Resolving system and facility barriers to advance care

planning across a Queensland Hospital and Health Service

Prof Liz Reymond & Dr Leyton Miller, Brisbane South Palliative Care Collaborative

2016 Advance Care Planning Conference, Sydney

Background

• Metro South Hospital and Health Service District (MSH)

– various unsynchronised projects across 6 public hospitals

– QIP ACP funding

• State wide strategies

– Clinical Senate: End-of-life initiative

– Statewide strategy for end-of-life care (2015)

• National initiatives

– “A national framework for advance care directives” (2011)

Australian Health Ministers Advisory Council

– “End-of-life care in acute hospitals”(2013) Aust. Commission

on Safety and Quality in Health Care

MSH End-of-Life Strategy

• The vision: in MSH, quality end-of-life care is a

routine health outcome when such care is

chosen by consumers and supported within core

healthcare practice across primary, secondary

and tertiary settings.

TodayBeginning of

Time

Percentage

Risk of Dying

0

100

50

Timeline

Individual’s lifetime risk of death since time began

Reframing end-of-life care

Advance Care Planning (ACP) Objectives

• Embed ACP into routine clinical care

dependent on:

- public acceptance

- clinical culture change (mostly medical)

Assumption: Advance care planning is a process that

ideally occurs within a primary healthcare setting

which benefits patients, families and

secondary and tertiary healthcare providers and is

supported by the hospital and health service.

Key elements of the MSH ACP implementation programme

• Governance and partnerships (PHN, GPs, RACFs)

• Development and use of standardised processes

and documentation – AHD, EPOA(H), Statement of

Choices informal advance care plan

• Raising public awareness of end-of-life issues

• Clinician education and cultural change across all

environments of care

• Interfaced communication systems to allow flow of

information between private homes, GP practices,

residential aged care facilities, QAS and hospitals –

the Viewer

Statement of Choices

Raising public awareness: Community engagement

Since January 2015:

• Over 200

presentations

• Reach over:

– 4000 community

members

– 350 RACF staff

– 320 GPs

www.mycaremychoices.com.au

MSH QIP-ACP outcomes for Oct 15 – Feb 16

Advance Care Planning: Completed Statement of Choices –

CPR Preference

Do not want CPR: 989 Want CPR: 182 Other: 31

Advance Care Planning: Completed Statement of Choices –

Preferred Place of Death

Home: 224 Hospital: 180 RACF: 402 Undecided: 396

Uptake of MSH SoC Across Queensland

• Central West HHS

• Darling Downs HHS

• Gold Coast HHS

• Mackay HHS

• MN HHS

• Sunshine Coast HHS

• Townsville HHS

• West Morton HHS

• (Children’s Hospital in

preparation)

• Blue care (RACF and

community)

• PresCare

• Home Instead

• Southern Cross Care

• St Vincents Healthcare

• Mackay PHN

What?

• Clinical lead – director of service + ACP CNC

• Before-after exploratory mixed-methods analysis

– 7 components to overcome barriers to ACP

• Procedures, forms, tools & resources

• Training and seminars

• Data tracking systems

How?

• Normalise ACP in tertiary hospital general medicine unit

– Develop, implement, explore effects of ACP

• Pre-program and post-program audit of ACPs

• Measure number of ACPs in eligible patients

• Staff questionnaire surveys – perceptions, training, resources

Evaluation?

Barriers to ACP

1. You JJ, Downar J, Fowler RA, et al. Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families: A

Multicenter Survey of Clinicians. JAMA Intern Med. 2015;175(4):549-556. doi:10.1001/jamainternmed.2014.7732

Barriers to ACP

Components of ACP program

• Identifying patients eligible for ACP

• Preparing patients and family for ACP

• Initiating ACP discussions

• Facilitating ACP discussions

• Recording and accessing ACPs

• Training staff in ACP

• Tracking and feedback systems

• General Medicine Service

• ‘ACP-eligible’

– Prognosis < 12 months

• SPICT Tool

• Surprise Question

• RACF

Identifying patients eligible for ACP

SPICT Tool• 2 or more indicators of deteriorating health

• Any clinical indicators of advanced conditions2. Highet G, Crawford D, Murray SA, Boyd K. Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT): A mixed methods study.BMJ

Supportive & Palliative Care. Published online First: 25 July 2013 Doi:10.1136/bmjspcare-2013-000488 www.spict.org.uk

Surprise question

‘No’ is the answer to this question:

“In light of all you know about this patient, would you be surprisedif he/she was to die within the next 12 months?”

- In HD pts: odds of dying within 1 yr in “no” group 3.5 times higher than “yes” group3

- In cancer patients: odds 7.0 times greater4,5

Sensitivity 69%; Specificity 84%; PPV 84%; NPV 69%

Preparing patients and family for ACP

• Resource folders, posters and other visuals in the wards

• Attaching ACP brochure, ACP form and tracking form to bedside charts of all ACP eligible patients

• Making ACP resources available in Gen Med OPD for discharged ACP eligible pts who missed out on discussion

• Reminders about outstanding ACP eligible pts in rapid checklist morning rounds and nurse handover rounds

Initiating and Facilitating ACP discussions

• Dedicated ACP facilitator– patient screening; introductory discussions; assistance in identifying SDMs and

convening family meetings

• Regular reminders and encouragement– Feedback on capture of eligible patients

• Ongoing education and review– Standing agenda item for unit meetings

– In-service training/workshops/seminars

• Flagging ACP eligible pts in Patient Flow and highlighting on journey boards

Monitoring and feedback of ACP

Recording ACPs

• Statement of Choices

– Based on RPC

• Standardise conversation

• Recognition by doctors

• Patients with or without

capacity (Form A or B) Statement of Choices

Storing and accessing ACP

• Attach copy of ACP to discharge summary

• ACP form to accompany patients being transferred to RACFs

• ACP is flagged under ‘Alerts’ in iEMR/HBCIS/ERIC systems

• Uploaded to QH-wide ‘The Viewer’– Document accessible across Qld Health

• Central repository – Metro South Health Office of Advance Care Planning

Results - Prevalence of ACP

• Princess Alexandra Hospital (PAH) 2008:

1% (22/2195) charts had some documentation of EOL care1

– 50% (11) had AHD

• 36% (4) incorrectly signed or witnessed

• 36% (4) conflicting requests

• PAH 2014:

50 consecutive deaths of patients (mean age 71 ±13 years):

– Only 1 had AHD

– Only 3 had EPOA

– 1 in 4 did not have ARP (NFR) at time of death

AuditsPre-program Post-program

n = 166 n = 215

1 documented ACP (0.6%) 89 documented ACPs (41%)

26 declined (12%)

Missed or declined ACP

• 215 ACP-eligible patients

– 100 not approached• discharge before clinical teams had opportunity to engage (63%)

• patient and/or family unsuitable to participate in ACP (26%)

• patient approached but failure to submit tracking form with details (11%)

– 26 declined• capacity constraints in engaging in ACP (15, 56%)

• desire not to discuss ACP (4, 16%)

• aware but considered prognosis not bad enough to warrant ACP (4, 16%)

• aware but felt family was already familiar with care preferences (2, 8%)

• no understanding of ACP (1, 4%)

Staff Surveys

35.6%

54.2%

Staff Surveys

ACP – Everyone’s business or specialised?

• 94.6% - Health professionals lack the time to fully undertake ACP

with patients and families.

• Significant drop when CNC absent

• Education and specialist knowledge

• ACP is everyone’s business but needs support of a specialist

Analysis up to July 2015

ACP facilitator away/part-time

CNC absence on ACP

Advance Care Planning Redlands Hospital - Occasions of Service

0

50

100

150

200

250

Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

Future developments

• Integration into EHR

• Follow-up study of outcomes of patients with ACPs

• Roll-out to other units within PAH

• Links with MS HHS-wide EoL program

• Improve flow information to community (GPs, RACFs, QAS)

Acknowledgements

• Dr Ian Scott

• Nala Rajakurana

• Dr Darshan Shah

• Prof Elizabeth Reymond

• Dr Michael Daly

• Dr Jeff Rowland

• Medical and nursing staff Internal Medicine, PAH

• Metro South Office of Advance Care Planning

References1. You JJ, Downar J, Fowler RA, et al. Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families: A Multicenter Survey of Clinicians.

JAMA Intern Med. 2015;175(4):549-556. doi:10.1001/jamainternmed.2014.7732

2. Highet G, Crawford D, Murray SA, Boyd K. Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT): A mixed methods study. BMJ

Supportive & Palliative Care. Published online First: 25 July 2013 Doi:10.1136/bmjspcare-2013-000488

3. Moss AH, Ganjoo J, Sharma S, et al. Utility of the “Surprise” Question to Identify Dialysis Patients with High Mortality. Clinical Journal of the American Society of

Nephrology : CJASN. 2008;3(5):1379-1384. doi:10.2215/CJN.00940208.

4. Moroni M, Zocchi D, Bolognesi D, Abernethy A, Rondelli R, Savorani G, et al. The “surprise” question in advanced cancer patients: A prospective study among general

practitioners. Palliat Med. 2014;28(7):959-64.

5. Moss AH, Lunney JR, Culp S, Auber M, Kurian S, Rogers J, et al. Prognostic significance of the “surprise” question in cancer patients. J Palliat Med. 2010;13(7):837-40.