conversations regarding issues around end of life care. Those rating this as an 8 (scale 1-10) increased from 14% at the start of their rotation to 36% at the end of their rotation. Junior doctors felt more confident in having conversations with relatives regarding issues around end of life care. Those rating this as an 8 (scale 1-10) increased from 19% at the start of their rotation to 39% at the end of their rotation. Junior doctors confidence in recognition that patients recovery was uncertain, also increased. To use learning from the survey to inform future support provided by the Dorothy House medical team for junior doctors on the wards, through training sessions, reflective review meetings and shadowing. 7.4 End of life care CQUIN - End of life care: Supporting Families A post bereavement survey was completed. Feedback was through a paper questionnaire or telephone contact with the palliative care team post bereavement. 36 families gave feedback on the care that their relative received in the last few days of life at the RUH. The feedback survey identified that the Agenda Item: 11 Page 8 of 11
bereaved families felt that: Patients dying in the RUH had their needs met 78% Families were given information in a timely and sensitive manner 70% Families felt involved in decisions about the patient s care 78% Families felt supported before and after the death 75% Overall, the bereaved families felt that their family members received good care at the RUH. Families appreciated that staff were trying to do their best, when they are very busy. Families stated that small things made a big difference kindness, cups of tea, somewhere to stay. Dying in hospital rather than at home was not an issue for this sample. Families valued the opportunity to talk about their experience. Learning from the feedback identified the need for effective communication especially around patient deterioration, the possibility of dying, fluid intake, the process for issuing Medical Certification of Death, and lack of continuity of care. This informed the work plan for 2014/15. Plan to develop guidance for transfer of patients at the end of life, to reduce inappropriate ward transfers of patients that are dying. Negotiated CQUIN for 2014/15 supports development and implementation for a feedback service for bereaved families. This will support ongoing monitoring of quality of care to the dying patient, will potentially prevent future complaints and allows bereavement advice and support to be provided. 5. Integrated Care Pathway The RUH had used a local Integrated Care Pathway (ICP) for care of the dying. The ICP documentation is used on all the adult wards. An ICP audit was completed in January 2013, however, this was not repeated in 2013/14, due to RUH participation in the National Care of the Dying Audit for Hospitals. The ICP pathway will be reviewed in light of the national Liverpool Care Pathway review More Care, Less Pathway (2013). 6. Ambassadors - a collaborative for end of life care This project has supported the development of ward Ambassadors to champion communication, compassion and end of life care on the wards. The Ambassadors are supported by the palliative care team with their roles on the wards and have the opportunity to attend study days to promote and share best practice in end of life care. Agenda Item: 11 Page 9 of 11
Number of RUH Ambassadors for end of life care 38 Number of wards/units with Ambassadors 24 Ambassador study days 2013/14 2 7. Support and education for staff The palliative care team provide a programme of education in end of life care, which includes sessions on the Trust induction. The team also provides ad hoc learning to staff in end of life care, symptom management, care of the dying during clinical activity on the wards. This educational activity is not recorded. The palliative care team also provide placements and training for medical students Monday afternoons and Friday mornings, during oncology placement. The following sessions have been provided in the last year: Session title Staff group Number of staff trained Induction Patients At Risk End of Life Care session Induction Introduction to care of the dying RNs and HCAs 311 HCAs 169 Ambassador study day RNs and HCAs 38 Syringe driver management RNs No data available Grand Round June 2013 Junior doctors sessions on palliative care Preceptorship sessions on end of life care x2 per year Consultants, SpRs, CT1s, SHOs, FY2s, FY1s FY1s, FY2s, SHOs, CT1s, SpRs Nurses on preceptorship No data available 28 No data available Student nurse sessions on end of life care x2 sessions/year Student nurse sessions on end of life care x2 sessions/year 1 st year students No data available 3 rd year students No data available Agenda Item: 11 Page 10 of 11
Training in end of life care provided through the Trust induction study days has provided data on staff numbers trained. There has been no formal process to record staff training in end of life care as a mandatory requirement for 2013/14. 8. Information for the public and staff An Internet website provides some information for the public around the care of the dying at the RUH. Also a leaflet is available for families to answer some of their concerns and questions about end of life care at the RUH. An internal intranet site for palliative and end of life care provides information and guidance for staff at the RUH, on all aspects of palliative and end of life care. All these resources will be reviewed again this coming year and updated as required. 9. The National Care of the Dying Audit The Trust participated in the National Care of the Dying Audit for Hospitals, this year. This was a retrospective audit of 130 sets of medical notes, of patients who had died in May 2013 and a post bereavement audit with bereaved relatives. 131 Trusts participated. The national audit will publish findings and a report for each participating Trust in May 2014. Information from this audit will inform the end of life care work plan for the coming year. 10. Partnership working with Dorothy House Hospice Dorothy House continues to support the RUH with consultant in palliative medicine sessions. Over the last year these have been 5 sessions/week. The hospice medical team representative supports the specialist palliative care MDT with the RUH palliative care team, supports assessments and reviews of patients with complex needs, provides on-going training and learning for medical students and junior doctors. 11. Future Developments The End of Life Care Working Group will continue to meet quarterly over the next year and monitor the progress of the end of life care work plan for 2014/15. This will include work streams on: Discussions as end of life approaches Assessment and care planning Coordination and experience of care Delivery of high quality care of the dying Care after death Education and on-going learning in end of life care Representatives from the End of Life Care working group will continue support local end of life care strategy groups for the Clinical Commissioning Groups to support partnership working, shared learning and quality outcomes for care across settings for patients with end of life care needs. Agenda Item: 11 Page 11 of 11