Strategic Challenges in Urgent &

Emergency Care: Supporting

Patients in their Last Months of Life

We interface with many other providers

SCAS Clinical Strategy

“Ambulance services need to work in

partnership with other community

health care and social care providers

to help deliver a consistent 24/7

urgent care service.

A Trusted Assessor working with

a Trusted Advisor

SCAS Accelerated Clinical Transformation

programme:

To accelerate the pace of planned change

Add clinical benefits for patients

Improve patient outcomes

Increase SCAS and partner provider efficiency

Generate new ideas using modern technology and joint

working with our partners, to support people in their own

homes

Test pilot concepts

Key Challenges To The Urgent Care

System Supporting Patients In Their Last

Months Of Life

Ambitions for Palliative and End of Life Care-

National Framework for Local Action published 2015

What We Know Now- Health care costs last year of life

About 1% of the population (approx half a million people) die each year

Although some deaths are unexpected, many more (approx.75%) can be predicted

30% of patients currently occupying a hospital bed will die in the next 12 months

80% of patients in care homes have a prognosis of less than 12 months

On average patients in last year of life have 3 or more unplanned hospital

admissions

Acute health costs increase significantly in the last days and weeks of life

EoLC and the Impact on the Urgent Care System

PATIENT

CRISIS SERVICES

GP

EMERGENCY DEPARTMENT

IN PATIENT ADMISSION With Rapid Discharge

DISCHARGE HOME

EARLY IDENTIFICATION

24/7 PALLIATIVE CARE SERVICE • Hospital Liaison • Specialist Palliative Care • 24/7 Phoneline / Visiting • Hospice at home

ADVANCE CARE PLAN • ReSPECT • DNACPR • Anticipatory Meds

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WALK IN CENTRES

AMBULANCE SERVICE

GP OUT OF HOURS

111

999

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TIMELY ELECTRONIC ACCESS OF CRISIS SERVICES TO EPaCCS AND 24/7 SUPPORT SERVICES CAN PREVENT UNNECESSARY IN PATIENT ADMISSIONS

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SCAS are the disruptors of pathways for people at end of life

The Story of Mrs Klein

Background:

• Mrs Klein was 93 years old when she died

• Mrs Klein had lived in her family home for 63 years

before going into residential care then nursing care.

• Mrs Klein was a frail lady. PMH – a number of strokes,

fractures to neck, collar bone, wrist and pelvis. Mrs Klein

had previously had bowel cancer and was deaf. Mrs

Klein moved from her home, when she was no longer

able to stand safely.

The Story of Mrs Klein

Care Plan

• had the following legal documents in place,

Advanced Directive setting out her wishes,

a DNACPR

Continuation of Care document.

• Mrs Klein’s son had Lasting Power of Attorney (health

and welfare)

• For many years Mrs Klein and her son had planned for

her dignified death, as set out in her Advance Directive.

• Nursing Home were aware of the Directive and held the

various documentation.

The Story of Mrs Klein

Final Journey

• Deteriorated over a four day period and the nursing home contacted

NHS 111 advising the patient was in respiratory distress. The triage

DX was an emergency ambulance. This was offered and accepted,

on 2 occasions by the nurse.

• A paramedic on an RRV arrived on scene and assessed Mrs

Klein. They determined that she should be conveyed to hospital,

even though she was a palliative patient

• No documentation was offered accept the DNACPR, however the

paramedic was informed that he should consult with Mrs Klein’s son

as he was LPA and there was a specific requirement that Mrs Klein

should remain at the nursing home.

The Story of Mrs Klein Final Journey(cont.)

• A back up ambulance was requested for conveyance. The ambulance was crewed by a Technician and an ECA.

• The Technician challenged the conveyance decision advising that Lisa was likely to ‘arrest’ when moved.

• The Technician attempted a number of times to speak with a Dr from the OOH service. Unfortunately a direct conversation with a Dr did not occur.

• The paramedic determined that Lisa should be moved ‘now’ and she was transferred to the stretcher and taken out to the ambulance.

The Story of Mrs Klein

Final Journey(cont.)

• Lisa’s breathing was supported, however her GCS continued to lower and she became unresponsive.

• The ECA provided comfort to Lisa and talked to her and held her hand when she passed away

• Lisa was conveyed to hospital.

• No interventions took place as SCAS were aware of the DNACPR.

• The Technician and ECA crew found the incident distressing and unnecessary.

The Story of Mrs Klein

Areas for Improvement

• SCAS failed to consult Lisa’s son prior to conveyance

• The nursing home failed to inform SCAS of the Advance

Directive (this had been in place for 17 years) which was

explicit setting out Lisa’s wishes

• The nursing home and SCAS failed to follow the

‘Continuation of Care’ plan which was explicit in ‘no

hospital treatment’ and ‘Not for Active Treatment’

• Lisa’s son informed the nursing home whilst the paramedic

was on scene, that his mother should not be conveyed, as

per her Advance Directive

Our journey so far; ACT 1 scene 1;

• 18 months ago

• Focused on face to face management:

– Support / develop decision making

– Empower staff and patients

– Suggests timeframes

– Improve data collection

• Red/ Amber on Gold standard pathway

• New mediums for bespoke Education material

• 24/7 direct access crucial

• Building relationships and trust takes time

• Feedback / support critical

Our journey so far - the enablers

ACT 1 scene 2;

• Directory of Services and Interoperability: working with

colleagues to improve access/sharing of records

Our journey so far; ACT 2 scene 1;

Patient with End of Life needs calling SCAS NHS 111 or

999 IN PATIENT

111 / 999 CONTACT

Senior Clinician Triage

Patient already has ACP on EPaCCS: Refer to and respect personalised choices

Patient does not have ACP: Identification if EoLC need in discussion with patient/carer

ASSESS NEED FOR SUPPORT

ACCESS COMMUNITY SUPPORT SERVICES TO PREVENT ADMISSION • OOH GP ASSESSMENT • 24/7 PALLIATIVE CARE SERVICE • RAPID RESPONSE NHS SPECIALIST CLINICAL COMMUNITY CARE • RAPID RESPONSE SOCIAL CARE • RAPID RESPONSE NHS COMMUNITY CARE – Intermediate care

ONGOING CARE AT

HOME

Hospice Care

Home Community

Hospital

REFER BACK for

GP follow up

Non Acute care Admission options 24/7

TIMELY ELECTRONIC ACCESS OF CRISIS

SERVICES TO EPaCCS AND 24/7 SUPPORT

SERVICES CAN PREVENT UNNECESSARY

IN PATIENT ADMISSIONS

EPaCCS updated

TIMELY ELECTRONIC ACCESS OF CRISIS SERVICES TO EPaCCS AND 24/7 SUPPORT SERVICES CAN PREVENT UNNECESSARY IN PATIENT ADMISSIONS

PATIENT

CRISIS SERVICES

GP

EMERGENCY DEPARTMENT

IN PATIENT ADMISSION With Rapid Discharge

DISCHARGE HOME

EARLY IDENTIFICATION

24/7 PALLIATIVE CARE SERVICE • Hospital Liaison • Specialist Palliative Care • 24/7 Phoneline / Visiting • Hospice at home

EPaCCS

ADVANCE CARE PLAN • ReSPECT • DNACPR • Anticipatory Meds

RAPID RESPONSE SOCIAL CARE COMMUNITY SUPPORT

RAPID RESPONSE NHS COMMUNITY CARE • Intermediate Care • Night Sitting • Falls • Occupational Therapy • Community IV Team

RAPID RESPONSE NHS COMMUNITY SPECIALIST CLINICAL CARE • Heart failure Team • Respiratory Team • Geriatrician • Palliative Care Nurse • District Nurse • Community Matron

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WALK IN CENTRES

AMBULANCE SERVICE

GP OUT OF HOURS

111

999

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* ACCESS TO SUPPORT SERVICES

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Electronic Palliative Care Co-ordination Systems

The optimum Emergency and Urgent care pathway for people

at end of life

Any Questions?