Treatment escalation plans

Introduction

Treatment escalation plans (TEP) guide level of life sustaining therapeutic interventions that should occur for each patient admitted to hospital and can prevent inappropriate and undignified interventions. However, implementation of TEP in routine clinical practise has been ad hoc partly due to the paucity of literature on their benefits. Our aim was to systematically review the literature to ascertain the use and benefits of TEP in adults.

Methods

A systematic search for studies reporting TEP use were performed in the databases OVID Medline, Embase, Scopus and Web of Science. Search terms were ‘Treatment Escalation Plan’ Treatment Limitation, ‘Therapy Escalation’, ‘Escalation of Care’, ‘Palliative’, End of Life’, ‘Advanced Care Plan’. Exclusion criteria included studies prior to 2007, systematic reviews, case reports and letters.

Results

468 records were retrieved, 117 duplicates removed, 351 records were screened. 302 were excluded by date or relevance. Of 49 eligible records, 39 were excluded by criteria or unavailability of full text articles. 10 Studies using case control and quality improvement methodology conducted between 2010-2022 involving 1614 patients were subject to a narrative review. 8 different TEP proformas were used. All studies reported an increase in TEP use across all clinical settings and after each PDSA intervention ranging from 78%-100%. TEP reduced the frequency of non-beneficial interventions and was associated with an average saving of £220 per patient.

Conclusions

TEP lead to more frequent and proactive discussions with patients on ceilings of care and provide clear guidance to clinical staff out of hours, facilitate patient handover over successive shifts and enable proactive discussions with critical care. We identified the need for TEP to be successfully implemented in a unified manner across all healthcare facilities in order to improve patient care, reduce the burden of non-beneficial interventions and align with the NHS Long Term Plan.

Introduction: Treatment Escalation Plans (TEPs) are helpful tools that reduce un-necessary treatment burden, improve patient experience and follow the principles of realistic medicine. This is relevant in orthopaedics where a high percentage of the patients are frail, co-morbid, and would benefit from clear and realistic care plans. We aim to improve TEP completion to >50% of orthopaedic patients, over the age of 65yrs old, in three trauma wards at the Royal Infirmary of Edinburgh by August 2023.

Methods: We sampled three patient notes on each ward twice weekly from May – August 2023, noting whether TEPs were present, if it was consultant endorsed or provisional, and what key sections were completed (resuscitation, treatment goals and communication). To be included, the patient had to ≥65 and under orthopaedics. Process mapping demonstrated 2 key targets- admission clerk-in and registrar review. PDSA 1 involved creating a prompt for documenting TEPs on FY1 clerk-in which was added to the admission proforma folder and displayed as posters. PDSA 2 was a teaching session designed for orthopaedic registrars and other team members about TEP conversations.

Results: Pre-intervention data, demonstrated a median of 28% of orthopaedic patients ≥65yo have a TEP. Of the completed TEPs: 88% solely consisted of a resuscitation decision; 33% had treatment goals, 33% communication; and 0% of TEPs were endorsed. After PDSA 2; median TEP completion increased to 33%. Of the completed TEPs; none had only a resus decision, 100% have treatment goals; 100% communication, and 83% are endorsed.

Conclusions: Our studies have demonstrated that education and proforma changes have increased TEP documentation rate, although not to our projected target. However importantly, the percentage of TEPs that contain goals, document communication and consultant endorsement has improved significantly. This project is ongoing with with planned further PDSA cycles.

Introduction:

East Lothian Community Hospital (ELCH) comprises of 95 medical beds for older patients undergoing rehabilitation following acute admission or discharge planning. Ideally, transfers from acute hospitals should have Treatment Escalation Plans (TEPs) in place, however only 67% of patients had a TEP documented electronically within three days of ELCH admission. Overnight and weekend cover is provided through nurse practitioners or Hospital at Night (off-site), therefore documented individualised plans by senior decision makers in the event of clinical deterioration is vital.

Objective:

95% of patients admitted to ELCH would have a provisional TEP documented electronically within 72 hours of admission by February 2023.

Methods:

Using quality improvement methodology, two Plan-Do-Study-Act cycles were completed. Firstly, a questionnaire was sent to junior doctors and nurse practitioners responsible for admitting patients to understand barriers to completing TEPs. Data was collected from electronic records on admission date, first documentation of provisional TEP (by a junior doctor or nurse practitioner) and admitting ward. The first cycle of change focused on increased awareness through posters reminding clinicians to consider TEP on admission. The second cycle of change involved two education sessions, highlighting the importance of TEP and how to approach difficult conversations.

Results:

28.5% of junior clinicians did not feel comfortable discussing TEPs on admission, with barriers being time constraints, level of responsibility and concern about making incorrect decisions. The first cycle (increased awareness) showed an improvement in documented provisional TEPs within 72 hours of admission from 67% to 79%. The second cycle (two education sessions) saw a further improvement to 94%.

Conclusions:

Basic interventions to increase awareness and education to address concerns surrounding TEP discussions were very effective. Future cycles are planned with new junior doctors to sustain the improvement. Next steps are to clarify the role of other medical practitioners in completing provisional TEPs.