Improving end-of-life care at an adult acute hospital

The Clinical Governance Unit in an adult acute hospital reviewed the minutes of all the morbidity and mortality meetings from the previous year. The review noted that one-third of patients who died had been seen by the rapid response team once or more before they died and, that of these patients, 40% had a new treatment limitation put in place by the rapid response team. Ideally, treatment limitations for end-of-life care should be put in place by the admitting team, after discussion with the patient and family, to avoid unnecessary and potentially distressing interventions. 

The morbidity and mortality minutes review prompted the Clinical Governance Unit to review their policies in light of the National Consensus Statement: essential elements for safe and high-quality end of life care. This statement, and the NSQHS Standards, require health service organisations to measure and improve the quality of end-of-life care. The Clinical Governance Unit asked the Safety and Quality manager to lead this work. 

The Safety and Quality manager assembled a team with medical, nursing, palliative care, consumer, and rapid response team representatives. The team decided to use the End of life Care Audit Toolkit, because it allows comparison with similar services and the rest of the hospital network was already using it. The End-of-Life Care Audit Toolkit includes:

• Audit tool for data collection from patient records
• Clinician survey tool 
• Hospital demographic information survey tool for benchmarking
• Data dictionary
• Analysis advice with a plan and table templates
• Presentation template.

The team audited the records for 200 randomly selected patients who died on an inpatient ward more than 48 hours after admission. Patients on the mental health ward or maternity ward were excluded.

The results showed:

• 20% of patients had an advance care plan documenting their goals of care
• 53% of patients were seen by the rapid response team in the last 48 hours of life (most more than once) and 90% had interventions like blood tests performed during this time
• 40% of patients were referred to specialist palliative care services, but 32% were referred within 24 hours prior to death. 

All clinicians from the relevant wards were asked to complete the audit survey. Responses from 109 clinicians found that 68% had not had any training about end of life conversations, and 80% of clinicians thought they were able to identify patients nearing end-of-life.

The data highlighted minimal use of advance care planning, late recognition of dying and that triggers to recognise patients who may be at the end of life were not always acted on, resulting in unnecessary, and potentially distressing, interventions for dying patients. Clinicians’ overestimated their ability to identify dying patients.

When compared to similar wards in the network, results were not significantly different. However, the team identified these areas for improvement because they varied significantly from the guiding principals of the National Consensus Statement: essential elements for safe and high-quality end-of-life care.

The team thought likely reasons for the poor results included:

• Inconsistent recording and storage of advance care plans across services in the facility
• Inconsistent documentation of goals of care on comprehensive care plan
• Insufficient clinician training
• Lack of a specific trigger tool for identifying end of life.

The team met again with several departments to discuss potential improvements, resulting in the following changes being introduced over the subsequent three months:

• Use of disease-specific assessment tools for all admitted patients in three wards, to help identify end of life
• Asking all patients “what is important to you?” as part of admission processes to support goal setting and care planning 
• Promotion of online training for clinicians (End-of-life essentials) by the clinical governance unit and palliative care service
• An audit of comprehensive care plans to ensure they were being developed using a multidisciplinary process.

The team conducted a follow up end-of-life care audit six months later, finding:

• 42% of patients admitted to the facility had an advance care plan (increased from 20%)
• 24% of patients were seen by the rapid response team in the last 48 hours of life (most more than once) and 72% had interventions like blood tests performed during this time (down from 53% and 90%, respectively)
• 73% of clinical staff had completed selected online training modules
• The specialist palliative care service saw an increase in telephone consultation although there was not a significant increase in referral or transfer of care. 

The team considered the successes of the program and looked at measures to refine and share the learning across the network to encourage further improvement. They conducted regular audits of end of life care every six months and provided the results to the Clinical Governance Unit. 

The team introduced further initiatives to address needs identified in the regular audits. Assessing the quality of end-of-life care was also introduced as a regular item in mortality review meetings in the network to maintain the focus and sustain the improvements.