Emergency Department (ED) Discharge to Die Pathway

How the pathway began

• National Statistics/Data (as previously mentioned by Dr Crede)

• Negative Personal and Professional experiences – Frustrated through own personal experience that patients ended up in ED when could have stayed home – felt need for a turnaround, discussed at appraisal

• Desire to respect patients dignity and dying wishes

• CQC recommendations • Initial Start date 2014

First Steps

• Initial meetings held with representatives from

• Palliative Care

• Front Door Response Team (FDRT)

• Emergency Dept. (Jayne and John)

Next Steps (3 year process) • Regular feedback meetings

• Obstacles that arose: • DNAR Forms – Yorkshire Ambulance Service brought in

• New Lorenzo system – District Nursing, Intensive Home Nursing brought in

• Pink Cards/pre-emptive medications – District Nursing, Pharmacy, Intensive Home Nursing brought in

• Availability of staff

• Initial pathway designed

• Further implementation issues identified

• Alterations made and pathway finalised

• This led to a 3 year process

Pathway

PATIENT IDENTIFIED TO BE IN THE LAST HOURS TO DAYS OF LIFE AND WISHES

TO DIE IN THEIR PLACE OF CHOICE

EMERGENCY DEPARTMENT DISCHARGE TO DIE IN HOURS PATHWAY. 0800-2000HRS

MEDICAL /NURSING STAFF USE SBAR GUIDANCE TO DISCUSS DYING WITH PATIENT AND THOSE

IMPORTANT TO THEM AND AS PART OF THE DISCUSSION ENSURE THEY KNOW:

THE LIKELY SCENARIO AS THEY ARE DYING I.E WHAT TO EXPECT

THERE MAY NOT BE PROFESSIONAL CARER SUPPORT AVAILABLE IMMEDIATELY. FRONT DOOR

RESPONSE TEAM WILL TRY TO SECURE CARERS AND DISTRICT NURSES (DNs) WILL VISIT IN

EMERGENCY. CHECK THAT FAMILY CAN COPE UNTIL CARERS AVAILABLE. AND IF THEY CANNOT

DELAY THE DISCHARGE

THAT IF PATIENT DIES IN THE AMBULANCE THEY WILL BE RETURNED TO ED (NOT HOME)

TO PHONE THE DNs IF THE PATIENT BECOMES SYMPTOMATIC AT HOME

WHEN THE PATIENT DIES NOT TO PHONE FOR AN AMBULANCE, PHONE THE DN OR GP

ENSURE A DNACPR IS COMPLETED AND DISCONTINUE SHEWS AND ROUTINE OBSERVATION

MEDICAL STAFF

REFER TO FRONT DOOR RESPONSE TEAM (FDRT-BLEEP 2880

CONTACT PALLIATIVE CARE VIA SWITCHBOARD TO DISCUSS

SYMPTOM MANAGEMENT IF NEEDED

WRITE PRN S/C PRE-EMPTIVE PRESCRIBING ON A DRUG CARD (STH INTRANET “Medicines Management of Community Patients in the Last Few Days of Life”)

WRITE AN ICE DISCHARGE LETTER WITH S/C PRE-EMPTIVE

MEDICATIONS PRESCRIBED STATING CLEARLY THE DRUGS,

DOSE, FREQUENCY, AND MAXIMUM IN 24HOURS AND

ORDER DRUGS FROM BOOTS PHARMACYY

CONTACT PATIENT’S GP TO

ALERT THEM THE PATIENT IS GOING HOME TO DIE,

INFORM OF DIAGNOSIS, SYMPTOMS AND PLAN OF

CARE.

ASK GP TO DO SPECIAL NOTES FOR OUT OF HOURS

(OOHs) GPs AND TO VISIT/COMPLETE PINK CARD FOR

PRE-EMPTIVES

COMPLETE URGENT HOOF FORM IF INDICATED AND FAX TO

OXYGEN COMPANY (fax 0800214709) AND ENSURE

REFERRAL RECEIVED (PHONE 0800373580).

FRONT DOOR RESPONSE TEAM (FDRT)

ASSESS PATIENTS NEEDS TO FACILITATE DISCHARGE: CARE,

CONTINENCE, EQUIPMENT, ACCESS (FOR AMBULANCE)

ESTABLISH IF INTENSIVE HOME NURSING (IHNS) IS INDICATED AND

AVAILABLE AND MAKE REFERRAL TO 01142716010 UP TO 1700

and then SPA 01142266500 until 2200hrs. If after 1700hrs please

ask Evening and Night Nurses to task Day DNs to do full telephone

referral to IHNS next day

CONTACT PATIENTS DNs (01142266500 Sheffield) AND INFORM

OF IMPENDING DISCHARGE, DIAGNOSIS, SYMPTOMS, SOCIAL

ISSUES, CONCERNS IF ANY AND FUTURE PLAN OF CARE., IHN’S

INPUT IF AGREED.

IF PATIENT IS A CARE HOME RESIDENT CONTACT CARE HOME

LIAISON FOR ADVICE. BLEEP 4027 OR LEAVE MESSAGE Out of

Hours 14368

SEND HOME WITH A PALLIATIVE CARE PACK (48 HOURS WORTH

OF KIT see checklist- stored in FDRT ) AND PRE-EMPTIVE DRUGS

IF REQUIRES OXYGEN CHECK MEDICAL STAFF HAVE SENT HOOF

FORM AND PHONE TO ENSURE HOOF REFERRAL RECEIVED AND

WHEN INSTALATION WILL HAPPEN (phone 0800373580)

ENSURE PRN MEDICATION GIVEN PRIOR TO TRANSFER IF NEEDED

GIVE PATIENT /RELATIVES THE GP and DNs CONTACT TEL NUMBER

(DNs in Sheffield is SPA 01142266500 24hr number) ADVISE THEM

IF THEY RING OOHS SAY “PALLIATIVE PATIENT NEEDING URGENT

HOME VISIT”

MEDICAL AND FDRT STAFF TO LIAISE WITH PATIENT AND THOSE IMPORTANT TO THEM AND

AGREE ON DISCHARGE PLAN ONCE PLAN CONFIRMED THAT NEEDS CAN BE MET BY

COMMUNITY SERVICES.

DISCHARGE BY AMBULANCE AND IDENTIFY PATIENT IS A END OF LIFE PATIENT

IF PATIENT LIVES ALONE AND COMMUNITY SERVICES CANNOT BE SECURED DISCUSS

ADMISSION AND ENSURE PATIENT IS FOLLOWED UP. IF PATIENT REMAINS WISHING TO GO

HOME AND HAS CAPACITY WE SHOULD FACILITATE THIS AS FAR AS POSSIBLE AND PROVIDE

TRANSPORT AND NOTIFY COMMUNITY TEAMS

DISCHARGE TO DIE OUT OF HOURS PATHWAY EMERGENCY DEPT. (AFTER 2000HOURS/WEEKENDS)

PATIENT IDENTIFIED TO BE IN THE LAST

HOURS TO DAYS OF LIFE AND WISHES TO

DIE IN PLACE OF CHOICE

MEDICAL/NURSING STAFF USE SBAR GUIDANCE TO DISCUSS DYING WITH PATIENT AND THOSE

IMPORTANT TO THEM. AS PART OF THE DISCUSSION ENSURE THEY KNOW:

THE LIKELY SCENARIO AS THEY ARE DYING I.E WHAT TO EXPECT

THAT IF PATIENT DIES IN THE AMBULANCE THE PATIENT WILL RETURN TO EMERGENCY DEPT. (NOT

HOME)

THERE MAY NOT BE PROFESSIONAL CARER SUPPORT AVAILABLE IMMEDIATELY. ED WILL TRY TO SECURE

CARERS AND DISTRICT NURSES (DNs) WILL VISIT IN EMERGENCY. CHECK THAT THEY CAN COPE UNTIL

CARERS AVAILABLE. AND IF THEY CANNOT DELAY THE DISCHARGE

TO PHONE THE DISTRICT NURSE IF PATIENT BECOMES SYMPTOMATIC AT HOME

WHEN THE PATIENT DIES NOT TO PHONE FOR AN AMBULANCE, PHONE THE GP/DISTRICT NURSE

ENSURE A DNACPR IS COMPLETED AND DISCONTINUE SHEWS AND ROUTINE OBSERVATION

MEDICAL/NURSING STAFF

REFER TO FRONT DOOR RESPONSE (FDRT-BLEEP 2880 (UP

UNTIL 2000)

CONTACT PALLIATIVE CARE ON CALL SPR VIA SWITCHBOARD

TO DISCUSS SYMPTOM MANAGEMENT IF NEEDED

WRITE s/c PRN PRE-EMPTIVE PRESCRIBING ON A DRUG CARD (STH INTRANET “Medicines Management of Community Patients in the Last Few Days of Life”)

CONTACT OUT OF HOURs GP COLLAB. (01143051412) TO

ALERT THAT THE PATIENT IS GOING HOME TO DIE

INFORM OF DIAGNOSIS, SYMPTOMS and PLAN OF CARE

AND REQUEST THEY ADD THIS INFO AS A SPECIAL NOTE

TO PATIENTS RECORDS.

ASK THE OOHs GP TO VISIT ED TO COMPLETE PINK

CARD FOR PRE-EMPTIVE DRUGS AND SUPPLY PRE-

EMPTIVE DRUGS FROM THE GP COLLABORATIVE DRUG

CUPBOARD (PALLIATIVE PACK)

COMPLETE URGENT HOOF FORM (ON INTRANET) IF

INDICATED AND FAX TO AIR PRODUCTS (fax 0800214709)

AND PHONE TO ENSURE REFERRAL RECEIVED (0800373580).

ED NURSING TEAM (FDRT BEFORE 1800)

ASSESS PATIENTS NEEDS TO FACILITATE DISCHARGE (CARE, CONTINENCE,

EQUIPMENT, ACCESS (FOR AMBULANCE)

CONTACT PATIENTS DISTRICT NURSES (01143051460) AND INFORM OF

IMPENDING DISCHARGE, DIAGNOSIS, SYMPTOMS, SOCIAL ISSUES,

CONCERNS IF ANY AND FUTURE PLAN OF CARE. IHN’S INPUT IF AGREED.

IF A CARE HOME PATIENT CONTACT CARE HOME DIRECTLY TO INFORM THE

PATIENT IS RETURNING. LEAVE MESSAGE FOR CARE HOME LIAISON TEAM

TO F/U NEXT DAY ext. 14368

ESTABLISH IF INTENSIVE HOME NURSING IS AVAILABLE AND MAKE

REFERRAL IF INDICATED. TEL 01142716010 UP TO 1700hrs AND THEN SPA

01143051460 UNTIL 2200hrs (if referred to IHNS after 1700hrs please ask

Evening and Night Nurses to task Day DNs to do full telephone referral to

IHNS next day

SEND HOME WITH A PALLIATIVE CARE PACK (48 HOURS WORTH OF KIT see

checklist) and PRE-EMPTIVE S/C DRUGS AND PINK CARD IF GP COLLAB

VISITED

IF REQUIRES OXYGEN CHECK MEDICAL STAFF HAVE SENT HOOF FORM AND

PHONE TO ENSURE HOOF REFERRAL RECEIVED AND WHEN INSTALATION

WILL HAPPEN (0800373580)

ENSURE PRN MEDICATION GIVEN PRIOR TO TRANSFER IF NEEDED

GIVE PATIENT/RELATIVE THE GP and DNs CONTACT TEL NUMBER (DNs in

Sheffield is SPA 01143051460 24hr number) AND IF THEY NEED TO RING

ADVISE THEY SAY “PALLIATIVE PATIENT NEEDS AN URGENT HOME VISIT”

SEND HOME PINK CARD AND DRUGS IF OOHS GP VISITED EDD

MEDICAL AND ED NURSING STAFF TO LIAISE WITH PATIENT AND

THOSE IMPORTANT TO THEM AND AGREE ON DISCHARGE PLAN

DISCHARGE BY AMBULANCE AND IDENTIFY PATIENT IS AN END OF

LIFE PATIENT

Reflection on how pathway worked

• Approximately 20 people have been discharged from the Emergency Department using the pathway.

• “Patients have the right to express their wishes about

where they would like to receive care and where they want to die. People who are approaching the end of life are entitled to high-quality care, wherever they're being cared for.” – ‘End of Life Care’ - NHS.UK

• Scenario

Patient Scenario

• Mr T presented to A&E with a 1 day history of dizziness, vertigo, photophobia and nausea on examination was found to have positive nystagmus Ct head showed a further right frontal haemorrhagic infarct. Initially was for transfer to the RHH stroke unit but Mr T declined this transfer and wanted to return home to die as he was in the terminal stage of his illness

• Mr T had a current diagnosis of a poorly differentiated adenocarcinoma of unknown primary with mid–line nodal disease. This was diagnosed following a stroke and a MI which prompted further investigations due to Mr T’s young age, long term prognosis was poor and for palliative support and care.

• Mr T was referred to FDRT for a fast track palliative discharge using the new palliative care pathway; an assessment was completed identifying Mr T’s care and equipment needs

• Referral made to Intensive home nursing for end of life care • Equipment hospital bed , etc. ordered from BRC • Referral made to DNS for palliative care and management of driver which was set up in ED • Liaised with GP/DN both verbally and electronically to inform that this gentleman was being sent

home to die • Obtained pre-emptive drugs and pink card • Comfort box given • A priority ambulance was organised due to being end of life • Using the pathway enabled team working throughout all professionals and services, using the

pathway enabled a timely save and smooth discharge meeting all the patients’ needs and wishes of not to be in hospital and die in his own home

• The discharge of Mr T that was successful and he was discharged home with the support of community services to die in his own home with his family.

Plan for the future

Apr-

Sept

Oct-

Mar

Grand

Total

NGH A&E 3 12 15

NGH AMU 173 234 407

NGH Frailty Unit 20 56 76

NGH Surgical Assessment

Centre 53 62 115

Grand Total 249 364 613

Pts Contacts Average

Hospital LOS

1909 11733 19.7 Pts Average Hospital

LOS

440 10.3

Patients seen within first 24 hours of admission March 2017 – March 2018 - ED Patients seen by Consultant

Plan to work alongside Palliative Care Consultants to reduce length of stay

HST Data - All Contacts HST Data - Seen On Day/ Next Day Of Hospital Admission

Checklist for discharge to die from Emergency Department

Checked

Copy of ICE TTO with patient (if

written)

DNACPR (Red bordered)Sent with

patient

Pre-emptive Prescribing Medications

to go with patient(in hours) or OOHs

GP contacted on 3051412 to visit and

take pre-emptive pack

Oxygen going in if needed

Palliative Care Pack with required kit

*given

GP/OOH GP aware by telephone

District Nurse referral done and

phoned

Transport booked (State End of Life)

Syringe driver recharged just before

discharge

Emergency contact number of GP

and DN given

PRN medication given prior to

transfer if needed

Advise relatives that when the

patient dies they need to ring the GP

*A palliative care pack should

contain

** Emergency contact numbers of

GP/DN to be given to patient 6 x green and orange needles GP number Out of Hours is 111

2 x30 ml luer lock syringes District Nurse- Sheffield 01142266500

6 x2 ml syringes District Nurse -Doncaster- 01302566999

2 tegaderms District Nurse -Barnsley-01226644575

1 or 2 syringe driver lines District Nurse- Retford- 01777274422

1 or 2 yellow butterfly cannulas for Syringe

Driver

District Nurse- Chesterfield/Derbyshire- Ring

Own GP or 111

6 continence pads Intensive Home Nursing 01142716010

wipes

approx. 10 prs gloves

approx. 10 aprons

1 urine bottle/bed pan (unless ordered by

FDRT)

Slide sheet (unless ordered by FDRT)

3 packs of mouth swabs

small sharps box

2 yellow bags

ED doctor needs to call the OOH doctors on the ‘Health Professional number 3051412` (Strictly for Professional use only). OOHs GP can put the patient onto the `Adastra’ system for an urgent home visit and bring pre-emptive drugs if unable to get dispensed by pharmacy in hours