Transcript xxxx - Amazon Web Services
The AMBER care bundle for patients whose recovery is uncertain
Susanna Shouls
, Irene Carey,
Adrian Hopper
AMBER care bundle design team Guy’s and St Thomas’ Foundation Trust April 2014 International Forum
Contributors
Anita Hayes, Transforming End of Life Care in Acute Hospitals Programme, NHS Improving Quality Peter Kennedy, Cliff Hughes, Bernadette King and Amanda Walker Commission for Clinical Excellence, New South Wales, Australia
Case-note review (14/20 consecutive deaths) (adapted 2x2 matrix review)
• Focus on treatment • Many patients likely to die
while ongoing active medical therapy
• Decision making/ escalation planning, patient/carer involvement inconsistent • Communication flows within (between staff) and between organisations Source: GSTFT, 2010 3
Care bundles and reliability
A care bundle: - 4/5 components - Can be rapidly answered yes/no - Based on good evidence or self evident good practice All or nothing Locally implemented / quality controlled Resar R, Griffin F, Haraden C, et al. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement 2012. ( www.ihi.org
)
5
6
A standardised approach to individualised care
Why focus on hospitals?
• 52% of people die in hospital in England • More likely to be in inpatient in the last year of life than any other time in adult life • Census study of 25 hospitals in Scotland of inpatients (2014) – 28.2% died within 1 year – 16.2% within 3 months 9 – http://pmj.sagepub.com/content/early/2014/03/17/0269216314526443.a
bstract – http://www.endoflifecare-intelligence.org.uk/home
Proxy measure of quality of care : death in usual place of residence
About 80% of those who had expressed a preference stated their own home was their preferred place to die but only half of these actually died at home (49%). In England, hospital is the most common place of death (52%).
VOICES survey, 2012. Published 2013. Office for National Statistics.
11
“Uncertain recovery”
Transforming End of Life Care in Acute Hospital National Programme: creating the receptive context for change at the level of the microsystem WARD IS THE MICROSYSTEM OF FOCUS PULL NOT PUSH FOR CHANGE INTERVENTION AT EVERY LEVEL HOSPITAL LEVEL STRATEGIC CAPABILITY KEY ENABLERS
Transforming End of Life Care in Acute Hospitals programme 3 MODULES
Getting Started End of Life Care Pathway Steps 1 - 6 How to sustain
‘HOW TO’ ENABLERS
Advance care planning Care for patients whose recovery is uncertain and are at risk of dying in 1-2 months -
AMBER care bundle
Electronic palliative care coordination systems (EPaCCS) Rapid Discharge Home Care of the dying patient individualised last days of life care plans
METRICS
Organisational Ward Spread at Feb 2013 x 71 Trusts across England
Jun 10 Launch Sep 11 How to guide Feb 2012 Regional workshops: cascade. East Midlands SHA: feasibility study Early
intervention package
, resources + 2 x workshop design, monthly calls Development of a faculty and regional support.
15 Australia … 8 hospitals New South Wales
16
Implementation package
• Board sign up • Standardised implementation – Clinical leadership (palliative care ++) – Workshop, materials, minimum data set – Network support • Ward by ward with clinical facilitation
How many patients may be suitable for the AMBER care bundle?
Retrospective review of deceased patient records, excludes critical care
Source: Baseline audit AMBER network. 2013 England N=212, 10 hospitals Australia 70%
Initial findings: improved processes
N= 154, 10 hospitals N= 96, 3 hospitals N= 154, 9 hospitals N= 105, 4 hospitals 18 Source: Baseline and follow-up audit AMBER network. 2013 18
Overall outcome: eg from a network hospital
35% 30% 25% 20% 15% 10% 5% 0% Patient died care supported by the AMBER care bundle Patient died supported with last days / hours of life care Patient discharged Patient recovered Patient transferred to ward where tool not yet implemented 46% patients died 39% discharged N=555, Sep 2012-Oct 2013 19 Hospital collected 100% data for patients receiving care supported by the care bundle
Patient, relative feedback
It was difficult to hear but I knew wasn’t feeling better, I know now what's happening to me
Source: AMBER network hospital trust, 2013
Knowing that he may not recover – (we just thought he would) earlier allowed us time to talk about what would happen to the house, and bank accounts. Which was important because at the end he couldn’t talk to me anymore
21
Staff feedback
I didn’t think the patient would deteriorate so quickly.
I am glad I was able to talk to the relatives and prepare them for what may happen. When I mention to a doctor that I think a patient’s recovery is uncertain and may be suitable for AMBER the doctor listens and revaluates the patients medical plan.
Patients who are discharged
30d emergency readmission rates
Before implementation 43% (n=40, 6 hospitals, patients suitable) After implementation 11% (n=25, 3 hospitals, patients received care supported by AMBER care bundle) 22 Source: AMBER care bundle design team, GSTFT June 2013
Rapid adoption: all teach all learn model
2014 2x countries 40 hospitals 2012 18 hospitals 3 pilots 2010 1
?Social movement
Connects to real clinical experience Expectation of peer support Ownership & emergent clinical leadership Community of practice
Standard programme & implementation Local pace
Set by hospitals
Challenges and opportunities
Unintended consequences Implementation
Benefits and impact
Intervention Neuberger review Evaluation and evidence Context 24
"I don't think we should tell them what we're going to do in advance. Let them think. Worry. Wonder. Uncertainty is the most chilling thing of all."
Vernon A. Walter A former United States army officer and diplomat.
26
www.ambercarebundle.org
AMBER care bundle design team
Dr Irene Carey Dr Adrian Hopper Michelle Morris Susanna Shouls Helen Thurkettle
NHS Improving Quality / NHS England
Anita Hayes Dr Bee Wee
Clinical Excellence Commission, NSW Australia
Amanda Walker Bernadette King
AMBER network hospitals and the AMBER faculty