RIPPLE: “Realising Individual Patient Preferences at Life’s End”
George Eliot Hospital Rapid Discharge Pathway
What is “RIPPLE”?
RIPPLE is a document which forms a multidisciplinary pathway of care to facilitate a
smooth and timely discharge when a patient has been identified as being in the final
hours, days or weeks of life and where the patient and family wish for care to be
delivered at home. RIPPLE stands for “Realising Individual Patient Preferences at Life’s
End”.
Why was it needed?
Anecdotal evidence had suggested that patients were not always being offered the
option of discharge at the end of life and that when discharge did happen; it was not
always as coordinated as it needed to be. Mary Ann Evans Hospice at Home had been
given the capacity to deliver care urgently through the NHS Warwickshire Hospice at
Home Project using money diverted from Continuing Healthcare but hospital referrals
were not as frequent as they might be.
What were the intended outcomes?
 Improved communication with patients and relatives at the end of life
 Patients’ preferences for end of life care are identified and achieved more often
 Improved discharges at the end of life, co-ordinated with community services
and addressing holistic care needs, including anticipating needs of patients and
families
Who was involved?
A multidisciplinary, multi-agency team worked together to identify what a good
discharge at the end of life would look like and to develop the documentation to support
this. The team included Consultant in Palliative Medicine, Practice Development Nurse
for End of Life Care, Nurse Manager for Hospice at Home, Hospice at Home Team,
Director of Nursing, Capacity Matron, Macmillan Nurses, District Nurse Teams, Ward
Nurses, Pharmacist and many others.
What is included in the RIPPLE Pathway?
The pathway is divided into sections:
 Identifying the dying patient (MDT Decision-making)
 Establishing patient’s and family’s preferences for care
 Establishing the appropriateness of the pathway
 Referral for discharge
 Assessment of current needs
 Prescribing and anticipatory planning
 Supporting documentation
What supporting documentation is necessary?
 District nurse authorisation sheet for sc bolus injections and continuous
infusions of end of life drugs
 End of life symptom control algorithms
 DNACPR discussed and form transferred home with the patient.
 WMAS and Harmoni informed of discharge by fax
 Letter for carer with information about services and contact numbers
 Carer information about what to expect at the end of life
RIPPLE: Realising Individual Patient Preferences at Life’s End


o “Understanding the Last Days of Life” or “End of Life: The Facts”
GP faxed with information about discharge, copied to DN
Patient/carer letter requesting feedback
Who completes the paperwork?
The ward nurse and doctor complete the paperwork with support from the Practice
Development Nurse for End of Life Care and/or the Discharge Team. The pathway is
discharged with the patient to provide continuity at a vulnerable time.
Which patients are included?
Patients identified as Level 2, 3 or 4 on the Prioritisation Tool are included.
How is it funded?
The Warwickshire Hospice at Home Pilot Project, (led by Jo Blackburn, Programme
Manager - End of Life Care, NHS Arden Commissioning Support Unit,
has facilitated Mary Ann Evans and other local hospices to deliver rapid end of life care
with Hospice at Home funded by Continuing Healthcare. The Fast Track Tool is
completed by the District Nurses after discharge reducing delays for the patient.
What were the challenges?
A large number of staff were involved but all shared a common vision to improve the
care we were providing. A balance was needed between ensuring all elements were
covered but that the document was usable. More work is needed to embed the process
with ward staff.
Access to a hospital bed presented a challenge because of the need for a site visit. This
was overcome by the hospital purchasing Repose mattresses to ensure good pressure
area care after discharge whilst assessment for a hospital bed took place after discharge.
How has it been successful?
29 patients have been discharged using the pathway, the majority with a cancer
diagnosis. Four patients died before discharge was possible.
Feedback from GPs about the pathway has been excellent. Patient and carer feedback
on the discharge has been more difficult to obtain, although their appreciation of the
Hospice at Home and District Nursing services is clear.
For patients discharged on RIPPLE, care has been provided for between one day and up
to 17. Potential savings have been difficult to estimate but for a cohort of just ten
patients discharged on RIPPLE, a total of seventy seven days has been spent at home
supported by the District Nurse and Hospice at Home Team.
The RIPPLE Pathway Group
Contact: Dr Julia Grant, Consultant in Palliative Medicine [email protected]
RIPPLE: Realising Individual Patient Preferences at Life’s End