Objectives & BackgroundPolicy in many countries focuses on preventing hospital admissions at the end of life. However, little attention has been paid to the role of the emergency department (ED) in this regard, despite the fact that a high proportion of hospital admissions among patients with palliative care needs originate in the ED. This paper aims to improve understanding of ED use within a palliative care context, which will subsequently facilitate decision-making around the constitution of an avoidable ED presentation.MethodsThe initial phase of this service evaluation comprised a literature review. Subsequently, the electronic records of all patients known to the specialist palliative care team at Whipps Cross hospital presenting to the ED over a three-month period were evaluated prospectively (n=112). These quantitative data were analysed using descriptive statistics. Finally, semi-structured interviews with seven patients from this sample were conducted and thematic analysis was applied.Results105 patients made 112 presentations to the ED. 53% were female; the mean age was 73. The two most common presenting complaints were shortness of breath (35%) and pain (28%). There is currently no internationally agreed definition of an appropriate ED presentation; therefore one was established for the purpose of this project. 76% of presentations were deemed to legitimately require ED management.Findings from the qualitative phase highlighted a significant lack of awareness of the availability of alternative services among patients. This often resulted in disjointed, inadequate care, and appeared to be complicated by the ‘postcode lottery’ phenomenon. Patients reported valuing continuity of care, which often resulted from being known to specialist services. Difficulties with data sharing between ED and specialty teams were observed, often delaying management, and communication between primary and secondary care was deemed problematic. Patients perceived the ED to be a safer environment than primary care, capable of providing a higher level of reassurance.ConclusionThis service evaluation explores the reasons for ED presentation among patients with palliative care needs from both the perspectives of healthcare professionals and service users. Findings challenge commonly held misconceptions regarding the presence of palliative patients in the ED, and direct potential changes in future service provision.
The need for urgent ICD deactivation was a recent issue with two hospice patients who deteriorated rapidly before deactivation had been performed. Given this risk, a process to support hospice staff in accessing urgent guidance and appropriate magnets is needed. Aim To create a clear process for staff to follow when ICDs need deactivating which increases knowledge and confidence in clinical staff, using a plan-do-study-act (PDSA) quality improvement approach. Method We are liaising with cardiology departments in hospitals serving our patient population to create a process which allows signposting to relevant teams to access urgent specialist expertise. This will include process to follow inhours, out of hours, the use of magnets, and after death processes. An assessment of hospice clinicians' knowledge and confidence will be carried out prior to disseminating the guidance and after it has been shared to ensure the aim of improving these has been successful, and to guide further improvements.Results We hope that we will be able to demonstrate a clear process with an improvement in knowledge and confidence.
0.0009. Those referred in for end of life care was 27 vs 35. Of those that died during their admission there was no difference in the length of stay 12.2 vs 10.1 days, p=0.41. There was no significant difference in length of stay prior to starting the care and communication record, 9.4 vs 5.6 days, p=0.06. Conclusions Though there were no differences in numbers of admission during the COVID 19 pandemic. There were significant differences in the length of stay. It was thought that the those coming in during the pandemic were more likely to be coming in for end of life care but as no significant difference between length of stay of patients that died nor in how quickly they were started on the care and communication record this was not the case. This information should be considered when improving current discharge processes.
work is required as less than half of the patients had entries on the Electronic Palliative Care Coordination System and only 6% had documented evidence of their wishes. Feedback -such as 'All care and treatment have been excellent.' (Patient) and 'Much better links between heart failure team and palliative care team with great benefits for patients' (Staff) -indicates that this collaborative project has been a positive experience, enabling more patients and families to access hospice and other end-of-life care services in their locality.
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