Abstract
Thinking about the future: a QI project to educate and improve the understanding of advance care planning in the AMU.
A Fisher; C Bruce; M Leyton; M Rainbow; J Evans
Acute Medical Unit; Torbay Hospital; Torbay and South Devon NHS Foundation Trust
Introduction:
Advance care planning (ACP) allows patients with serious illness or deteriorating health to discuss future care preferences, supporting a more holistic, patient-centred approach. However, public awareness of ACP remains low and is cited as a key barrier to its uptake in clinical practice.
A 2014 audit by the Royal College of Physicians revealed only 4% of 9000 hospital inpatients had any ACP documentation prior to admission. Lack of accessible information and insufficient training for health care professionals contributes to this gap, forming the focus of this quality improvement project (QIP).
Methods:
Using the Supportive and Palliative Care Indicators tool (SPICT), we identified 10-25 patients per cycle who were suitable for ACP conversations. Reviewing clinical notes, we assessed whether ACP conversations occurred and whether patients were given any signposting information. All data was recorded in Excel to track progress across cycles.
Interventions:
Our planned interventions included highlighting the project at daily AMU handover meetings, disseminating a high-quality leaflet with ACP information and signposting to locally and nationally endorsed resources, and use of ward posters to raise awareness of the project.
Results:
From this review, we were able to evidence that of 10 patients initially audited, 0% had any ACP conversations during their AMU admission, 0% were given any information on ACP, and 0% had any form of ACP subsequently completed during their AMU stay.
Following the planned interventions, 44% of 18 patients audited had ACP conversations during their AMU admission, 0% were given any information on ACP, and 39% had any form of ACP subsequently completed during their AMU stay.
Conclusions:
Our interventions improved rates of ACP conversations and documentation but highlighted the continued lack of information provision. For the next QIP cycle, we plan to provide targeted teaching sessions for AMU resident doctors with the aim of improving ACP engagement. Our hope is that this QIP sets the precedent for and is the catalyst of change.
Comments
Electronic patient record options
This is a great QI project highlighting lots of good work. Do you have an electronic patient record at your hospital? If so, is there a set clerking template with a compulsory advanced care planning section? I know a lot of hospitals have this for DNACPR/For CPR discussions. Also, was the signposting information easily available/already printed for patients? In my hospital there is always the challenge of printing out resources for patients especially on a busy acute medical unit
Thank you so much. We don't…
Thank you so much. We don't currently, but we're due to have electronic records coming next year so I'm hoping this can be part of the next step of improving engagement with ACP. I absolutely did my best to make sure the signposting information was readily available in every clinical area on our AMU but unfortunately it kept getting moved around so this was a reallyyy big challenge in our project. Lots to learn and improve for next time!
Identifying community ACPs
Interesting project. You have identified a clear need for ACP conversations using SPICT but these can be difficult on AMU.
Have you done any work to look at whether plans in place in the community are identified by the AMU staff when a patient is admitted?
Did you involve AMU consultants in your teaching sessions or was it just the residents? Our experience is that if Consultants see ACPs as important this feeds down to the residents.
No we haven't actually, but…
No we haven't actually, but that is a great suggestion. My feeling is that once our Trust starts utilising an electronic patient record we will find that these are a lot easier to locate and implement. Unfortunately oftentimes people come in without their ACP documents and it's not obvious that they have any - my hope is that electronic patient records will significantly reduce this issue. We only included resident doctors in our teaching sessions, but the next step in this project would certainly involve a greater involvement of the AMU consultants as I feel that senior buy in would improve engagement in ACP. Thank you for your comments!
Modelling by senior clinicians
Such an important piece of work. One of the themes that I noticed in the first morning education session yesterday was the importance of Consultant buy-in and subsequent modelling to resident trainees. Did you collect any data on those undertaking ACP conversations? Appreciate that it isn't always clearly documented in notes...
Thank you so much…
Thank you so much. Absolutely, I couldn't agree more - and that is something we were definitely missing in our project. We discussed undertaking a qualitative survey of doctors on AMU to establish barriers to ACP but we ran out of time to complete this. It's certainly something that could be carried forward in the next steps of the project.