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Saving lives and supporting “good” deaths in hospital

This study focuses on saving lives and ensuring "good" deaths in hospitals, with an emphasis on recognizing deterioration, timely interventions, and improving end-of-life conversations. It examines the impact of outreach teams, multi-professional collaboration, and measures to evaluate care quality.

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Saving lives and supporting “good” deaths in hospital

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  1. Saving lives and supporting “good” deaths in hospital John Welch University College London Hospitals

  2. 300 219 deaths following time in English hospitals • 131 Trusts, 2017-18 • 2,292 deaths each

  3. PLoS Med. 2014;11(6): e1001667.

  4. A 45 year old presents with pancreatitis

  5. A 45 year old presents with pancreatitis • He’s admitted, has Consultant review, is handed over to next day’s medical team as being “fine”. • 08:00: Medical FY1 is asked to look after patient. • Patient is in severe pain and has low urine output. • iv fluid and pain killers are given. No improvement. • Referral to gastroenterologist; advises examination of the patient and review of the history. • Respiratory and heart rate rise, urine output falls further, pain worsens; all is not well.

  6. Patient says the catheter hurts; it’s removed - losing important monitoring. • Blood tests show significant kidney and liver problems. These are not escalated to senior staff. • 17:00: blood pressure low, blood sugar high. • Patient is cold and clammy (shocked); and the iv cannula is failing (i.e., the main means of treatment). • FY1 seeks help from FY2 and anaesthesia to re-site cannula. They’re busy. • When visited at 19:25, the patient is not in bed. Other patients say he’s gone to the toilet. • No answer from the toilet.

  7. There were signs of respiratory, circulatory, kidney, liver and clotting problems thro’ the day …

  8. There were signs of respiratory, circulatory, kidney, liver and clotting problems thro’ the day … But it’s not straightforward • The FY1 is a new doctor, who’d had panic attacks just coming to work. The nurse was new too. • The nurse had four other patients; three on the other side of the ward, one with recurrent hypoglycaemia, one being prepared for theatre. • The nurse didn't have a lunch break until 16:00. • The Registrar was also new, still learning. • Support was requested from Gastroenterology (unhelpful) and Anaesthesia (unable).

  9. Chain of Survival for Deteriorating Patient Subbe CP, Welch JR. Clin Risk. 2013;19(1):6-11.

  10. Recognition of Deterioration Corfield AR, et al. Emerg Med J. 2014. 31(6):482-7.

  11. But it’s more than just T, P, R, BP, SpO2, A-nC-V-P-U …

  12. Patient- and relative-activated outreach:seven years of data • 10 006 referrals a year for clinical concern, early warning score breaches • 0.8% were Call 4 Concern referrals, involving 312 patients Odell M. Br J Nurs. 2019;28(2):116-121.

  13. Thinking about deaths again

  14. How many patients can be saved? Clark D, et al. Palliat Med. 2014;28(6):474-479.

  15. Deteriorating Patients Care Bundle

  16. 22% go to ICU, 78% stay • 8.4% die in a day • 24% get care limits • Outreach Teams diagnose dying … Bannard-Smith J, et al. Resuscitation. 2016;107:7-12.

  17. “Elderly people who are dying need to be protected from heroic but intrusive live-saving hospital interventions that often only prolong suffering rather than enhance quality of remaining life.”

  18. What does good look like?

  19. The UCH acute medical unit has had 138 days without a cardiac arrest … • “nursing and medical leadership and team working has been key” • “better decision-making, clear treatment escalation planning and DNAPR decisions, sepsis management, better vital sign recording, using the NEWS, and timely escalation to critical care • “There has been real engagement with learning from cardiac arrests, and a clear commitment to improve outcomes for our patients, including improving end-of-life conversations.”

  20. Multi professional change: “Talking DNACPR” • Outreach Team (PERRT) • Psychologists • Educationalists • Lawyers, Ethicists • Palliative Care • Critical Care • Patients

  21. Multi professional change: “Talking DNACPR”

  22. What are your thoughts? John.Welch@nhs.net

  23. Measure / evaluate • Cardiac arrests - and potentially avoidable cardiac arrests • Timeliness of response to deterioration • Timeliness of critical care interventions • Whether patients with breach of escalation criteria have timely documentation of goals of care

  24. Measure / evaluate • Whether means are provided for patients and family members to activate the Outreach Team - and the frequency of activation • The safety culture in relation to deteriorating patients and their care • Length of stay on wards of patients with breach of escalation criteria • Length of ICU stay of patients transferred to ICU following breach of escalation criteria

  25. Rapid Response Systems (Outreach) & End of Life Care Jones D et al. CurrOpinCrit Care. 2013;19(6): 616-23.

  26. 46% of all deaths occur in hospital … Did patient die in right place?

  27. 46% of all deaths occur in hospital … Did patient die in right place? Quality of care by place of death

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