Caring to the End

8/17/2019 Caring to the End

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Study aim

To explore remediable factors in theprocesses of care for patients who diedwithin 96 hours of admission to hospital.



Study objectives

Processes of referral from admission tobeing seen by first consultant

Handover and multidisciplinary team

woring

!evels of supervision

"ppropriateness of surgery andanaesthesia



Study objectives

#eneral clinical issues includingprophylaxis for venousthromboembolism and access toinvestigations including radiology

services

Paediatric practice

Palliative care in an acute setting



Study population

$st %ctober &''6 ( )$st *arch &''+

96 hours of admission

,xclusion -eonates under & days



*ethod and data overview



/ase ascertainment

-otified of all patients who died withinhospital during the study period

regardless of disease type or disorder



Sample Si0e

121,405 cases reported

44,807 died within 96 hours of admission

4571 cases included in the study

1 clinical questionnaire per consultant



1ata collection

2uestionnaires /linical

"naesthetic

%rganisational

/asenotes

"dvisors



1ata returns



1ata returns

Paediatric cases analysed separately

!059 clinical questionnaires

1442 admitted under a physician

1!54 admitted under a sur"eon

26! una#le to determine admittin" specialty

2225 casenotes

709 underwent a procedure



"ge and gender



,mergency admission



Health status on admission



%verall 3uality of care



Process of care



1elay between arrival and first assessment



4nitial assessment



1elays in initial assessment

%verall 5.6 7$)68&9+



/onsultant involvement in diagnosis

%verall 5+ 7$)658&99'



#rade of doctor maing diagnosis by time

Ti f d i i t



Time from admission tofirst consultant review

Ti f d i i t



Time from admission tofirst consultant review : paediatrics



/ommunication

%verall $).; 7&6+8$9)



<Hospital at -ight= teams

>sed in 6&.5 7$68&9 hospitals



?ey @indings

/onsultant involvement in diagnosisbecomes less fre3uent at night.

/linically important delays in &; of

first consultant reviews.

Poor communication between andwithin clinical teams coupled with poor

documentation.

1istrict hospitals may have particularproblems delivering a high standard ofcare when dealing with very sicchildren and it is recognised that a well



Aecommendations

Seniority of staff should be appropriate tothe clinical need of the patient.

Better systems of handover and betterdocumentation must be established.

Benefits and riss of reduced woringhours should be fully assessed and clinicalteams organised to ensure continuity of

care.



Surgery and anaesthesia



Surgery and anaesthesia

%f $);5 patients admitted under a

surgeonC almost half 765; did notundergo an operation



/lassification of urgency of procedure



/lassification of urgency and "S"

@ailure to recognise severity of illness and



@ailure to recognise severity of illness andavoiding operation

" teenager became neutropenic followingchemotherapy for a sarcoma. The patientwas admitted under the generalpaediatriciansC unwell and with soft tissueinfection over the chest wall. " paediatricspecialist registrar diagnosed cellulitis. Thepatient was reviewed by a surgical specialistregistrar who raised the possibility ofnecrotising fasciitis. There was no senior

surgical input and no action was taen. Thepatient deteriorated over the next $& hoursand died without further surgical review orintervention.




Un-operated necrotising fasciitis is fatal.In the view of the advisors earlyconsultant review and active treatmentmight have prevented the death of this patient.





" teenager was involved in a road trafficaccident. %n admission they had a#lasgow /oma Score 7#/S of $58$;. " /Tscan demonstrated a subduralhaematoma. "n emergency departmentspecialist registrar discussed the patientwith a neurosurgical SpA and a further /Twas ordered. Transfer was not accepteddespite deterioration in the patients #/S

to $&8$; over the next two hours.





@ollowing a further deterioration overanother hour to #/S 8$; the patient wasintubated and following further discussionwith a neurosurgical specialist registrar athird /T scan was ordered. 1uring the scanthe patients endotracheal tube becamebloced and the patient became hypoxicwhich lead to raised intracranial pressure.Thirty six hours later the patient was

declared brain dead and ventilationwithdrawn.





The advisors questioned whether withsenior involvement at an earlier stage,clear diagnosis and a decisivemanagement plan, could this patienthave undergone craniotomy and potentially avoided this outcome? Wasthis a case of over-enthusiastic “gateeeping! to protect scarce neurosurgicalresources?


/onsultant involvement in the



/onsultant involvement in thedecision to operate



/onsent



1elays between admission and surgery

%verall delays in $). 7;86$+

!ac of theatre time

1elay in consultant review

1elay in junior reaching diagnosis

@ailure to recognise seriousness of the

condition

@ailure by juniors to see consultant advice



#rade of staff in theatre



Supervision of trainees in theatre



"ppropriate grade of anaesthetist

#rade of anaesthetist by



#rade of anaesthetist byseverity of condition

d



Poor documentation

-o evidence of pre:operative anaesthetic

assessment in ;6.$ of cases7&)585$+

"naesthetic information was not

provided in 5).6 of cases 7998&&+

"dvisors were only able to assess in$685' cases whether supervision wasappropriate when a consultant was not alead anaesthetist.



Denous thromboembolism



Denous thromboembolismand surgical specialty

h d f h l



*ethod of prophylaxis

A i th



Aecurring themes

Poor communication.

!ac of multidisciplinary input.

Poor end of life care planning.

!ac of palliative care involvement.

A i th



4nade3uate consent

1eficiencies in diagnosis

1elay in assessment and treatment

Aecurring themes

A i th



Poor fluid and electrolyte management.

@ailure to recognise or managemalnourishment.

Poor documentation.

Aecurring themes

A i th



@ailure to adapt to healthcare status.

@ailure of audit and critical incident

reporting.

-eglect of 1DT and antibioticprophylaxis.

Aecurring themes

/ t d l



/ase study : general surgery

"n elderly "S" ) patient was re:admittedunder general surgeons from a residentialhome. The patient had recently beendischarged from a different team followingcare for abdominal pain associated with

nown diverticular diseaseE this had beenresolved with conservative management.%n this admission the patient complainedof right hypochondrial pain and tendernesswith a temperature of ).;F/. %vernight

the patient became hypotensive and wasgiven & litres of intravenous fluidsC but noantibiotics.

/ase study general surgery




"t '9G'' the next day on the consultantward round a diagnosis of peritonitis wasestablished and arrangements were madeto tae the patient to theatre forlaparotomy. HoweverC before a theatre

became available the patient suffered agastrointestinal bleed and died.

/ase study general surgery




The advisors noted that the autopsyshowed perforated diverticular diseaseand questioned whether there shouldhave "een a senior review earlier andwhether the patient should have "een

given intravenous anti"iotics.

/ase study orthopaedics



/ase study : orthopaedics

"n elderly patient was returned to a

general surgical ward following a hemi:arthroplasty for a fractured nec of femur.4n the immediate postoperative period $'litres of intravenous saline were

administered over $& hours. There was nosenior input to careC which was managedby an orthopaedic senior house officer whodid not see any advice. -o urinarycatheter had been placed and the fluidbalance charts were poorly completed. Thepatient died &' hours postoperatively. Thecause of death given on the deathcertificate was cardiac failureI.

/ase study orthopaedics



/ase study : orthopaedics

The advisors considered it inappropriatefor this patient to have "een sentdirectly to a general surgery ward. The patient would have "enefited from agreater degree of senior input and

interdisciplinary care with medicine forthe elderly.

?ey @indings



?ey @indings

There was a lac of involvement oftrainees in emergency surgery

There was poor communication

There was poor record eeping

There was poor decision maing andlac of senior input

Some aspects of basic care continue tobe neglected

Aecommendations



Aecommendations

Systems of communication between andwithin teams must improve.

Training of doctors and nurses must

place emphasis on basic sills ofmonitoring vital functionsC recognisingdeterioration and acting appropriately.

Aecommendations



Aecommendations

"ll trainees need to be appropriatelyexposed to the management ofemergency patients and theorganisation of services must addresstraining needs.



4nvestigations

,ssential investigations



,ssential investigations

%mission of investigations



%mission of investigations

1elays



1elays



Aadiology

Aadiology



&)+9 patients had radiological exam

6'; patients underwent no radiology

Aadiology

Aadiology and expectation of survival



Aadiology and expectation of survival

Aadiology and health status



Aadiology and health status

Aadiology use



Aadiology use

$5+$ patients not expected to survive onadmission $'+ had radiological investigation 7+)

6$' patients moribund on admission 5&6 had radiological investigation 769

"ppropriatenessJ

Patient care Aesource utilisation

Timing of radiology



Timing of radiology

"vailability of radiology




/T scanning and hospital type




@irst documented report



%ut of hours ( 6& v )

4n hours ( ;& v 5

@irst documented report

#rade of re3uesting doctor



#rade of re3uesting doctor

1id the results alter the managementJ



1id the results alter the managementJ

Provisional and final reports



Provisional and final reports

?ey @indings



$& patients did not have all essentialinvestigations performed.

; of patients had a delay in theirinvestigations being performed.

$&5$8&)) 7;).$ of initial radiological

investigations were performed out ofhours.

"ccess to /T scanning and *A4 scanningis a substantial problem with many sites

having no or limited 7K&5hours on siteprovision.

%nly $;'8&9+ hospitals have on siteangiography 7non:cardiac and of theseonly +6 have &5 hour access.

?ey @indings

Aecommendations



Hospitals which admit patients as anemergency must have access to plainradiology and /T scanning &5 hours perdayC with immediate reporting 7Thisrecommendation was previously reported

in <,mergency "dmissionsG " Lourney inthe Aight 1irectionJ= in &''+.

There should be robust mechanisms toensure communication of criticalC urgent or

unexpected radiological findings in linewith guidance issued by the Aoyal /ollegeof Aadiologists.

Aecommendations

Aecommendations



"ny difference between the provisional

and final radiology report should beclearly documented in the final report.

1iagnostic and interventional radiology

services should be ade3uately resourcedto support the &5 hour needs of their

clinicians and patients.

Aecommendations



,nd of life care

Bacground



g

M'.; million die a year in >?

*ajority of people who die do so in acutehospitals

M+; years of age from chronic illness

*ost would rather die at home

Nide range of people who care for the

dying

-eed for improvement in 3uality of care

http://www.endoflifecareforadults.nhs.uk/eolc

Bacground



g

Better community care

4mproving lins withspecialist ,!/ services

,nhancing education O

training

@urther developingPalliative /are Teams

Aesearch

"udit

Themes



,xpectation of survival and admission

process

1ecision maing on end of life care

pathways

,nd of life care documentation

>se of 1-"A

4nvolvement of Palliative /are Teams

Sills and training of healthcareprofessionals

2uality of end of life care management

Terminology



gy

,xpectation of survival on admissionG

not expected to survive for terminalcareI

mainly included patients with cancer.

not expected to survive but not terminalcareI the majority of these patients had end stage

non cancer disease for example pulmonaryCneurologicalC cardiac diseases and patientswith inoperable surgical pathology

,xpectation of survival



p

"pproximately ;' of admissions notexpected to survive

&5.+ should have had someconsideration for treatment limitations O,!/

-ecessity of admission



y

$&8&9$ 75.& of admissions unnecessary

%pinion of the advisors $&)8&'9' 7;.9 ofadmission was considered unnecessary

/ase study &'Q



"n elderly patient was admitted from

homeC unconsciousC to the ,1 in the early

hours of the morning following a 999 call

by a distressed relative. The patient was

receiving palliative care at home through

their #P for asbestosis and mesothelioma.There was a history of increasing shortness

of breath in the last &5 hours and they had

been waiting for the out of hours #P

service to attend the patient=s home. Thepatient died three hours after arrival$

y Q

/ase study



Why was this patient admitted to the

emergency department?

The advisors considered that there waslac of community support for this

patient and their family.

#etter arrangements should have "eenmade for out of hours home care.

y

"dmission



*ore medical patients admitted for not terminal carecompared to surgical patients

;58+&5 7+.; of patients who were not expected tosurviveC terminal careI were admitted to level ) units

9$8+)9 7$&.) of patients who were not expected to

survive not terminal careI were admitted to level ) units

1ecision maing



1elays in being seen by a consultant >nable to determine in )& 75+.+ in ,"

&; 7);8$;;) over all 7$6 in ,"

&& for those not expect to survive

1ecision maing



6;58&$) 7&).9 no discussion of treatment withdrawal

$6.9 7&$98$&9) not expected to survive

,nd of life care pathways



%nly )) 75+58$5)6 of patients expected to die

had an ,!/P 56.$ 7)&) 8+'$ of patients with nown

terminal disease had an ,!/P

&'.; 7$;$8+); of patients not terminal careIhad an ,!/P

1o -ot "ttempt Aesuscitation decisions



;; 7$&)$8&&&; of patients had a1-"A order

%f the patients not expected to survive

&9.; 7&98$'' did not have a 1-"Aorder

$5.6 7$;+8$'++ of 1-"A ordersnot discussed with patient or relative

#rade of doctor signing the 1-"A order



R %nly )'.; 7&$;8+'6 consultants signed 1-"A

R Dery junior doctors signed &$. 7$;58+'6

R >nable to answer or not answered in ;&+ cases

4nvolvement of palliative care team



%nly $&.; patients had involvement of

palliative care teams. Palliative care teams mainly involved with

terminal careI patients.

,ven so only involved in K ;' of these

patients.

/ase study &$Q



"n elderly patient was admitted via the ,1

with abdominal painC hypotension andhypothermia. "n abdominal ultrasound

revealed distended loops of bowelC ascites

and an enlarged liver. " /T scan showed a

large carcinoma.

The patient was admitted to an "> under

the surgeons and given 4D fluid

resuscitation. The first consultant surgeonreview was $ hours later.

/ase study &$Q



The patient remained hypotensive and

further intravenous fluids were given. "different consultant reviewed them a daylater and stated that there was a need todiscuss resuscitation status with relativesI." 1-"A order was made but there was no

documentary evidence of this discussion.The patient was transferred to a H1> due toa persistent metabolic acidosis. The patientremained hypotensive and becameprogressively hypoxic. They died six hourslater having had hourly observations andrepeated arterial blood gas analysis.

/ase study



What was the clinical management intentfor this patient?

The advisors considered that there was poor decision maing "y the surgical teamand any active management was liely to

"e futile. The most appropriate care for this patient

should have "een involvement of a palliative care team and commencementof an end of life care pathway.

$dmission to a level % care wasinappropriate and undignified in the lasthours of this patient&s life.

/ase study &&Q



" middle aged patient with advanced

carcinoma and bony secondaries wasadmitted following a #P referral via theemergency department complaining ofabdominal pain. The patient lived in a

warden controlled flat and was having dailyvisits from a community nurse. They werediagnosed as having cholecystitis andadmitted to a surgical ward.

/ase study &&Q



4ntravenous fluids and antibiotics were

commenced. The patient was notconsidered fit for surgery. " do not attemptresuscitation order was made in the casenotes following discussion with the patient

by a surgical senior house officer. Thepatient died two days later without furtherreview.

/ase study



The advisors were of the view that a palliative care team should "eeninvolved.

There was no '() pathway

This patient&s admission could have "eenavoided if there had "een "ettercommunication with community care.

Indeed admission to a hospice wouldhave "een the "est scenario for this patient.

Sills and training



The "udit /ommission found that only $ of

nurses and &9 of doctors stated that their pre:registration training covered end of life care.

However in the same study healthcare

professions were of the view that they were fairlyconfident in their abilities in identifyingC deliveringand communicating end of life care.

,vidence that this may not be true. !ac of sillsG

to identify patients approaching the end of life to implementation of ,!/ to communicate with patientsC relatives and

other healthcare professions.

End of Life Care. National Audit Office, London 2008

o!orrow"s #octors. $%C, 200& '( )*+.

/ase study &)Q



"n elderly patient with advanced lung

carcinoma was admitted under theoncologists in the early hours of themorning due to increasing shortness ofbreath and chest pain. The patient was seenby a medical registrar who prescribedintramuscular morphine $' mg 5 hourly anda 1-"A order was written in the notes.There was no documentation of any

discussions with the patient or relatives.

/ase study &)Q



Twelve hours after admission the patient

had received )' mg of morphine and wasdescribed as drowsy by the nursing staff.The patient was reviewed by a SH% whoprescribed intramuscular naloxone '.5 mgas re3uired.

"fter administration of naloxone the patientbecame agitatedC complained of increasingpain and died 5 hours later without beingseen by a consultant.

/ase study



The advisors considered that an '() pathway

should have "een commenced on admission. While the *+$ order was appropriate,

discussions with the patient and or their relativesshould have taen place and have "eendocumented.

The patient&s pain control management was very poorly managed and their last hours of life wouldhave "een unimagina"ly distressing.

There was clear lac of nowledge amongst thehealthcare staff. This patient should have had

palliative care team involvement at an early stagefollowing admission.

The advisors regarded that the lac of senior levelinput may have contri"uted to this patient&ssu"standard end of life care.

2uality of care



/ase study &6Q



" middle aged patient with nown

metastatic carcinoma was receivingpalliative care at home by their #P. %ver the&5 hours prior to admission the patientbecame increasingly short of breath andwas brought to the emergency departmentby a relative following discussion with the#P. " diagnosis of pneumonia was madeand initially the patient wanted activetreatment. They already had a 1-"A order

which was brought to the hospital with anadvance directive.

/ase study &6Q



The patient was seen by a palliative care

team within &5 hours of admission by whichtime his condition had deteriorated.@ollowing further discussion with the patientand their relativesC active treatment wasstopped and the patient were started on an,!/ pathway. The patient received goodanalgesia and was visited on three furtheroccasions by palliative care team beforetheir death &5 hours later.

/ase study



The advisors considered that the patient

had received good care with a highstandard of documentation.

There had "een good communicationwith the . There was early palliative

care team involvement which resultedin appropriate change in management.

This case study was viewed as ane/cellent e/ample of com"inedcommunity and hospital end of life care.

Paediatric end of life care



5;895 children not expected to survive on

admission 7&$ for terminal care

& had 1-"A orders

1iscussion on treatment limitations withfamily in 668++ cases

4n $& cases discussion also with child

Palliative care teams involved in 5 children

$$ cases reviewed at * O * meetings




" young child with complex needs including

microcephalyC asthmaC renal impairment wasadmitted with pneumonia. 1uring a previousadmissionC 6 months earlier including a stayon P4/>C the child=s parents had agreed thatit would not be in the child=s interests toundergo full resuscitation if they should

arrest. Ten hours after admissionC in the early hoursof the morningC the child deteriorated. Theparents re3uested that the child undergo fulltreatment including P4/> referralC which wasaccepted. The child arrested and died soonafter intubation despite prolonged efforts toresuscitate.




The consultant commented that it had

been difficult to discuss a care plan withthe child=s parents between admissions as the patient was not improving and gettingtowards the end of their lifeI. The

consultant felt that the parents were notready for discussions which might haveprepared them for the future.




The advisors stated that it wasunfortunate that no plan was in place

The fact that latterly there was lac ofrecognition of the need for senior inputinto the decision maing with this childwas a particular issue.

?ey @indings



59. of patientsC who died within 5 days ofadmission to acute hospitalsC were not expectedto survive and 6.+ of these were considered tohave received good practice

The advisors considered that ;.9 of patients

had an unnecessary admission to hospital andthis was due to a deficiency of social and medicalsupport in the community.

4n $6.9 7&$98$&9) of patients who were notexpected to survive on admission there was no

evidence of any discussion between thehealthcare team and either the patient orrelatives on treatment limitation.

?ey @indings



%f those patients not expected to survive on

admission in only a third were end of life carepathways used and )' did not have do notattempt resuscitation 71-"A orders.

4n &$. of cases 1-"A orders were signed byvery junior trainee doctors.

Palliative care teams were rarely involved in thecare of patients who died in this study.

There were examples of where healthcareprofessionals were judged not to have the sills

re3uired to care for patients nearing the end oftheir lives %ac& of a#ility to identify patients approachin" end of life 'nadequate implementation of (%) Poor communication with patients, relati*es + other

healthcare teams



1eath certification Oautopsies

/oronial involvement



4nformation on &99&8)$;) cases 79;

/oroner=s autopsy



+' cases $9 hospital autopsies

6&) no hospital autopsies

; unnown

>nexpected findings



/linicians : )68&&& cases

"dvisors : $'$8))' cases



Summary

Summary



"ppropriately trained doctors must seesic patients in a timely manner

The systems of care need to beoverhauled to ensure that emergencypatients get a uniformly high standard ofcare

Summary



/ommunicationC documentation andhandover must improve

/are of dying patients should be betterplanned and coordinated across socialCprimary and secondary health careenvironments



www.ncepod.org.uk

Caring to the End

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