Why develop a Regional DNACPR Policy? Steve Barnard, Head of Clinical Governance, North West Ambulance Service NHS Trust
Why develop a Regional DNACPR Policy? Steve Barnard, Head of Clinical Governance, North West Ambulance Service NHS Trust [email protected] Bob is an 88 year old retired mill worker who is suffering from end stage COPD. Bob has been in hospital for the past 2 weeks and is now rapidly deteriorating. Bob currently has a DNACPR in place which, his wife Elsie is aware of. The hospital team believe Bob has only days to live and inform his wife. Bob and Elsie agree that it would good for Bob to be at home for his final days. Delivering the right care, at the right time, in the right place Late Friday afternoon – Bob is discharged home by an emergency ambulance. A copy of the DNACPR is provided for the journey home but, is not valid once the transfer is complete. The ambulance crew transfer Bob into his home and make him as comfortable as they can. Saturday afternoon – Bob begins to struggle with his breathing. Elsie panics and phones 999 for an ambulance. Delivering the right care, at the right time, in the right place An ambulance crew arrive and recognise Bob is dying and about to stop breathing. Elsie is so distraught that all she can say is that Bob is dying and that he has just come out of hospital. The ambulance crew ask if there is any paperwork or care plan for Bob but, there is nothing. The Out of Hour Services are contacted, who are able to confirm that Bob is suffering from end stage COPD but, hold no further information and advise Bob is taken to hospital. Delivering the right care, at the right time, in the right place Bob stops breathing and the ambulance crew reluctantly start to resuscitate, performing CPR on his frail chest. Bob is transferred to hospital while CPR and Advanced Life Support is performed on him. 1 hour later, Bob is confirmed dead in a hospital resuscitation room. Elsie is in a small room in the ED where she is told about Bob by a nurse she has never met before. A good death??? Delivering the right care, at the right time, in the right place Background Lack of DNACPR Policy across NW in community setting High degree of variance regarding DNACPR documentation/recording Variable/lack of communication – patient, professional & organisational Lack of policy integration between care settings and services Evidence of some areas developing/developed policy Delivering the right care, at the right time, in the right place NWAS Perspective 12 month period before death is expected – frequency of contact with ambulance service Almost always ‘go in blind’ to patients Not part of MDT planning or discussions No prior knowledge of patient or family/carers Limited access to care planning or referral pathways Delivering the right care, at the right time, in the right place National DNACPR Developments National EoLC Programme developing principles North East produced Deciding Right Deciding Right includes Emergency Health Care Planning, ADRT and DNACPR Yorkshire, East of England and South Central SHAs have implemented single DNACPR Policies with standard forms. National principles will reflect Deciding Right publication Delivering the right care, at the right time, in the right place Why Regional? Patients move around Patients move between many different care settings, providers and cross boundaries Ambulance crews work increasingly across wider geographical areas Opportunity to harness existing or developing good practice and share across the NW Avoid duplication of work and effort Delivering the right care, at the right time, in the right place Regional DNACPR Concept Unified regional approach to organisation policy design A common decision making process for DNACPRs A common communication and info sharing process A common policy statement to enable validity of DNACPRs for 7 days following a change in care setting A single DNACPR document for all settings Individualised roles, responsibilities, procedures and governance Recognise current progress in NW and learn from other areas Delivering the right care, at the right time, in the right place Benefits Supports a more integrated approach across different care settings and organisations ‐ offering potentially seamless care and reducing the risk of inappropriate clinical decisions Improved communication with patients and carers Improved information sharing between organisations – more robust and timely A potential reduction in 999 demand A potential reduction in inappropriate admissions Improved quality of care for EoL patients Delivering the right care, at the right time, in the right place How do we get there? DNACPR Principle Workshop 4th April 2012 Approx. 14 organisations attending Share existing/best practice Review Deciding Right Develop principles by consensus Pilot principles and documentation Delivering the right care, at the right time, in the right place How can NWAS support Information Sharing? Communication of DNACPR/Care Planning information Secure, web‐based process using Electronic Referral & Information Sharing System (ERISS) Patient demographics only Flagging of addresses – not patient Pre‐alert ambulance staff to review care plans Supports decisions around resuscitation and referral management ERISS will automatically prompt for alerts to be reviewed Delivering the right care, at the right time, in the right place Delivering the right care, at the right time, in the right place ERISS Benefits & Issues Easy and quick to use system that overcomes need for integration with large number of systems Good governance in terms of security and currency of patient information held Supports audit and activity reporting Some services concerned about duplication of work/inputting Difficult to use for discharging patients Not ideal for multiple‐occupancy sites Delivering the right care, at the right time, in the right place And Finally…. Delivering the right care, at the right time, in the right place Questions? Delivering the right care, at the right time, in the right place
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