Improving compliance with Treatment Escalation Planning in Medicine of the Elderly (MOE) and Stroke.

Introduction - Treatment Escalation Planning (TEP) is an essential part of delivering person-centred care and is a key component of Realistic Medicine. A TEP can help to avoid unnecessary interventions, demonstrates respect for patient’s autonomy, and reduces uncertainty for both patients and staff who deliver their care. Our aim was to improve TEP compliance across MOE & Stroke in the Royal Infirmary of Edinburgh to >90% by June 2025.    

Methods - Data was collected from electronic records (5 patients per ward, per week) for a total of eight months. Data collected included: a) presence of a TEP,  b) documentation of: resuscitation status, c) goals of treatment, d) appropriate interventions and e) communication with patient/family.

Results - Data was collected from 385 patients, from October 2024 to May 2025. During this period five PDSA cycles were completed: PDSA 1 - TEP Leaflet, PSDA 2 – TEP Poster, PDSA 3 – Weekly TEP Champion appointed, PDSA 4 – Departmental TEP teaching and PDSA 5 –TEP Poster edited based on feedback from doctors. TEP compliance remained stable with a median of 100% since January 2023. Documentation of resuscitation status was most reliably documented with a median of 70% since October 2022. There were improvements in documentation of communication (median 55% to 74%) and goals of treatment (median 58% to 80%). The median for documentation of specific interventions remained stable at 58%.

Conclusion - Completion of TEPs in MOE and Stroke remains high, and recent PDSA cycles have demonstrated improvements in communication and documentation of goals of treatment. These interventions have improved the quality of TEPs. We would postulate that this is a reflection of shared decision-making and a shift towards more person-centred care. Next steps will aim to embed TEP conversations in routine clinical practice for all patients who are frail, co-morbid and at risk of deterioration.