Increasing the use of "Treatment Escalation Plan" Proformas in Acute Admissions - QIP

Introduction:  

A Treatment Escalation Plan (TEP) is used to guide the level of appropriate care for patients at risk of deterioration. The aim is to prevent iatrogenic harm by reducing inappropriate investigations and treatments. Benefits of early escalation discussions are well-documented and TEPs are gold standard in the SIGN 167 guideline. Additionally, clarification of care escalation is undeniably beneficial for out-of-hours teams who may unnecessarily investigate and overtreat. 

The aim of this audit was to 1) identify barriers to TEP decisions on admission to AMU, and 2) increase the completion of TEP proformas.  

Methods:  

Data was taken from AMU at 08:00 on 7 dates from January-June 2025. Patients at risk of deterioration were identified by NEWS parameters; scoring ≥ 5 or ≥ 3 in one category. Baseline data was collated and a survey highlighted barriers to TEP documentation. Three PDSA cycles were implemented; delivering a teaching session on the importance of TEPs; poster distribution in clinical areas; and TEP champion sticker incentives.  

Results:  

Initially, 22% of high-risk patients had a TEP, this increased to 33% and 50% after the  sticker incentive and teaching session respectively but decreased to 11% after poster circulation. Notably, for the same patient cohort, CPR decisions were better documented in 2 of 3 cycles.  

Conclusions: 

Ultimately, the percentage of TEP forms completed remained low and inconsistent. Variability of AMU patient cohorts, and difficulties with staff continuity presented limitations to the study. Discussions highlighted the nuances of TEP decisions and difficulties in ensuring safe and appropriate implementation.  Barriers to TEP decisions included; clinical acuity and time pressures; lack of confidence in having TEP discussions; and availability of NOK.  

Moving forwards, all members of the MDT should feel empowered to advocate for TEP discussions, and for patients at higher risk of deterioration, considering care escalation should be prioritised.