Improving resuscitation decisions: a trust-wide initiative

Abstract

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.

Implementation of a weekend ceilings of care intervention in surgical inpatients at a District General Hospital

“…The intervention sticker provided a succinct and useful adjunct to patient notes which prompted surgical teams to consider the documentation of weekend plan and escalation status. This reflects evidence from other authors who state that escalation decisions are best planned by a patient’s daily consultant-led team 3–5. The majority of out-of-hours clinical deterioration may be potentially avoidable with adequate anticipation and planning 6.…”

Responding to the deteriorating patient: The rationale for treatment escalation plans

“…The TEP is used to 37 Patients with a TEP (n = 152) had a mean reduction in hospital admission costs of GB £220.29 compared to those without a TEP (n = 132) (p < 0.001). Reduced number of referrals to intensive care unit Fadel et al 14 The introduction of a TEP across regional hospitals resulted in a 12% reduction in ICU referrals Reduced likelihood of complaints by relatives following a hospital death Taylor et al 38 TEPs were used signficantly less frequently in complaint cases compared to matched controls (23.8% vs 47.2%, p = 0.01). Reduced number of complaints related to DNACPR orders Shermon et al 12 After 2 years of regular use of TEP, the number of complaints about DNACPR was reduced to zero in NHS Weston Area Health Patient satisfaction with discussion about goals of treatment/TEP Obolensky et al 39 34% of patients (n = 55) experienced some anxiety when the TEP was being discussed, but 96% of the same patient thought that the TEP process was a worthwhile exercise rationalise how a complex array of investigations and treatments is used, that is, appropriately rather than indiscriminately.…”

“…Many validated TEPs are now available. [14][15][16] Reinventing the wheel is rarely worth the effort although in some settings modifications are helpful. 17 The recorded details in a TEP include:…”

“…The test-of-change model for assessing the performance of a TEP can be complex. 3,[12][13][14][15][16] What to measure? Is the focus on process or on outcomes?…”

Reducing Futile Acute Care Services for Terminally Ill Patients With Cancer: The Dignity Project

“… 5 It has been recognized that the introduction of a standardized form for the documentation of GOCs can reduce the unnecessary mobilization of the code team and ineffective resuscitation attempts. 6 …”