Storyboard Entry Form 2014
Main author: Tanya Strange
Email: [email protected]
Telephone:07837 022488
1100 words max
1. Storyboard title: a clear concise title which describes the work
Advance Care Planning: Respecting patients’ wishes and healthcare
choices in a nursing home setting- a case study.
2. Brief outline of context: where this improvement work was done;
what sort of unit/department; what staff/client groups were involved
This work was undertaken within all nursing homes within/outside of the
geographical area (55 homes) where Aneurin Bevan University Health
Board (ABuHB) commissions care. Staff groups included:
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Patients/Relatives/Advocates
Nursing home staff/ NHS nurses
GP Macmillan Facilitator/Primary Care GP’s
Ambulance/Out of Hours services
Pharmacists/Palliative care/voluntary services
Care Forum Wales
Local authorities
3. Brief outline of problem: statement of problem; how you set out to
tackle it; how it affected patient/client care
Locally, nursing homes care for over 1,500 NHS patients. Patients are
living longer. However, the acuity status of patients entering nursing
homes means that the average life expectancy on admission is around
12/18 months compared to 3-4 years five years ago.
In 2012, a significant number of patients were inappropriately admitted to
hospital at end of their life. Advance Care Plans (ACP), End of Life (EoL)
care plans and the resuscitation status of patients were not clear. An
analysis of relative complaints, safeguarding referrals, feedback from
nursing home/NHS staff and recommendations from a Public Service
Ombudsman for Wales’ investigation informed the need to address patient
choice/wishes and EoL management across the sector.
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4. Assessment of problem and analysis of its causes: quantified
problem; staff involvement; assessment of the cause of problem;
solutions/changes needed to make improvements
ACP requires complex case management both in initiating emotive
communication and across all stages of planning through the course of an
individuals’ illness. The impact of repeated inappropriate admissions from
care homes at the end of patients’ lives and the distress caused to those
‘left behind’ following deaths in hospital was considerable.
The absence of ACP’s/confirmed resuscitation status in homes resulted in
many elderly/frail people being conveyed to/dying in hospital. In effect,
unless an individual was identified as ‘palliative’/EoL, hospital admission
was often facilitated. Unknown patient choices, complaints and the
general distress of relatives/staff informed the urgent need to focus on
ACP/EoL wishes. This needed engagement from a wide range of partners.
ACP is essentially a process of discussion between an individual and their
care providers about what kind of care they would like to receive now and
in the future (DoH Guidance on Advance Care Planning, End of Life Care
Programme, 2008). Although most commonly associated with palliative
care/EoL, the process of exploring patients’ wishes/preferences regarding
their future care is particularly important for frail elderly/individuals with
multiple co-morbidities. This was generally lacking in nursing homes.
The complexities of patients meant that ACP needed to be carried out in
advance of anticipated deterioration. Patients’ wishes/preferences would
be used to plan the individual’s care now and when they no longer have
the capacity to make care decisions. ACP would also be used to discuss
what a patient does NOT want to happen. Fundamentally, the NHS and
providers have a duty of care to patients to explore these issues with
patients.
5. Strategy for change: how the proposed change was implemented;
clear client or staff group described; explain how you disseminated the
results of the analysis and plans for change to the groups involved
with/affected by the planned change; include a timetable for change
In 2013 a provider forum was established, representative of all nursing
homes within/outside of the ABuHB. Analysis of complaints/incidents,
safeguarding referrals/conveyances data and NHS visiting professional
feedback identified the themes affecting choice/care in nursing homes.
A shared vision to improve choice/care/quality of life led to the
development of an annual improvement programme. Monthly forums were
established, each covering specific themes. Training was delivered by NHS
staff including GP’s, Out of Hours /ambulance staff/nurses and
pharmacists. Training sessions included:
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Introduction to ACP
Engaging patients/families
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Communication
Best interest decisions/mental capacity
Risk management/incident reporting
DNACPR Orders
GP enhanced services/Ambulance protocols
‘Just in case’ medication/Out of Hours support
Led by a GP McMillan Facilitator, all nursing home matrons, district nurses
and palliative care services were invited to ACP training. The matrons
agreed to commence the process of ACP across their homes. Audits would
be evaluated in January 2014.
6. Measurement of improvement: details of how the effects of the
planned changes were measured
An ACP audit tool was used which gathers data on:
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Patient age/gender/illness stage
Consultation: patient/relative
Conversation trigger/patient response
Actions taken eg ACP implemented, DNaR discussed
Place of death
Nursing homes were provided with ACP tools (wIPADS Framework)
http://wales.pallcare.info/index.php?p=sections&sid=68.
All homes were requested to undertake a baseline audit of where they
were prior to commencing ACP. The following case study demonstrates
the outcome of a completed audit, indicating 100% successful
implementation.
7. Effects of changes: statement of the effects of the change; how far
these changes resolve the problem that triggered the work; how this
improved patient/client care; the problems encountered with the process
of changes or with the changes
All nursing homes are introducing ACP. Success has been achieved by
training multi-agency staff and involving patients/families.
The following case study demonstrates the outcome of a completed
audit.
Nursing Home X accommodates 39 patients. The acuity of these residents
represents very complex needs/co-morbidities. ACP was introduced into
the home in August 2013 by:
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Discussions at resident/relative meetings
Triggers/deterioration of condition
Review of care plans
Following hospital admissions
Communication triggers (relatives/relatives)
GP/Nurse reviews
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Pre ACP audit data indicated:
Total Number of Patients
39
Age 60-69
6
Age 70-79
6
Age 80-89
9
Age 90-99
16
Age 100+
2
DNaR Status Confirmed
ACP in Place
Mental capacity to make health/ACP decisions
16/39
0/39
14
Initial challenges included:
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Staff reluctance to start conversations
When is the right time?
Reluctance of families to acknowledge need
During acute illness
Staff supervision/training and critical event debriefs (eg sudden death)
addressed staffs initial reluctance to start ACP discussions. ACP patient
information leaflets helped inform patients/relatives. Support from GP
enhanced services/palliative care teams significantly supported
implementation.
Post ACP audit data indicates:
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Total Number of Patients
DNaR in place (excludes those for resuscitation)
ACP in Place
39
34/39
39/39
(100% increase)
Mental Capacity to make health/ACP decisions
Best Interest Assessments
14
11
(4 patients with
capacity)
Number of Deaths
7
Number of Deaths at Nursing Home
6
Number of Deaths in Hospital
1
(Patient choice)
All patients now have an individual ACP indicating their wishes/choices.
There is 100% recorded resuscitation status. 6 patients died in their
preferred location. Of the 1 patient who died in hospital, this patient had
‘changed her mind’ in the hope that treatment may prolong her life.
The success in nursing homes has prompted 2 further training
programmes:
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Community services (district nursing/complex care)
Residential (non nursing) homes with social services
Work is now progressing with the RCN to develop a competency
framework for independent sector staff (non-existent in the UK).
8. Lessons learnt: statement of lessons learnt from the work; what
would be done differently next time
Nursing homes are critical partners in the care of frail patients with very
complex needs. Locally, ABuHB would need 56 additional wards if it were
to care for nursing home patients in hospital.
Identifying the common themes that negatively impacted on care/choice
was critical to informing the programme of actions for improvement.
Patients/families/advocates have been fully engaged. Rapid change was
enabled through a shared vision/commitment/ dedication to introduce ACP
to better respect patients’ healthcare choices. Management teams
internally/in partner organisations trusted clinicians to make positive
change.
Engaging district nurses/social services from the outset would have
enabled wider introduction of ACP. However, to ensure ‘maximum impact’,
it is important to concentrate on specific clinical areas to ensure
sustainability at the outset.
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9. Message for others: statement of the main message you would like
to convey to others, based on the experience described
ACP is about knowing what the patient wants. If we don’t know, we can’t
help it happen. If we don’t ask, we don’t know. It provides a model of
patient inclusion which is transferrable across all care settings.
ACP is changing culture, positively promoting the voice/choice and control
of frail elderly living in nursing homes. No additional financial resource
was required. Cost savings are realised through non-admissions.
The NHS Wales Awards are organised by the 1000
Lives Improvement Service in Public Health Wales.
www.1000livesi.wales.nhs.uk
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