Transcript Rapid Admission / Discharge of Palliative Patients.

Rapid Admission of Palliative
Patients.
Hospital Macmillan Specialist Palliative Care Nurse.
Lung Cancer Specialist Palliative Care Nurse.
September 2008
Problems Encountered
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Significant numbers of patients with advanced
malignant disease and a limited life
expectancy are admitted to the emergency
floor for various reasons.
Some of these patients will die within the
department and they may have expressed a
wish to die at home.
Problems Encountered
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A number of these patients are dying within
the department whilst waiting for a bed on a
ward.
The department does not have the
resources/training to administer palliative care
in the terminal phase of the patients illness.
Complaints received from relatives.
Problems Encountered
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Recognising that the patient is actually dying.
Issues around DNAR, syringe drivers, ICP
etc.
Investigating and acting upon patients wishes
regarding preferred place of care / death.
Poor communication between the Emergency
floor staff and the Cancer Care Teams.
How Can We Make Things Better?
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Working party with representatives from:
Specialist Nurses
Palliative care team
Pharmacy
District Nurses
Clinical case manager
Ward Manager
Emergency Floor Staff
What Issues Needed to be
Addressed?
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Education / training in the use of the ICP.
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Education / training in the use of syringe drivers.
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How are the Emergency floor staff going to identify
palliative patients suitable for fast tracking?
Continued
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When they are identified how are they going
to proceed?
What mechanism can be put in place to
improve communication between the
Emergency floor staff and the Specialist
Nurse and her Team?
Proposed Way Forward
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Specialist nurses Palliative care nurses both in
primary and secondary care will have access to the
“PURPLE ALERTCARD”
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This card will be issued to patients deemed to be
palliative who it is felt may at some time present to
the emergency floor.
The patient / carer will have been instructed to show
the card to the emergency floor staff who in turn will
either contact the key worker named on the card or if
out of hours follow the rapid admission / discharge
flow chart.
Example of Purple Alert Card
PALLIATIVE CARE ALERT CARD
My name is ____________________________
Date of birth ___________________________
Hospital Number _______________________
If I am admitted to hospital please contact
_____________________________________
Telephone number ______________________
If attending the Emergency Care Floor
At Wrightington Wigan & Leigh NHS Trust
Please present this card to a
member of staff
Purple Alert Card Pilot
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The pilot ran for 3 months from the 28th May.
Each member of the palliative care team were
given 5 alert cards each.
The emergency floor staff have all received
training and information regarding this pilot.
What Happens Now When the Patient is
Admitted to Emergency Floor?
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Patient is identified by alert card.
Patient then has a senior review.
If it is deemed that patient is dying then
preferred place of care is ascertained.
If the patient wants to die at home then
reversible causes should be treated and the
rapid discharge pathway used.
Continued
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If the patient is dying and needs admission
then the ICP should be started and the patient
fast tracked through the Emergency floor into
a bed.
Inform bed manager that the patient is dying
and in need of a priority bed on a ward.
Relevant Specialist Nurse and Palliative care
team member informed and involved.
Continued
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Acute admission/Oncological emergency.
Investigate and treat following Trust
guidelines.
All staff are aware that spinal cord
compression, hypercalcaemia and SVCO are
conditions needing urgent treatment.
Bed manager informed and made aware that
patient needs a priority bed.
Training Issues Resolved
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3 trained staff from the emergency floor were
identified to become palliative care link
nurses and attend the core themes in palliative
care.
24 staff identified to undertake the ‘train the
trainers’ course with regards to syringe
drivers.
ICP facilitator now delivering education
sessions to all shifts on the emergency floor.
Out of Hours
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Information packs containing all the relevant
paperwork regarding rapid
admission/discharge are available on all areas
on the emergency floor for both in and out of
hours.
All staff have been made aware that for out
of hours advice they should ring the hospice.
Why Did We Look at the Area of
Rapid Discharge of Palliative Patients?
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Hospital discharge group already in place.
Discharges in general were presenting some
concerns.
One of a number of issues raised by patients.
We were “asked” to look at this area as we
had identified it as a cause for concern.
What Did We Find?
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Palliative patients on acute wards who were within
their final hours / days of life and who had expressed
a wish to die at home were prevented from doing
this for several reasons.
Our Experiences Showed
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Staff unaware that discharge can in fact be expedited
in these circumstances.
No identified person to co-ordinate the discharge.
Delays in obtaining discharge medications.
Delays around Continuing Care.
No practical information for carers
Access to equipment.
Issues around syringe drivers, DNAR, ICP etc
Proposed Solutions
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Mechanism for informing specialised teams
that the patient is in hospital.
Identifying and documenting the patients
preferred place of care /death
Easy access to equipment.
Access to fast tracking of continuing care.
Rapid access to pharmacy.
Understandable information for carers.
Working Party
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Representatives of specialist nurses and
palliative care team.
Pharmacy representative.
District nurse.
Clinical case manager
Ward manager
Flow Chart for Rapid Discharge
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All patients should be on the ICP.
Relatives and district nurses aware of ICP.
Ensure ICP drugs are included on prescription
and on fast track route for pharmacy.
DNAR form to be completed and signed.
GP to be informed of pending discharge.
Supply continence / dressing products for first
24 hours.
Staff Responsibilities
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Although rapid discharge involves no extra
duties each person now has identified tasks
and responsibilities.
Update on Rapid Discharge
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The rapid discharge flow chart has now been
used on 16 occasions over the last 12 months.
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It is now being audited and the findings will
be presented at medical audit.
Thank You
Any Questions?