Abstract
Topic
Clear escalation and treatment plans created in discussion with patients are crucial to managing patients safely and appropriately. Our goal was to introduce a standardised, easily identifiable document for this purpose, with an aim of 90% of medical inpatients having a clear escalation plan discussed and documented.
Intervention
We developed a Treatment Escalation Plan (TEP), raised awareness via different platforms and delivered teaching for staff. For baseline and subsequent data collections following interventions, we reviewed the notes of twenty random medical inpatients for decisions regarding escalation, patient involvement in decision making including capacity and specific interventions considered. We also included time taken to find information; documented patient/family discussions and whether a TEP was present. We collected qualitative feedback from staff.
Improvement
After introduction, TEP was present in 35/60 patients (58%). Improvement was demonstrated across all measured domains when a TEP form was present: escalation decision (no TEP 80%, TEP 100%), discussion with patient/relative (no TEP 4%, TEP 85%), capacity decision regarding escalation (no TEP 52%, TEP 91%), decision on specific interventions (no TEP 12%, TEP 94%), mean time taken to find information (no TEP 84 seconds, TEP 34 seconds). Qualitative feedback from staff was positive, particularly the inclusion of specific care decisions beyond “DNACPR”.
Discussion
We felt it was critical to develop a TEP to ensure appropriate decisions are made and clearly documented for medical inpatients, especially in light of COVID-19. In patients with a TEP completed, we observed improvements in all domains, particularly in the involvement of patients/relatives in escalation decisions, which is key to delivering patient-centered care. Implementing a new system in a pandemic had challenges, such as continuity of staffing, however feedback was uniformly positive. This is an ongoing project that will continue to promote TEPs to improve patient care.