Thursday 24th September 2015
Treatment Escalation Plan Seminar
WELCOME
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Welcome & Introduction
Alison Richardson
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• Introduce Wessex CLAHRC
• Aims of project
• Objectives of meeting
• Programme
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What do CLAHRCs do?
In 2008, the National Institute for Health Research (NIHR) created Collaborations for Leadership in Applied Health
Research and Care (CLAHRCs).
We all have a specific aim:
To bridge the gap between the world class research conducted by academics and its
implementation on the NHS frontline, where it can impact on patient lives and the quality of
service provided to them.
We bring together local NHS providers and commissioners with academics, other relevant local organisations,
industry partners and health research infrastructures together with our local Academic Health Science Network
(AHSN).
We undertake high quality applied research and evidence based implementations that are responsive to, and in
partnership with, our collaborating organisations, patients, carers and the public, the outcome being an improvement
in both the health and wealth of our population.
“Bridging the gap between research and the frontline
NHS”
There are 13 CLAHRCs in England and they work
together as a college ensuring we share our
learning across the country and work in a cohesive
and collaborative way.
CLAHRC Wessex is physically based at the
University of Southampton and University Hospital
Southampton, with researchers working in many of
the Wessex NHS Trusts.
CLAHRC Wessex
Established in January 2014 with a five year programme of work. We are a Wessex wide
partnership of providers, commissioners, patients, the public, clinicians and researchers. We aim
to put into practice what we learn from undertaking research. Our focus is on bringing benefits to
people living in Wessex through better integration of pathways of care for people with long term
conditions and to reduce hospital admissions through more appropriate use of health care
Integrated Respiratory Care
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Identify variation in outcomes
Improve diagnosis
Improve case management, selfmanagement and rehabilitation
Public Health and Primary Care
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Patient and Public
Involvement
Ageing and Dementia
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Identify early cognitive impairment
Improve assessment
Implement volunteer mealtime and
mobilisation assistants
Reduce antibiotic prescribing
Improve early detection and
prevention of chronic liver disease and
acute kidney injury
Self-management long term conditions
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Methodological hub
Create tools to support management
of conditions and care pathways
Improve commissioning of self
management resources
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3
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Identify deficiencies in fundamental
care
Test strategies to improve safety,
nursing capacity and patients physical
needs
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Complexity and end of life care
Fundamental Care in Hospital
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Improve patient experience by better
understanding complexity
Develop resources to help more
effective navigation of care pathways
and support interactions with care
professional and health services
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Our partners
Theme 6: Complexity, patient experience &
organisational behaviour
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Focus on people with complex and often co-morbid conditions
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Towards the end of life
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Whose management moves back and forth between primary and secondary care
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Develop and test interventions that acknowledge and mobilise patient preferences, reduce complexity &
burden of treatment
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Exploit theoretical models to promote and implement change across healthcare services
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Seminar objectives
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Introduce CLAHRC Wessex treatment escalation planning project
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Hear about experiences of Devon TEP team
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Learn about relevant projects underway in Wessex
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Brief about work underway nationally to develop Emergency Care and Treatment Plan
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Present findings from scoping exercise to determine who is using what and where in NHS Trusts in
England
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Work together to identify implementation challenges and how to evaluate impact and outcome
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Treatment escalation plans: making shared decisions
about treatment
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TEPs set out individualised patient plans for those at risk of suffering clinical deterioration
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Can be shared between patients, families, urgent care providers and clinicians in primary and secondary
care
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Can be a means to empower shared decision making and ensure decisions are enacted
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Underpinned by process to enable positive conversations about treatment actions to be pursued and
agreement about other options, including CPR, agreed to be inappropriate
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Our project
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Working with NHS partners and other providers in Wessex co-produce, implement and evaluate a TEP
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Started in April 2015
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Initial partners: University Hospital Southampton, Salisbury District Hospital and Hampshire Hospitals
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Currently securing involvement from primary and community care providers in these 3 localities
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These sites will be involved in prototype design, testing, implementation across organisation
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Evaluation will focus on factors that promote and inhibit implementation
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Plan to develop wider implementation plan in conjunction with Wessex End of Life Care Programme Board
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Will now incorporate involvement in national work under auspices of Resuscitation Council (UK) and Royal
College of Nursing to develop a form about CPR and other life sustaining treatment
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Build on learning from South Central unified DNACPR policy development
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Aims of our project
By the end of 2017 anticipatory decisions about CPR and other life sustaining treatments will be recorded
using the same documentation, be valid across all care settings, in three localities in Wessex and a plan
agreed to support implementation in Wessex
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Learning from others
Experiences of developing and implementing Devon TEP
across care settings
Speakers: Dr Michael Mercer and Mr George Lillie
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Introduction to national
work
David Pitcher, Co-Chair of national working group
& Alison Richardson, Member of national working group
Findings from a scoping exercise to determine
who is using what and where.
A survey of NHS Trusts in England
Dr Susi Lund
Consultant Nurse, Royal Berkshire NHS Foundation Trust
Clinical advisor to CLAHRC Wessex
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Components of ACP
The negotiation of an ACP between a patient, family, and clinicians is therefore a
good deal more than a personal, existential, set of decisions. It is both a rite of
passage that defines a person’s shifting identity and clinical status in relation to
both the self and others, and a procedural device intended to reduce uncertainty
about the actions that different groups will take in response to that status in a
specific set of clinically defined circumstances
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Methods for scoping exercise
• Letter to all medical directors and directors of nursing of acute hospital Trusts in
England
• Signposted to most appropriate person to respond
• Follow up telephone interview and request to share any documentation used
• Tabulating and comparing results
• Internet searching
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Results
• Out of the 150 Trusts contacted there was no response from 90. Of the 60 (40.4%) Trusts from
which responses were received 66.6 % (n=40) provided information. The responses came from
either leads for resuscitation, palliative care or acute medicine/ITU/Anaesthetists
• Thirty three Trusts were using, or had used, records that are recognised as having been
implemented and audited in other areas, such as;
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Modified Devon TEP (11)
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Amber (7) positive and negative
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Deciding Right (3)
• Own design of TEP (12) including the Cambridge UFTO.
• Seven trusts reported having no formal process for documenting decision-making. Internet
searches and ongoing contact with interested clinicians identified 5 other TEPs in use by NHS
Trusts not identified through the survey exercise.
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Colour
TEP used
Orange
AMBER
Purple
UFTO
Green
Deciding right
Yellow
Trial AMBER
unsuccessful
Blue
Modified Devon TEP
Red
Own version of TEP
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Analysis
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Transferable vs organisational
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DNACPR as part of form or separate
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Colour
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Tick box versus free text
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Condition specific (2) versus generic
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MCA record
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Review
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Only one version electronic
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Table work briefing
Alison Richardson
Table work
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Context: intention to develop a national form and a process that will cross boundaries
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Work together to identify implementation challenges to considering, recording and communicating
anticipatory decisions about CPR and other life sustaining treatment and how to overcome these…
– Processes
– Products
– People
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How to evaluate impact and outcome
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Tables will address different questions
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Feedback by facilitators at 15.50, top 3 points from each table
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