The Wales perspective of using an ICP for the last days of life. Dr Helen Mitchell Dr Marlise Poolman Ros Johnstone

Transcription

1 The Wales perspective of using an ICP for the last days of life Dr Helen Mitchell Dr Marlise Poolman Ros Johnstone

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4 Population reporting 'good' general health (Darker colours indicate better health) Wales local authorities, 2011

5 Population reporting 'good' general health (Darker colours indicate better health) English local authorities, 2011

6 UK Mortality Statistics Wales England Scotland NI UK Population estimate (millions) All deaths (ONS, GROS, NISRA, 2012) , ,829 54,937 14, ,024 Deaths from cancer (Cancer Research UK, 2011) 8, ,032 15,457 4, ,178

7 Health Boards in Wales

8 Number of deaths by Welsh health board Total deaths 31,502 Office of National Statistics, 2012

9 ICP for the Last Days of Life

10 Care pathways for the dying To transfer the hospice model of best practice to other settings a good death for ALL 1994: Liverpool care pathway developed by MCPCIL 2000: All Wales ICP for the last days of life launched across Wales A system for centrally collecting, analysing and feeding back outcomes from the ICP was implemented alongside the clinical use of the pathway.

11 ICP for the last days of life ,000 deaths in Wales Widespread use - all hospitals, all hospices and most community settings Recommended in NICE guidance Included in GMC guidance on decisions in End of Life Care (July 2010) Publications in peer reviewed journals

12 ICP changes made in 2012 Criteria for use strengthened: Reversible causes of deterioration have been excluded The patient and / or family are aware that the patient is in the last days of life The clinical team agree that the ICP is appropriate Patient priorities assessed & documented Hydration / nutritional needs reviewed if appropriate (and discussed with relatives) Suggested medication reviewed

13 A ll W a le s In te g r a te d C a r e P r io r itie s fo r th e L a s t D a y s o f L ife (IC P ) T h is m u lti-d is c ip lin a r y d o c u m e n t is p a r t o f th e c o n fid e n tia l c lin ic a l r e c o r d. T h e IC P D o c u m e n t is o n ly a g u id e to c a re fo r th e p a tie n t a n d th e ir fa m ily in th e la s t d a y s o f life. T h is IC P is b a s e d o n b e s t a c c e p te d p ra c tic e. E a c h p ro fe s s io n a l s h o u ld e x e rc is e th e ir p ro fe s s io n a l ju d g m e n t w h e n u s in g th is g u id a n c e. M e d ic a l & N u r s in g A s s e s s m e n ts s h o u ld b e c o m p le te d w h e n c a re is g u id e d b y IC P R is k a s s e s s m e n ts (p re s s u re a re a, p e rs o n a l c a re e tc.) c o n tin u e a s b e fo re O n g o in g r e v ie w (n u rs in g ) s h o u ld b e c o m p le te d 4 h o u r ly o r at e a c h v is it, u s in g a n e w s h e e t daily. V a r ia n c e o c c u rs if a n u n e x p e c te d e v e n t o c c u rs. A n y v a ria n c e s h o u ld b e re c o rd e d o n th e v a ria n c e s h e e t, If a b o x in ita lic s is tic k e d, e x p la in a c tio n /in a c tio n o n v a ria n c e s h e e t. N.B. A v a r ia n c e is n o t w r o n g, b u t it is im p o rta n t to re c o rd it, to h e lp w ith q u a lity and a u d it. M u lti-d is c ip lin a r y p r o g r e s s n o te s a llo w s c o p e to re c o rd a n y th in g n o t c o v e re d b y th e IC P. T h e s e n o te s s h o u ld re c o rd c o m m u n ic a tio n w ith th e p a tie n t a n d fa m ily. T h is d o c u m e n t re p la c e s th e m e d ic a l a n d n u rs in g n o te s d u rin g th is p e rio d o f c a re. T h e IC P s h o u ld o n ly b e u s e d w h e n th e fo llo w in g th re e c rite ria h a v e A L L b e e n fu lfille d : R e v e rs ib le c a u s e s o f d e te rio ra tio n h a v e b e e n e x c lu d e d T h e p a tie n t a n d /o r fa m ily a re a w a re th a t th e p a tie n t is in th e la s t d a y s o f life T h e c lin ic a l te a m a g re e th a t th e IC P is a p p ro p ria te

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15 Sites using the Wales ICP

16 The Variance Sheet Key component of any ICP Records a change to expected plan of care Feedback from Variance events informs the tool and can change practice Quality monitoring tool Supports audit Not WRONG just a variation from what was expected Atwal and Caldwell (2002): any deviation from the proposed standard of care listed in the pathway. The recording of variances gives staff a means to practice professional autonomy as it enables them to individualize care

17 Sites returning ICP Variance Sheets by Health Board Area Variances Returned April 2010 Variances Returned April 2011 Variances Returned April 2012 Variances Returned April 2013 Hywel Dda Health Board Cardiff & Vale University Health Board Betsi Cadwaladr University Health Board Aneurin Bevan Health Board Cwm Taf Health Board Abertawe Bro Morgannwg University Health Board Powys Teaching Health Board Total 2,494 3,217 3,738 3,828

18 % Reported Variances ICP Variance Analysis:All Sites, Pain, Agitation & Rattle April 2013 n= Pain Agitation Rattle Symptom Variances % Variance % No Variances

19 Bench-marking meetings Twice yearly 3 regional sites (North, Mid, South Wales) Project team and user participation Feedback on local performance Comparison to similar clinical settings Discussion / reflection on local issues Shared learning and future planning

20 % Reported Variances Bench-marking ICP Variance Analysis:Community North PAIN April %Goal Variance %Goal Achieved 0 NWM21C NWM15C NWM24C NWM25C NWM50DN NWM14C NWM48DN NWM49M POWYS Community North

21 % reported Variance POWYS SCA8COM SCA16COM SCA4COM SCA7COM SCA63CE GW5 GW2 GW4 GW3 SCA6COM GW1 Bench-marking ICP Variance Analysis: Community SOUTH &POWYS PAIN April %Goal Variance %Goal Achieved 25 0 Community SOUTH & Powys

22 ICP for the last days of life: Annual audit Annual audit cycle established in 2008 Audit provides additional information about how the tool is used to deliver end of life care. Documentation review to: ascertain completeness of record keeping within the ICP check most current ICP version is in use identify strengths and weaknesses, to target future training and education.

23 2013 Audit 51 sites using ICP in Wales asked to participate Each site to review 10 case notes where patient died on ICP. 61% response rate 31 sites across all 7 Welsh Health Boards 234 cases for review

24 Audit results 2013 % % Not No. Standard Achieved Achieved 1. Documentation Medical Measures Nursing Assessment Communication Daily review Religious/Spiritual Support Variance Reporting Variance Sheet Demographic Data PRN Medications Syringe Driver Charts Were the recommended drugs available 95 5

25 Audit results 2013 Compared to previous outcomes, improvement on most of the 11 goals Exception of Syringe Driver Charts Many sites use in-house documentation rather than the charts included in the ICP Record of Religious/Spiritual support has improved from 26% in 2012, to 64% in 2013 Variance reporting remains an issue. Training and education will be targeted accordingly

26 Action points Training and Education to target issues around variance reporting using the ICP independently from the main medical records record keeping in general: if it is not recorded, it did not happen completion of syringe driver charts Consider including All Wales medication charts with ICP documentation

27 Recent developments

28 Neuberger Enquiry / Report July recommendations regarding use of the Liverpool Care Pathway Main messages from Welsh viewpoint:- Communication with families poor Responsibility for care unclear Support lacking out of hours / for junior teams Rigid implementation of guidance (e.g. fluids) Need for individual / personalised care plans

29 ICP in Wales Current Strengths Concise documentation Discussion with family & carers is key Clinicians prompted to check appropriate actions taken eg fluids / other treatments Centrally led audit / feedback mechanism Devolved management and education delivery maintains local ownership

30 ICP in Wales Areas of potential concern Evidencing senior clinical responsibility consultant / GP sign off? Individualised / personal care delivery - how to demonstrate this Adequate audit and monitoring - variances under-reported Does the ICP actually improve quality? research needed to assess effect of ICP on quality of care delivered / received

31 ICP in Wales - Where now? Feedback from users and national leaders has informed future proposals:- Continue to use the ICP as a valuable tool Keep to current simple format Clarify senior clinician taking responsibility Strengthen communication between families and clinical teams

32 ICP in Wales - Where now? Review (re-name?) variance sheet Include individualised care plan Include other relevant data measures (preferred place of death documented?) Support discussion about starting the ICP with an information leaflet

33 ICP in Wales - Where now? Improve quality of local and national audit data Develop programme of research to assess impact of ICP on quality of end of life care

34 WCCPP research agenda To improve understanding and quality of variance reporting To seek alternative methods of ICP data collection (including qualitative and quantitative measures) To include the carer experience To evidence the effectiveness of the ICP in delivering end of life care

35 ICP in Wales - Conclusions Nationally agreed end of life care tool used in hospital, hospice and community settings Locally evolved to suit the different care environments throughout Wales Centralised system for the collection, analysis and return of variance sheets (29,700 reports to date) Annual audit cycle to monitor activity Systematic support and feedback to clinical teams.

36 ICP in Wales - Conclusions Recent LCP enquiry has triggered constructive critical review and highlighted need for renewed education Centrally led but locally delivered training supports ongoing use of ICP WCCPP team challenged to improve quality of data returns and evidence good care via future research activity

37 National web resource with updates on national projects and activities educational information and news link to All Wales ICP for last days of life clinical guidelines for symptom control

38 Further information Palliative Care in Wales Together for Health Delivering End of Life Care. A Delivery Plan up to 2016 for NHS Wales and its Partners Welsh Government 2013

39 Wales ICP for the Last Days of Life Dr Helen Mitchell Clinical Lead Dr Marlise Poolman Academic Lead Ros Johnstone Project Manager