Improving documentation of treatment escalation decisions in acute care

Dahill, Mark; Powter, Louise; Garland, Lynn; Mallett, Mark; Nolan, Jerry P.

doi:10.1136/bmjquality.u200617.w1077

Cited by 20 publications

(27 citation statements)

References 2 publications

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“… 32 42 47 Similarly, support from individual senior managers in ensuring compliance with training and interventions, promoting sustained use, as well as acting as catalysts for initial implementation was valuable. 32 35 42 46 47 49 Trust level managerial support was also evident through incorporation into policy and protocol 34 45 49–52 and approval from directors. 39 40 Managerial backing could be influential for organisational change, although in reality, engagement with the management of healthcare organisations was recognised by some for its complexity.…”

Section: Resultsmentioning

confidence: 99%

Implementing communication and decision-making interventions directed at goals of care: a theory-led scoping review

et al. 2017

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ObjectivesTo identify the factors that promote and inhibit the implementation of interventions that improve communication and decision-making directed at goals of care in the event of acute clinical deterioration.Design and methodsA scoping review was undertaken based on the methodological framework of Arksey and O’Malley for conducting this type of review. Searches were carried out in Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL) to identify peer-reviewed papers and in Google to identify grey literature. Searches were limited to those published in the English language from 2000 onwards. Inclusion and exclusion criteria were applied, and only papers that had a specific focus on implementation in practice were selected. Data extracted were treated as qualitative and subjected to directed content analysis. A theory-informed coding framework using Normalisation Process Theory (NPT) was applied to characterise and explain implementation processes.ResultsSearches identified 2619 citations, 43 of which met the inclusion criteria. Analysis generated six themes fundamental to successful implementation of goals of care interventions: (1) input into development; (2) key clinical proponents; (3) training and education; (4) intervention workability and functionality; (5) setting and context; and (6) perceived value and appraisal.ConclusionsA broad and diverse literature focusing on implementation of goals of care interventions was identified. Our review recognised these interventions as both complex and contentious in nature, making their incorporation into routine clinical practice dependent on a number of factors. Implementing such interventions presents challenges at individual, organisational and systems levels, which make them difficult to introduce and embed. We have identified a series of factors that influence successful implementation and our analysis has distilled key learning points, conceptualised as a set of propositions, we consider relevant to implementing other complex and contentious interventions.

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Section: Resultsmentioning

confidence: 99%

Implementing communication and decision-making interventions directed at goals of care: a theory-led scoping review

et al. 2017

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“…The broader, and vitally important, aim of the TEP is to allow both patients and doctors to explore the appropriateness of a wider range of treatment options and normalise these discussions 4. TEPs are essential in preventing unwanted or unnecessary treatment in patients, preserving autonomy when patients are unable to communicate and allowing doctors to make informed decisions in the patients’ best interest at the most difficult of times.…”

Section: Introductionmentioning

confidence: 99%

Improving the use of treatment escalation plans: a quality-improvement study

Sayma

Nowell

O’Connor

et al. 2018

Postgraduate Medical Journal

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“…There is another national project called the Recommended Summary Plan for Emergency Care and Treatment campaign which hopes to ensure that dialogue between patient and clinicians is central to decision-making and that resuscitation decisions should be considered in the context of overall treatment plans 7. TEPs have generally been shown to be helpful in improving documentation on treatment escalation decisions and prompting discussion with patients and relatives 8. A universal escalation planning form is yet to be established 9 10…”

Section: Introductionmentioning

confidence: 99%

Improving resuscitation decisions: a trust-wide initiative

Fadel

Parekh

Hayden³

et al. 2018

BMJ Open Qual

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IntroductionTreatment escalation plans (TEPs) are important to ensure that every patient has their ceiling of care discussed and documented formally. At Medway Foundation Trust, we introduced TEP forms in September 2016 which are to be completed by the relevant consultant within 24 hours of admission.Aims and methodsTo evaluate whether TEP forms had been effective at improving escalation planning and whether they had a subsequent impact in do not attempt cardiopulmonary resuscitation (DNACPR) decision-making. We carried out three plan-do-study-act cycles over a 2-year period across 100 patients in medicine and surgery.ResultsTEP forms were initially found in 66% (66/100) of the patient notes and 34% (34/100) were completed appropriately. There was a 13% relative improvement in resuscitation decision-making, since the introduction of the TEP forms from November 2015 to January 2017. There was also a 12% reduction in inappropriate referrals to critical care during the same period. We decided to revise the TEP form through extensive collaboration and educate all staff members about the importance of escalation planning. This has led to an improvement in TEP discussion and documentation across the entire trust.ConclusionTEPs can be an effective way of considering and communicating ceilings of care. They should encourage doctors to consider DNACPR decisions for patients who otherwise would not have been considered, and therefore may help reduce inappropriate referrals to critical care. The higher completion rates of the new form and increased clarity among staff regarding escalation planning should lead to an improvement in patient safety outcomes and communication between all patients and staff members. We believe it would be feasible to implement our user-friendly TEP form across other National Health Service organisations in order to develop a universal TEP form.

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Improving documentation of treatment escalation decisions in acute care

Cited by 20 publications

References 2 publications

Implementing communication and decision-making interventions directed at goals of care: a theory-led scoping review

Implementing communication and decision-making interventions directed at goals of care: a theory-led scoping review

Improving the use of treatment escalation plans: a quality-improvement study

Improving resuscitation decisions: a trust-wide initiative

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