Electronic Palliative Care Summary (ePCS) December 2009 Dr Peter Kiehlmann GP, Aberdeen & National...
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Transcript of Electronic Palliative Care Summary (ePCS) December 2009 Dr Peter Kiehlmann GP, Aberdeen & National...
electronic Palliative Care Summary (ePCS)
December 2009
Dr Peter KiehlmannGP, Aberdeen & National Clinical Lead
Palliative Care eHealth
http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/LivingandDyingWellhttp://www.ecs.scot.nhs.uk/epcs.html
Ann
43 yearsDiagnosed Breast cancer Dec Intensive investigationsPlanned surgeryCancelledRapid deterioration – liver, brain spreadDied after weekend 999 admission Feb
… daughter
“I feel that even when my mother was diagnosed with cancer that I was left to deal with it without professional help…”
“…although I argued and screamed at the hospital doctors they would not listen until it was too late….”
Improving experience?
No key GP- changes in practice Communication & coordination in secondary care Failure to recognise divide between
expectations and reality Impact of investigations Symptom control SEA Bereavement support
3 Steps in Gold Standards Framework
1. Identify
2. Assess
3. Plan
+ com
munic
ate
GSFS - Key Tasks - 7 Cs
C1 Communication
C2 Co-ordinator
C3 Control of Symptoms
C4 Continuity Out of Hours
C5 Continued Learning
C6 Carer Support
Cancer Register & Team Meetings, Pt info, Treatment cards, PHR
Key Person, Checklist
Assessment, body chart, SPC etc
Faxed Form
Learning about conditions on patients seen
Practical, emotional, bereavement, National Carer’s Strategy
C7 Care in dying phase
Reactive patient journey: in last months of life
• GP and DN ad hoc arrangements & no ACP in place - was PPoC discussed or anticipated? - what is pt/carer understanding of diagnosis /prognosis?• Problems of anxiety & symptom control • OOH Crisis call - no ACPor drugs available in the home• Admitted to and dies in hospital • Was Carer supported before/after loved one’s death?• Did OOH, PHCT or Hospital reflect on care given?• Was use of hospital bed appropriate?
GSFS Proactive pt journey: in last months of life
• On Pall Care Register - reviewed at PHCT meeting (C1)
• DS1500 and info given to pt + carer (home pack) (C1, C6)
• Regular support, visits phone calls - proactive (C1, C2) • Assessment of symptoms, partnership with SPC -
customised care to pt and carer needs (C3)
• Carer assessed incl psychosocial needs (C3, C6)
• Preferred Place of Care (PPoC) noted & organised (C1, C2)
• OOH form sent – care plan & drugs in home (C4)
• End of Life pathway/LCP/minimum protocol used (C7)
• Pt dies in their preferred place - bereavement support • Staff reflect-SEA, audit gaps improve care, learn (C5, C6)
Illness trajectories GP will have 20 pts die every year
Cancer
Dementiaand
decline
A
B
C
Organ
failure
Sudden death
Palliative Care for whom?
diagnosis of a progressive or life-limiting illness
critical events or significant deterioration during the disease trajectory indicating the need for a change in care and management
significant changes in patient or carer ability to ‘cope’ indicating the need for additional support
the ‘surprise question’ (clinicians would not be surprised if the patient were to die within the next 12 months)
onset of the end of life phase –‘diagnosing dying’
Place of death Scotland 1981-2006
Place of death. Scotland 1981 to 2006 Source GRO Scotland
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Home
NursingHomesetc.
Hospital
So by 2030…if current trends continue
home deaths will reduce by 42.3%
Less than one in 10 (9.6%) will die at home
increase in institutional deaths of 20.3%.
Choice-preferred/actual place of death Higginson I (2003) Priorities for End of Life Care in England Wales and Scotland National Council
Place: Home Hospital Hospice Care Home
Preference 56% 11% 24% 4%
Cancer 25% 47% 17% 12%
All causes 20% 56% 4% 20%
What stops people dying at home?
Susan Munroe, Marie Curie Cancer Care and Scott Murray, University of Edinburgh, & Scottish Partnership for Palliative Care 2005
Symptoms Carer Breakdown They don’t know
they can They don’t know
they are dying
Home situation Patient and family
wishes Lack of services Admitted by out of
hours doctor
Living and Dying Well
Living and Dying Well
•Assessment and Review of palliative and end of life care needs
•Planning and delivery of care for patients with palliative and end of life care needs
•Communication and Coordination
•Education, training and workforce development
•Implementation and future developments
Activities from Living and Dying Well
Board Delivery Plans Triggers and Assessment tools Palliative Care Registers Service Information Directories Community Nursing Care Homes Education champions Anticipatory Rx & Equipment DNA CPR Policy E-Health inc. ePCS 1st 6month review encouraging
ECS
New GP Contract GP not responsible 24/7 Risks to safe, effective care Patient info from GP computers -> ECS store twice daily Medication & Allergies 99.5% of GP Practices >5.4 million patients Explicit Consent to view ‘Read only’ available to… NHS24, A&E, AMAU, SAS
ePCS - What is it?
An electronic Palliative Care Summary An extension to Emergency Care Summary (ECS) & Gold Standards Framework Scotland (GSFS) For use both In Hours & OOH ePCS replaces current faxed communications Allows GPs & Nurses to record in one place
Diagnosis, Rx, Pt Understanding & Wishes, Anticipatory Care Plans, review dates, lists for meetings
ePCS Overview
OOH clinician ePCS display
ePCS update 1. During
consultation
2. Due to prescription
3. Team meeting or other contact
Audit
trail
ECSStore
NHS 24
A&E
Ambulance
TBD…
Practice Admin. Staff
PracticeServer
GP /DN
consultation
ePCS Dataset Consent - Palliative care data transfer Carer details and key professionals Diagnosis – as agreed by patient by pt & GP Current Rx –Rpt, 30/7 Acute, Allergies; Patient wishes
Preferred Place of Care [PPoC] )DNA CPR decision ) Anticipatory
Patient’s & Carer’s understanding of ) Care diagnosis/prognosis ) Plan
Just in Case – Rx & equipment ) Advice for OOH care )
GP Mobile no., death expected? Cert. etc )
EMIS - Summary
ePCS no diagnosis added yet
Diagnosis agreed with pt & added
Patient/Carer Wishes
GP View – Dr Brown DalmellingtonePCS on Gpass
•Live document•Easily updatable•Can be filled in by any member of team•Out of hours only need notified when initially commenced.
New ECS build screenshots
Access to PCS Information
Base ePCS –view in Adastra
Mobile ePCS - Adastra
Using ePCS in practice –a continuing process
Does this pt have Palliative Care Needs?Does this pt have Palliative Care Needs? Add to Pall Care Register, Add to Pall Care Register, Once Consents to send ePCS ->OOH,Once Consents to send ePCS ->OOH,
agree Medical History, set review dateagree Medical History, set review date Once consented any new info goes automaticallyOnce consented any new info goes automatically Not expected to complete in one go!Not expected to complete in one go! Complete pt wishes and Understanding, DNA CPR, record Complete pt wishes and Understanding, DNA CPR, record
“Just in case” Rx and Equipment as appropriate“Just in case” Rx and Equipment as appropriate Regular review at PHCTRegular review at PHCT Keep updating!Keep updating!
Palliative Care DES (1 of 26!)
1. Put pt on Palliative Care Register Clinical, Pt choice, Surprise Question From Prognostic Indicator Guidance
2. Make Anticipatory Care Plan – as ePCS
3. Send OOH form/ePCS within 2w
4. When dying use LCP /locally agreed pathway
Aim- encourage anticipatory care, for all diagnoses
When will it be available?
Pilots completed Aug 09 EMIS, Vision – Grampian, Gpass – A&A, Lothian
Issues addressed included acceptability & ease of use, improving the consultation & communication, anticipatory care planning,
NHS Lothian Rollout Sep 09 Vision more user-friendly late 09 Evaluation, national rollout late 09 Link with Board Leads for timings
Palliative Care, eHealth,OOH
ePCS – Benefits
Natural progression from GSFS & ECS Fits into day to day work of GPs & DNs Aims to identify patients “upstream” ie last 6-12 months, not just last days/weeks Encourages Anticipatory Care Planning Prompts to remind to ask about “difficult” issues
“Just in Case”, DNA CPR, PPoC Shares critical info. on vulnerable patients at important times. OOH & Secondary Care say it transforms care Patients & carers reassured Safer, better experience
Questions?
How best to roll out in your Board? Lothian Pall Care/Oncology Discharge letters Benefits to Sec Care EPS /ePCS
Meetings planned with key stakeholders eHealth Primary Care Palliative Care OOH
Living and Dying Well delivery 2010 Assessment Tools Anticipatory Care Plans Palliative Care DES ongoing Communication Training National Resuscitation Policy – DNA CPR “Public awareness Death, Dying & Bereavement”