Anticipatory Care Planning in the Acute Hospital:
A Structured Approach
What are we trying to achieve?
Patients in the last year of life will receive care aligned to their
needs and wishes
 Early & reliable identification of patients where anticipatory
planning is appropriate
 Involvement of patients and families: Goals of Care
 Clear plan for management
 Reliable response to deterioration / change
Information Reconciliation
On Admission to Hospital
During Hospital Stay
KIS/ ePCS, GP letter,
previous admissions,
clinical case-notes
Structured Ward Round
Discharge From Hospital
Immediate Discharge Letter
Key information fields
included in the immediate
discharge letter & emailed to
GP Practice mailbox
Key information fields in
clinical case-notes
Deteriorating Patient
Package
Access, Review & Share
Deterioration
Primary Care
Out of Hours servicesinformed care at home
Key information used to
create or update KIS/
ePCS.
Admission to hospitalkey information
included in GP letter
Informed discussions
Informed decisions
Informed care
Deterioration at the End of Life
80
70
% of all deaths
60
50
40
30
20
10
0
Cancer
centre
MOE
North
MOE
South
SJH med
RIE Med
WGH Res RIE A&E,
CAA
SJH front
Door
53% of all deaths (n=958) ‘expected death’
• End of life care plan commenced: median 32 hrs prior to death
28% of all deaths = ‘rapid decline’
Both groups: indicators of ‘limited reversibility’, uncertainty of recovery, risk of
deterioration = need for active upstream planning
What changes are we testing first?
NHS Lothian Deteriorating
Patient Programme
• Structured Ward Round: tested vehicle for improvement in acute care
• Templates: documentation fields to prompt & record
• Key fields: Identification (SPICT)
Escalation and treatment plan
DNACPR status
Communication with patient and family
Goals of care
Two pilot areas: Acute Medicine & Medicine of the Elderly wards
Local ownership & leadership: Scottish Patient Safety Fellows
The picture so far….
Baseline Data Capture
Case note review
20 patients that died in hospital
17 patients observed on ward round
+ track post discharge : 3, 6, 12 months
Observation
Ward rounds (n= 4)
MDT meetings
Nursing handovers
Patient interviews
10 patients observed on ward round
Staff perspectives
Interviews (n=3)
Area 1: Electronic templates- refining key fields- PDSA 1
Area 2: Paper template- refining key fields- PDSA 3
Early lessons….
• Target group: acute medicine
medicine of the elderly
54- 74% of patients
80 - 100%
• Complexities of care: time to complete ward rounds/ per patient
communication ‘dams’
terminology
•
•
•
•
Declining functional ability = key indicator- AHP involvement
Patient experiences and expectations
Power of ‘ fresh’ local data
Limitations of case-note review alone for improvement …
Key Questions…..
• ‘Conversation Ready’: staff ?
patients and families ?
• Glossary of terms
• Immediate discharge letters
• Measurement and reporting:
Clinical Quality Indicator for End of Life care: 5 deaths per month
within Morbidity & Mortality reviews