Eleanor Grogan

10 Developing guidelines for opioid prescribing and adjustment in renal impairment in an acute medical admissions unit

Background Incorrect opioid prescribing can significantly impact patient care and safety, resulting in poor pain control or risk of opioid toxicity. Renal failure often means adjustment of opioid doses is needed. Local audit demonstrated incorrect prescribing in acute medical admissions, particularly in patients with renal impairment, and a survey showed low confidence amongst junior doctors in prescribing opioids. Methods Local specific guidelines were developed for opioid prescribing and adjustment in Acute Kidney Injury (AKI) and for initiating opioids in patients with a reduced eGFR on the medical admissions unit. These were in line with the North of England Cancer Network Palliative Care Guidelines and were reviewed by the Trust’s Palliative Care team. Teaching was conducted with the junior doctors working in acute medicine about the guidelines and practicing using them with example cases. Questionnaires were completed before and after the teaching to assess confidence in prescribing opioids. The guidelines were downloaded on the doctors’ work phones and laminated on the wards. Results Junior doctors were not confident in opioid prescribing and adjusting in AKI and Chronic Kidney Disease (CKD) prior to the teaching and availability of new guidelines. Confidence increased after the teaching for prescribing opioids, particularly in patients with renal impairment. For example, confidence in initiating opioids in patients with AKI was on average 5.63 out of 10 before the teaching (1 not confident and 10 very confident) and 7.93 afterwards. Conclusions The availability of specific guidelines for prescribing and adjusting opioids in acute medical admissions for patients with renal impairment significantly increased junior doctors’ confidence in this. A repeat audit will now be conducted to determine if this has impacted on the prescribing of opioids in practice. Results of this will be available at the conference.

Excellence in cost-effective inpatient specialist palliative care in the NHS – a new model

There is little in the literature describing hospital specialist palliative care units (PCUs) within the NHS. This paper describes how specialist PCUs can be set up within and be entirely funded by the NHS, and outlines some of the challenges and successes of the units. Having PCUs within hospitals has offered patients increased choice over their place of care and death; perhaps not surprisingly leading to a reduced death rate in the acute hospital. However, since the opening of the PCUs there has also been an increased home death rate. The PCUs are well received by patients, families and other staff within the hospital. We believe they offer a model for excellence in cost-effective inpatient specialist palliative care within the NHS.

‘I see you're angry’: actor-reported anger scores

Teaching communication skills using role‐play addresses an important learning need for medical students, with the debriefing process being central to the learning that occurs. In this work we examine the feasibility of using actor‐reported ‘anger scores’, during a challenging communication scenario, as a tool to stimulate debriefing.

HOW COMMON IS DELIRIUM IN PALLIATIVE CARE INPATIENT UNITS AND WHAT IS THE OUTCOME FOR THESE PATIENTS

Background Delirium affects up to 50% of patients on medical wards (NICE), however the impact in palliative care units is unclear, with prevalence estimates ranging from 13–64%. Use of delirium screening tools in palliative care is inconsistent and consensus opinion is lacking. The short-CAM is a well-researched, observational tool, recommended by NICE in high-risk in-patients. It is often favoured for its ease of use and inter-rater reliability and is one of a limited number to be validated in the palliative care setting. Aim To identify the prevalence, incidence and outcome of delirium in five specialist palliative care inpatient units (SPCUs) in the North East using the short-CAM. Methods Adult patients admitted to five SPCUs were screened for delirium using the short-CAM. Patients with significant communication barriers were excluded. Screening occurred on admission, weekly and if clinical change raised the suspicion of delirium. Anonymised patient data was collected by clinical staff based on the units between April and August 2013. Results Two hundred and ninety-one patients were screened for delirium using the short-CAM during the study period. Thirty-four (11.7%) patients were delirious (CAM-positive) on admission to the SPCUs. Twenty-four patients (8.2%) became delirious during their admission. Resolution of delirium occurred in 38.6% of cases. Of 126 patients who died during their admission, 58 (46%) had been delirious prior to death. Conclusion Overall, delirium (as identified by the short-CAM) affected 20% of patients included in this study. Our findings demonstrate a lower prevalence and incidence of delirium amongst palliative care patients than many published studies. This may relate to diagnostic limitations of the short-CAM, as well as variations in the sensitivity of screening tools employed in these studies. It is clear that delirium is associated with poor prognosis. Further studies to explore the impact and management of this distressing condition are warranted.

CHANGING THE TIMES OF ADMINISTRATION OF CONTROLLED DRUGS REDUCES ERRORS

Background An innovative new palliative care unit opened in December 2011 within an NHS hospital with a completely new team, many of whom had not worked in a predominantly palliative setting before. A high volume of controlled drugs was given to patients and the number of errors, as reported by the electronic internal error reporting system, was higher than desired. Controlled drugs were given out to patients at the end of the nursing night shift (for morning drugs) and end of the late shift (for evening drugs). Changing the times of administration of drugs so that this was done at the start rather than the end of a shift was thought to offer a possible solution to this problem. Aim To reduce the number of errors made with controlled drug administration in a cost effective way. Result Before changing the timing of the controlled drug rounds there were 23 errors relating to controlled drugs reported in 13 months (7 relating to administration and 5 of these to administration of regular, rather than “as required”, medication). The controlled drug timings were altered slightly so that, instead of being done by the nurses at the end of a shift, they were administered by nurses at the start of their shift when they were less tired. Since changing to the slightly different times there have been 4 reported errors relating to controlled drugs in 6 months, none of which relate to administration of controlled drugs. Conclusion Maintaining a 12 hour gap between controlled drug administration but giving the medicine out at the start of nursing shifts has been a free and effective way to reduce the number of controlled drug errors occurring on the ward and reduce administration errors to zero.

End of Life Care

There are two aspects to this: the recognition of the palliative phase of an illness, often considered to be the last 6–12 months of life and the end of life itself, culminating in death, lasting hours or a few days. The various tools and ways to recognise these phases are described. Communication about such issues is clearly very important for the patient and family so that they can make choices about the type of care they may or may not choose to receive as death approaches. The concept of advance care planning in general and some specific tools to assist the process are described, as are the ethical issues associated with this time of life and death.

Hospital specialist palliative care units – an innovative model delivering cost-effective choice?

Background The End of Life Strategy makes clear the importance of patient choice. The subsequent drive towards community end of life care masks the reality that even in the best performing areas, over 40% of people will continue to die in hospital. Patients preferences change as death approaches, with the popularity of hospices significantly increasing. This paper describes one approach by a NHS trust seeking to improve the delivery of palliative and end of life care. The trust made a strategic decision, alongside community initiatives, to invest in a 19 bedded hospital palliative care unit. Aim To examine the effectiveness of a hospital palliative care unit. Methods The effectiveness of the unit was measured in terms of patient statistics, complexity and quality of care. Results The average length of stay was 13 days, proportion of patients who died 62% and occupancy running over 80%. Patient experience data demonstrates high levels of satisfaction, especially in the domains of pain control, respect and dignity, doctors and nurses. Patients were found to have a poorer performance status and require non-oral drugs than a nearby hospice. Staff satisfaction was high. Overall trust performance in Liverpool Care Pathway measures also improved over this time. Conclusion The unit successfully improved the general dissatisfaction with hospital palliative and end of life care. Positive patient/family feedback and high usage demonstrated that this model could achieve 3 goals: -a better level of palliative care for patients than can be delivered in non-palliative care environments -a cost-effective model: the costs were the same as other medical wards -patient choice. The number of patients who died in a palliative care setting raised the proportion of patients dying in a specialist palliative care environment to the highest in the country. A second unit will open shortly.