P-48 Antimicrobials in end of life care: an audit at the royal trinity hospice

Abstract

Grampian introduced new AWI Section 47 documentation and its use was audited in an acute palliative care unit. Methods Data was collected from all in-patients in an acute palliative care unit over a 1 week period. Information was collected on four domains:. was an AWI certificate present in the medical notes, . was the decision to complete an AWI certificate documented in the medical notes (including the reasons for this decision), . was the AWI certificate completed correctly, . was there documentation of a discussion with Welfare Power of Attorney or next of kin regarding the decision to complete an AWI certificate. Background Autonomic dysfunction (AD) is common in advanced cancer. Cardiovascular signs include loss of heart rate variability (HRV) and later, orthostatic hypotension (OH). OH increases risk of falls and mortality. HRV is the time difference between successive heartbeats, measured as a standard deviation (SDNN). The mean SDNN found in normative population is 41.51ms (s:26.28ms). OH is a decrease of ! 20mHg in systolic and/or 10mHg in diastolic blood pressure (BP) upon orthostatic stress. Persistence of OH (POH) is OH beyond three minutes Methods This prospective, observational study aimed to identify prevalence of OH and POH, examine the relationship between autonomic symptoms (AS) and OH, and to ascertain whether OH and HRV are equivocally reliable for AD diagnosis. Consecutive ambulant adults attending day or in-patient hospice services were recruited. Interviews established demographics and AS. Objective tests for HRV and BP measurement were conducted. Postural symptoms were recorded during testing. Background Prevalence studies show that 15%-42% of patients admitted to specialist palliative care inpatient units have delirium. Symptoms of delirium are often subtle and easily missed, or misdiagnosed as fatigue or even depression, and so the use of a screening tool could improve early identification and management of delirium and lead to improved outcomes. Patients admitted to the hospice are often frail and tired, therefore a quick and easy-to-use method of cognitive assessment is essential. Methods A quality improvement (QI) approach (PDSA: Plan, Do, Study, Act) was used to improve screening for delirium on admission to a hospice unit. A baseline measure was taken of the rate of performing cognitive assessment on admission. Five PDSA cycles were then undertaken which involved implementing change and then evaluating results through auditing case-notes and interviewing staff. Results The first cycle determined staff preference between the Short CAM and the 4AT. Two further PDSA cycles embedded the 4AT (the preferred tool) into the admission process, establishing it as a usable tool in the hospice setting for up to 92% of admissions. A subsequent cycle showing poor sustainability prompted further improvements to staff education and changes to admission documentation. Conclusions The 4AT is a usable tool in the hospice inpatient setting to assess patients' cognitive state on admission, and can eas...