Strategic Challenges in Urgent & Emergency Care...
Transcript of Strategic Challenges in Urgent & Emergency Care...
Strategic Challenges in Urgent &
Emergency Care: Supporting
Patients in their Last Months of Life
We interface with many other providers
SCAS Clinical Strategy
“Ambulance services need to work in
partnership with other community
health care and social care providers
to help deliver a consistent 24/7
urgent care service.
A Trusted Assessor working with
a Trusted Advisor
SCAS Accelerated Clinical Transformation
programme:
To accelerate the pace of planned change
Add clinical benefits for patients
Improve patient outcomes
Increase SCAS and partner provider efficiency
Generate new ideas using modern technology and joint
working with our partners, to support people in their own
homes
Test pilot concepts
Key Challenges To The Urgent Care
System Supporting Patients In Their Last
Months Of Life
Ambitions for Palliative and End of Life Care-
National Framework for Local Action published 2015
What We Know Now- Health care costs last year of life
About 1% of the population (approx half a million people) die each year
Although some deaths are unexpected, many more (approx.75%) can be predicted
30% of patients currently occupying a hospital bed will die in the next 12 months
80% of patients in care homes have a prognosis of less than 12 months
On average patients in last year of life have 3 or more unplanned hospital
admissions
Acute health costs increase significantly in the last days and weeks of life
EoLC and the Impact on the Urgent Care System
PATIENT
CRISIS SERVICES
GP
EMERGENCY DEPARTMENT
IN PATIENT ADMISSION With Rapid Discharge
DISCHARGE HOME
EARLY IDENTIFICATION
24/7 PALLIATIVE CARE SERVICE • Hospital Liaison • Specialist Palliative Care • 24/7 Phoneline / Visiting • Hospice at home
ADVANCE CARE PLAN • ReSPECT • DNACPR • Anticipatory Meds
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WALK IN CENTRES
AMBULANCE SERVICE
GP OUT OF HOURS
111
999
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TIMELY ELECTRONIC ACCESS OF CRISIS SERVICES TO EPaCCS AND 24/7 SUPPORT SERVICES CAN PREVENT UNNECESSARY IN PATIENT ADMISSIONS
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SCAS are the disruptors of pathways for people at end of life
The Story of Mrs Klein
Background:
• Mrs Klein was 93 years old when she died
• Mrs Klein had lived in her family home for 63 years
before going into residential care then nursing care.
• Mrs Klein was a frail lady. PMH – a number of strokes,
fractures to neck, collar bone, wrist and pelvis. Mrs Klein
had previously had bowel cancer and was deaf. Mrs
Klein moved from her home, when she was no longer
able to stand safely.
The Story of Mrs Klein
Care Plan
• had the following legal documents in place,
Advanced Directive setting out her wishes,
a DNACPR
Continuation of Care document.
• Mrs Klein’s son had Lasting Power of Attorney (health
and welfare)
• For many years Mrs Klein and her son had planned for
her dignified death, as set out in her Advance Directive.
• Nursing Home were aware of the Directive and held the
various documentation.
The Story of Mrs Klein
Final Journey
• Deteriorated over a four day period and the nursing home contacted
NHS 111 advising the patient was in respiratory distress. The triage
DX was an emergency ambulance. This was offered and accepted,
on 2 occasions by the nurse.
• A paramedic on an RRV arrived on scene and assessed Mrs
Klein. They determined that she should be conveyed to hospital,
even though she was a palliative patient
• No documentation was offered accept the DNACPR, however the
paramedic was informed that he should consult with Mrs Klein’s son
as he was LPA and there was a specific requirement that Mrs Klein
should remain at the nursing home.
The Story of Mrs Klein Final Journey(cont.)
• A back up ambulance was requested for conveyance. The ambulance was crewed by a Technician and an ECA.
• The Technician challenged the conveyance decision advising that Lisa was likely to ‘arrest’ when moved.
• The Technician attempted a number of times to speak with a Dr from the OOH service. Unfortunately a direct conversation with a Dr did not occur.
• The paramedic determined that Lisa should be moved ‘now’ and she was transferred to the stretcher and taken out to the ambulance.
The Story of Mrs Klein
Final Journey(cont.)
• Lisa’s breathing was supported, however her GCS continued to lower and she became unresponsive.
• The ECA provided comfort to Lisa and talked to her and held her hand when she passed away
• Lisa was conveyed to hospital.
• No interventions took place as SCAS were aware of the DNACPR.
• The Technician and ECA crew found the incident distressing and unnecessary.
The Story of Mrs Klein
Areas for Improvement
• SCAS failed to consult Lisa’s son prior to conveyance
• The nursing home failed to inform SCAS of the Advance
Directive (this had been in place for 17 years) which was
explicit setting out Lisa’s wishes
• The nursing home and SCAS failed to follow the
‘Continuation of Care’ plan which was explicit in ‘no
hospital treatment’ and ‘Not for Active Treatment’
• Lisa’s son informed the nursing home whilst the paramedic
was on scene, that his mother should not be conveyed, as
per her Advance Directive
Our journey so far; ACT 1 scene 1;
• 18 months ago
• Focused on face to face management:
– Support / develop decision making
– Empower staff and patients
– Suggests timeframes
– Improve data collection
• Red/ Amber on Gold standard pathway
• New mediums for bespoke Education material
• 24/7 direct access crucial
• Building relationships and trust takes time
• Feedback / support critical
Our journey so far - the enablers
ACT 1 scene 2;
• Directory of Services and Interoperability: working with
colleagues to improve access/sharing of records
Our journey so far; ACT 2 scene 1;
Patient with End of Life needs calling SCAS NHS 111 or
999 IN PATIENT
111 / 999 CONTACT
Senior Clinician Triage
Patient already has ACP on EPaCCS: Refer to and respect personalised choices
Patient does not have ACP: Identification if EoLC need in discussion with patient/carer
ASSESS NEED FOR SUPPORT
ACCESS COMMUNITY SUPPORT SERVICES TO PREVENT ADMISSION • OOH GP ASSESSMENT • 24/7 PALLIATIVE CARE SERVICE • RAPID RESPONSE NHS SPECIALIST CLINICAL COMMUNITY CARE • RAPID RESPONSE SOCIAL CARE • RAPID RESPONSE NHS COMMUNITY CARE – Intermediate care
ONGOING CARE AT
HOME
Hospice Care
Home Community
Hospital
REFER BACK for
GP follow up
Non Acute care Admission options 24/7
TIMELY ELECTRONIC ACCESS OF CRISIS
SERVICES TO EPaCCS AND 24/7 SUPPORT
SERVICES CAN PREVENT UNNECESSARY
IN PATIENT ADMISSIONS
EPaCCS updated
TIMELY ELECTRONIC ACCESS OF CRISIS SERVICES TO EPaCCS AND 24/7 SUPPORT SERVICES CAN PREVENT UNNECESSARY IN PATIENT ADMISSIONS
PATIENT
CRISIS SERVICES
GP
EMERGENCY DEPARTMENT
IN PATIENT ADMISSION With Rapid Discharge
DISCHARGE HOME
EARLY IDENTIFICATION
24/7 PALLIATIVE CARE SERVICE • Hospital Liaison • Specialist Palliative Care • 24/7 Phoneline / Visiting • Hospice at home
EPaCCS
ADVANCE CARE PLAN • ReSPECT • DNACPR • Anticipatory Meds
RAPID RESPONSE SOCIAL CARE COMMUNITY SUPPORT
RAPID RESPONSE NHS COMMUNITY CARE • Intermediate Care • Night Sitting • Falls • Occupational Therapy • Community IV Team
RAPID RESPONSE NHS COMMUNITY SPECIALIST CLINICAL CARE • Heart failure Team • Respiratory Team • Geriatrician • Palliative Care Nurse • District Nurse • Community Matron
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WALK IN CENTRES
AMBULANCE SERVICE
GP OUT OF HOURS
111
999
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Electronic Palliative Care Co-ordination Systems
The optimum Emergency and Urgent care pathway for people
at end of life
Any Questions?