Improving Timely Completion of Treatment Escalation Plans (TEPs) on a Care of the Elderly Rehabilitation Ward

Background:
Timely completion of Treatment Escalation Plans (TEPs) support appropriate clinical decision-making, ensure patients' wishes are respected, and help avoid inappropriate interventions. Delays in escalation planning may lead to unnecessary treatments or resuscitation attempts, particularly in older adults with frailty and multimorbidity who are at high risk of deterioration. This quality improvement project aimed to increase timely TEP completion, targeting 90% of patients having a documented TEP within 72 hours of admission.

Methods:
Between February and July 2026, three Plan-Do-Study-Act (PDSA) cycles were undertaken. Interventions included: (1) adding TEP status to the daily board round list; (2) delivering targeted educational sessions on TEP completion; and (3) displaying reminder posters across four geriatric wards. Data was collected retrospectively from electronic patient records.

Results:
Baseline audit showed that 70% (n=41) of patients admitted to the ward had a completed TEP. Among those without one, only 46% had a TEP completed within 72 hours, well below the target of 90%. Following the first PDSA cycle, TEP completion improved from 86% to 100%; however, on re-audit 72-hour completion fell from 66% to 50%, likely reflecting the impact of industrial action and a bank holiday period. Following the second PDSA cycle, audits of two Care of the Elderly wards demonstrated admission TEP completion rates of 58% and 62%, with only 37% and 35% of patients, respectively, having a TEP completed within 72 hours.

Conclusions:
TEP discussions remain challenging due to limited clinician confidence, time pressures, cognitive impairment and cultural expectations. This project highlighted the challenges of achieving sustained improvements and embedding a culture of proactive escalation planning. Education alone is unlikely to achieve lasting change without ongoing reinforcement, senior support, and integration into routine clinical workflows. This project led to the establishment of a Trust-wide Treatment Escalation Plan Quality Priority Working Group to support ongoing education, address implementation barriers, and drive sustained improvements in timely TEP completion.