Report out 1st July 2009

Palliative Care RIE Ward 3 Ninewells Hospital

Team Goals

• End of life patients will be appropriately managed in their preferred place of care wherever possible. This may be home, nursing home or hospice.

• Assure rapid implementation of discharge package.• Smooth transfer for patient from hospital to home / nursing home /

hospice.• Improve communication and collaboration between the multi-

disciplinary teams, and ensure equity of service provision.• Shared discharge plan between multi-disciplinary teams, patients and

carers.• Identify gaps in community services for patient who did not receive

their preferred choice.

Our approach

Patient –centred care

So there are no surprises for the patient or the family because they have been involved in care planning and

given choices about their care

Smooth transition between the agencies

The Boss

What changes did we make?• Assessment • Choice• Communication• 12 weeks

Driver diagram

Assessment

• Identifying patients in the palliative / end stage of disease

• Trialling tools• Triggers

Choice • Discussing with patients where they want to be cared for

• How they want to be cared for• Involving the Intensive Care at Home

Team for patient wishing to return home

• Flow charts developed for community nurses to standardise care

• Forward planning for equipment, medication that patient may need.

Communication • District Nurses activating the voicemail on their mobiles for urgent calls.

• Faxing the Gold Standard Palliative Care Summary Sheet to GPs, OOHs and OOH DNs.

• Patients going home with the original to put in their patient held record.

• District nurses visiting the day of discharge patient at end of life.

Eleven patients identified as being at end of life

• Preferred place of care discussed and documented:

• Home 6• Roxburgh House 2• Hospital 3

• Place of care achieved• Yes 10• 4 care continues in PPC• 4 died in PPC• 2 readmitted ( 1 new

medical event, 1 declined any additional care).

• No 1 • Patient died in the ward.

Changes in the patient journeyFinding out if we got it right

Following 3 patient journeys

1 hospital patient1nursing home patient1 patient returning home

Patient Staying in the Ward

• New diagnosis of lung cancer.. • Advanced disease - PPS 30%.• Roxburghe House discussed.• Rapid deterioration over weekend – family

expressed wish for patient to remain in ward in familiar environment with staff they knew.

Patient Returning Home• 87 year old lady, new diagnosis of lung cancer• PPS 50%/PPI 8.5• Expressed choice to be cared for at home, family

keen and lived with her• Intensive care at home for personal care and DNS for

support contacted• Barrier to discharge regarding assessment and supply

of appropriate equipment• Gold standard palliative care summary completed

and sent to primary care

Patient Returning to Nursing Home• 73yr old lady who was admitted from a nursing home 3

times in 10 days• Assessed as end stage COPD - PPS 50% PPI 6• Chose to go back to the nursing home for place of care as

that was her home.• Family were upset but supported her decision.• GSF summary sent to primary care and nursing home• Discharged home in palliative care ambulance with

anticipatory medication and her wishes communicated to the nursing home and GPs.

Differences in the Ward• Development of an end of life careplan for patients

choosing hospital for place of care• Raised the profile of generalist palliative care in the

acute setting• Staff becoming more confident in proactively

identifying, assessing and planning care for palliative care patients in their care

• All the nursing staff have found the tools helpful in managing palliative care patients

Differences in the Community• Agreed District Nursing standard of care response to patients.• Rapid Response mobile for OOH GP commenced at Christmas –

successful and now continues• Anticipatory Prescribing tested with Just in Case Boxes – successful

now been accepted for roll out by NHS Tayside Drugs and Therapeutics Committee.

• Gold Standard Framework Palliative Care Summary audited over Christmas in Primary Care and shown to help support patients at home – continues to be used by most practices

• Planning ahead campaign over Christmas in Primary Care using GSF standards of – co-ordination, care planning, communication, control of symptoms and carer support also helped support patients at home. – ONCE PATIENTS ARE CLEARLY IDENTIFIED

Where to next

• Advanced care planning to improve care for patient in the last few months of life who want to be at home eg– joint social/health packages of care for

patient of all ages • Sustainability

– Refining the package– Plan of spread– Resources both human and financial

• Further testing of palliative care prognostic indicators for non cancer patients– Predicting “end of life” for COPD

patients remains a challenge however PPI may offer us an indication of need

There are still some challenges ahead

What we have managed to achieve

AcknowledgementsHuge thanks to all the staff of ward 3 NinewellsPrimary Care Staff day and OOHThanks also to the RIE team members who gave up a week of their lives to come up with a planRoss International for guiding us through LEAN principals.Elaine Bruce and Jean Irvine for running with this from the day they commenced post – certainly the stars who have made this all possible.