The BMJ Awards 2018: Palliative and Hospice Care Team of the YearBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1669 (Published 16 April 2018) Cite this as: BMJ 2018;361:k1669
- Nigel Hawkes, freelance journalist, London, UK
Applying quality improvement methods in hospice
At Woodgrange Day Centre, part of St Luke’s Hospice in Harrow, north west London, “we’d always done as we’d always done,” says Charles Daniels, medical director. It’s a claim perhaps too many in healthcare could make, and at St Luke’s it wasn’t felt to be good enough. “Actually, we were frustrated because we’d have liked to do things better,” he says. “But the first step was recognising that something needed doing.”
With support from north west London CLAHRC (Collaborations for Leadership in Applied Health Research and Care) they set about systematically looking at what they did and how it could be done better. The centre sees about 60 patients a week and involved some of them in a public engagement event, which identified speed of access to the centre as a concern. “Once they were in, they got wonderful care,” he says, “but the admission process was taking too long.”
Looking at how this might be improved was, he says, the eureka moment for staff. They had feared that change would mean more work, but by focusing on dividing the task up and evaluating each small change successively, they gained ownership of the process.
Duplication of effort was eliminated, systems were changed, and the time to access was halved, from 20 to 10.5 days. The improvement has been sustained, and with patient input staff are now looking at other things they can improve, such as fewer internal doors blocking wheelchair users and better information before arrival. Just because a service is good doesn’t mean it can’t be better.
Integrated clinic service
Early involvement of palliative care experts in the treatment of cancer patients is recognised as a good thing yet is seldom achieved. Most patients are referred late, an average of only a month or so before their deaths, reinforcing the view of palliative care as being what happens when curative options are exhausted.
History helped Cornwall to pioneer a different path. “Before we had our own cancer unit, patients were treated at Plymouth,” says Carolyn Campbell, consultant in palliative medicine at Cornwall Hospice Care. “It wasn’t ideal, as it was a long way to travel. This meant that palliative care doctors, who were on the spot, were more likely to be involved early with patients.”
So when a cancer unit was established in Truro, joint working was more easily established, through integrated clinics in which the transitions between oncology and palliative care are seamless. “A lot of centres run parallel clinics, but it still needs a referral to move from one to the other,” she says. “We’ve taken that barrier out. If a patient is having a bad time, say with pain from breast cancer, she can be seen quickly, often straight away or in the next few days.”
The result has been earlier access for patients, 80% of whom are still receiving oncological treatment at the time of their first palliative care consultation. “A lot of patients find the idea of palliative care quite frightening, but we reassure them that it’s no big scary thing and there’s no assumption that they’re dying. There has been a huge impact on the place of death—we’re more than halving the deaths in hospital through a combination of good symptom control and taking the fear out of it.”
Supportive care in cirrhosis
Patients with end stage liver disease often do not access palliative care until the very end, often the last 24 hours of life, says Fiona Finlay, consultant in palliative medicine at Queen Elizabeth University Hospital in Glasgow. A retrospective analysis of the case notes of 77 patients who died of the condition at the hospital over 12 months (August 2015-August 2016) showed that despite advanced disease, a poor prognosis, and regular admissions, only 19% were ever referred to the palliative care team, with a median time between referral and death of 6.5 days.
“There are lots of reasons why,” she says. “Patients with end stage liver disease often have chaotic lifestyles and alcohol misuse. They don’t tend to access healthcare of any kind except when they come in unwell. So conversations don’t happen until close to death.”
At Queen Elizabeth, many changes were made. Palliative medicine consultants joined the teams responsible for care, ensuring appropriate referrals were made. All patients had a comprehensive review, including checking they were getting the state benefits to which they were entitled. Discharges were planned in advance, and escalation plans drawn up in case the patient should deteriorate.
Referrals increased, as did median time from referral to death, from 6.5 to 26 days, in the pilot ward where the initiative was launched. “There was a culture change,” she says. “The gastro team was very receptive, staff feedback has been positive, and patients are also supportive once it’s been explained to them that palliative care doesn’t necessarily mean they’re dying.”
Purple butterfly project
Providing consistent, high quality care at the end of life in a huge hospital is demanding, says Clare Kendall, consultant in palliative care medicine at North Bristol NHS Trust, which provides end-of-life care to 1700 patients a year. “The specialist palliative care team is involved with 40% of these deaths, but we can’t expect to see every patient who’s dying,” she says.
The trust had used a version of the Liverpool Care Pathway but was not totally happy with it: “It seemed formulaic,” she says. After the pathway was withdrawn the trust moved to more individual planning of care but that, too, had failings. A successful bid to the Point of Care Foundation gained the funds for a new, more wide ranging effort.
Starting in one ward, a team redesigned the paperwork, introduced systems for measuring quality of care, and used door stickers depicting a purple butterfly to indicate patients receiving end-of-life care. “Three quarters of our patients are in single rooms, which helped a lot,” she says. “Why a butterfly? We needed something culturally sensitive and thought of flowers, but particular flowers mean different things to different cultures. Butterflies seemed a good choice.”
Any fears that signposting the end of life so obviously would offend patients or relatives were misplaced, she says. “It was very well received. Of course, we don’t put the stickers up until patients and families understand what it’s about—that patients at the end of life will be spared pointless interruptions, for example, and given the best possible care.”
Results show much better staff confidence, better adherence to medication, and better documentation. Buoyed by many letters of thanks from bereaved relatives, the plan went trust-wide early in April.
Think Delirium project
Delirium is common among hospice patients but often goes unrecognised or is confused with terminal agitation. In a survey carried out in 2016 in Cheshire and Merseyside, only two out of 62 staff were aware of any tools for diagnosing delirium. As it happens, neither of them worked at Willowbrook Hospice, a 12 bed unit at Prescot on Merseyside, says Paula Powell, consultant clinical lead.
A retrospective audit of case notes at the hospice confirmed that recognition of the condition was poor, with only half the patients having a comprehensive review of the reversible causes of delirium (such as infection). “Since then we have undertaken further work in policy, education, and awareness,” she says. “The underlying message is: ‘If a patient is confused, think delirium.’”
A screening tool, the Confusion Assessment Method (CAM), was introduced; a stepwise approach to managing the condition developed; and a training package written and delivered to all staff covering recognition, diagnosis, management, and communication. Willowbrook was the first unit in the region to embed this approach, and the educational toolkit has since been adopted by four other inpatient hospices.
A snapshot audit taken after the changes were introduced showed that CAM was being used in 44% of patients (compared with none before), while a comprehensive review of reversible causes is now given to 78% of patients, from 50% before. Appropriate use of drugs has increased from 80% of patients to 89%. “Now 90% of staff say they’re much more confident about recognising and managing delirium than they were before,” Powell says.
The Palliative and Hospice Care Team of the Year award is sponsored by Hospice UK. The awards ceremony takes place on 10 May at the Park Plaza Hotel, Westminster. To find out more go to thebmjawards.bmj.com
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.