Abstract
Background: Whilst working within the Older Person Medicine (OPM) department, we noted that there were many frail patients who were not having Advanced Care Plan (ACP) discussions. Our preliminary retrospective data collection showed that 39% of OPM inpatients died within a year of their admission. Patients with a Clinical Frailty Score (CFS) >/=7 or >2 admissions in the last year were at highest risk of this 1-year mortality.
Aim: Our quality improvement project aimed to highlight patients in which an ACP discussion may be appropriate and therefore improve the frequency of ACP discussions and their documentation, especially on the discharge summary for their General Practitioner (GP) and other Allied Health Professionals to access.
Methods: We developed a sticker which was placed in the medical notes of patients who met our inclusion criteria (CFS ≥ 7 and >2 admissions in last year) during a 2-week period in April/May 2024. This acted as a visual prompt to clinicians to consider ACPs and document if discussions had been initiated. It also prompted transcribing this information onto hospital discharge letters.
Results: Following our intervention, within 2 different clinical areas (OPM Same Day Emergency Care (SDEC) and an OPM inpatient ward), there was an 88% increase in the number of ACPs being completed for the appropriate patient cohort.
Conclusions: We expect that an increased number of appropriate ACPs being completed will result in reduced numbers of inappropriate hospital readmissions for patients who would be best managed in the community, including primary care. By more clinicians taking part in ACP discussions, we expect staff will feel more confident in having these conversations and subsequently ensure that the patient remains at the centre of all care, respecting their autonomy and involvement in shared decision making with regards to their health and advanced wishes.
Comments
Informative QIP
Having also just completed an ACP QIP I'm so pleased to see such a successful intervention! A sticker is a great idea, and something I will take forward in my own Trust. Well done!
Thank you very much, I hope…
A very important area and a…
A very important area and a good idea - I am pleased to see it had a positive impact. I'd be interested to know more about how it fitted into the escalation discussion protocol at your hospital
Our trust has separate…
Advanced care plans
Good idea to help prompt clinicians to have ACP discussions- helping to highlight patient priorities and wishes.
Does the ACP in your hospital have a prescribed framework/ template to work to in having these discussions?
Do you plan on re-auditing to see if there has been a sustained change in practice? Do you know if the details of the ACPs are being complied with in the community? e.g. not for readmission or not for invasive medical procedures.
Thank you for your comments…
Discharge letter documentation
Great project! Did you audit the documentation in the discharge letters before and after your interventions? I sometimes find that these discussions take place, but the discharge letters do not communicate the information to the GP and ambulance service, leading to inappropriate admissions in patients who have expressed a wish to remain at home.
Thank you for your comment…
Number of ACPs
Interesting project - we have previously used a prompt on our e-whiteboard to consider advance care planning. I have a few questions
Was the sticker just used for the 2 weeks or did it continue to be used afterwards? If so whose responsibility is it to add this to the notes?
When did you look at the number of patients with an ACP (for both the before and after group) and what numbers of patients had an ACP?
Do you know what % of the patients you identified by the sticker had an ACP (conversation or plan)?
And what % of your ward were identified by your criteria and had a sticker added to the notes?
Did you do any other education around ACPs or just use the sticker?
Thanks very much.