One Record, Shared Decisions: Improving Communication of Treatment Escalation Plans Across Care Settings

Introduction
Treatment Escalation Plans (TEPs) and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions are important components of person-centred care, particularly for people with complex and potentially deteriorating illness. The Pan-London Universal Care Plan (UCP) is a shared digital care plan supporting communication of patients' wishes, preferences and treatment escalation decisions across health and care settings. At Whittington Health NHS Trust, baseline audit identified gaps between escalation decisions documented during hospital admission and their availability on the UCP. This quality improvement project aimed to improve communication and continuity of treatment escalation decisions across care settings.

Method
A baseline audit assessed: (1) whether an existing DNACPR decision was documented on the UCP prior to admission; (2) whether a new DNACPR decision was made during admission; and (3) whether the UCP was subsequently updated. Documentation review and stakeholder engagement identified barriers to information transfer and informed a multifaceted intervention. This included redesign of the TEP section within post-take ward-round documentation, staff education and communication, supporting guidance, prompts to consider UCP documentation during DNACPR discussions, and revised discharge summary wording. Medical and nursing staff were surveyed after implementation.

Results
Of 35 patients assessed for pre-existing DNACPR documentation, 7 (20%) had a DNACPR decision documented on the UCP prior to admission. During admission, 21/37 patients (57%) had a new DNACPR decision. Of the 13 new decisions where the UCP could be checked, none (0%) had a documented UCP update. Key barriers were uncertainty about responsibility for UCP updates, difficulty accessing existing care plans and competing workflow pressures. In the post-implementation staff survey (n=22), 7/10 doctors and 4/9 nurses found the new TEP options unclear, particularly around ward-based ceilings of care, and the TEP options were revised in response. The post-intervention audit is ongoing.

Conclusion
Baseline findings identified a patient-safety gap between treatment escalation decisions made during acute hospital care and their availability within a shared care-planning system. Documentation redesign, education and workflow prompts were implemented, and staff feedback has already shaped a second iteration of the TEP options. The second audit cycle will assess the impact on UCP documentation.