INTEGRATED CARE PATHWAYS Jo Hockley RGN MSc PhD University of Edinburgh Jo.hockleyed.ac.uk stcolumbashospice.uk

1. ‘INTEGRATED CARE PATHWAYS’ Jo Hockley RGN MSc PhD University of Edinburgh Jo.hockley@ed.ac.uk www.stcolumbashospice.org.uk Who has been involved with ‘setting standards’? How was it? Structure….process…..outcome! Quality circles Total Quality Management (TQM)Who has been involved with ‘setting standards’? How was it? Structure….process…..outcome! Quality circles Total Quality Management (TQM)

2. Similarities between TQM and critical pathways (Zander 1992) TQM Principle definition of quality consumer orientation work process focus preventative systems management by fact continuous improvement Critical Pathways sets process goals patient specific paths defines services required constant variance analysis & corrective actions documentation of problem & corrective action ongoing review & modifications

3. A pathway…. forms part of the clinical record & is ‘multi-disciplinary’ it is goal orientated includes ‘time intervals’ in which care is planned incorporates evidence-based guidelines is dynamic and variations from the pathway MUST BE documented provides a continuous evaluation of clinical practice Critical examination of clinical practice should be an integral part of patient care Use of guidelines which are research based wherever possible Failure to complete the audit cycle has largely been related to an inability to achieve changes in clinical practice or a failure to reassess the effect after changes have beenintroducedCritical examination of clinical practice should be an integral part of patient care Use of guidelines which are research based wherever possible Failure to complete the audit cycle has largely been related to an inability to achieve changes in clinical practice or a failure to reassess the effect after changes have beenintroduced

4. An ‘ICP’ for the last days of life What would be the ‘objectives’ for an integrated care pathway for residents dying in a NH?

5. What might some of the objectives be for developing a care pathway for dying residents in NHs? To monitor or document care being given in the last days of life To increase communication with the families of those residents who are dying when there might be a tendency to avoid To adopt ‘clinical guidelines’ into everyday practice - practicing ‘evidenced-base practice’ continued/…..

6. Objectives continued… To enhance greater multi-disciplinary working To increase staff awareness of the process of dying To improve the holistic care given to the dying and their families To increase nursing home staff competence in caring for the dying and

7. Diagnosing ‘dying’ The patient is: deteriorating without any reversible causes semi-comatose bed-bound taking little food/fluids & having difficulty with oral medication not wishing further investigations/interventions (BMA website)

8. Commencing a ‘pathway’ Multidisciplinary together nurses and the doctor establish whether the resident/patient is dying Initial Assessment Holistic Residents and family – physical and psychosocial Ongoing Assessments 4hrly assessments pain, agitation, breathlessness, nausea/vomiting, mouthcare, pressure areas, bowels/retention of urine, bedsides etc Daily assessments communication with resident/patient & family, spiritual needs, arrangements for family, dressings, bowels psychosocial aspects of care - communication with resident/patient & family

9. Reasons for ‘variance’ Patient’s clinical condition Patient’s social circumstances Associated diagnoses Changing technology or techniques Clinician’s decision not to follow the integrated care pathway

10. Conclusion - ICP’s locally agreed multidisciplinary documents care given uses guidelines & evidence specific patient/client group facilitates evaluation tool for audit & quality improvement

12. Changes in Prescribing after ICP implementation (Hockley et al 2004)

13. Change in recording/treating ‘end-of-life’ symptoms

14. Impact of the development for staff Overarching pattern: ‘DYING WAS LESS PERIPHERAL TO NURSING HOME CARE’ 5 themes: A greater ‘openness’ around death & dying Recognising dying & taking responsibility Better Teamwork Critically using PC knowledge to influence practice More meaningful communication There was this gradual realisation not only with us but with the staff that dying was now less peripheral to the care and taking a much more appropriate focus. 5 themes also emergedThere was this gradual realisation not only with us but with the staff that dying was now less peripheral to the care and taking a much more appropriate focus. 5 themes also emerged

15. A greater ‘openness’ around death and dying “..it’s not ‘hushed hushed’ discussion now – it is more open – the fact that now this person…they are on the ICP..OK, we’re expecting this person is going to die – quite imminent. It is not as ‘hushed hushed’ now – you are talking about it.” [KC. NH.D] “Yes, and instead of shutting people away – especially in the dementia unit, we used to put them in the sitting room with somebody standing outside the glass door so that they couldn’t leave – I don’t do that at all now. We prepare them.. And say, ‘so and so died and they’re going away shortly’..” [KC. NH.E]

16. Recognising dying and taking responsibility “I feel better equipped to anticipate problems whereas the contrast before the pathway…we were always on the back foot – the problems would happen and then we would try and deal with them and often there was a time lapse…getting drugs to deal with it whereas now everything is anticipated and you are prepared and so therefore you deliver a far better service.” [KC. NH.C] Nurses became more aware of their responsibility to the dying. Because the culture was so closed many hadn’t realised the importance of their role. The LCP document gave them confidence. McCue (1995) stresses the importance of making a diagnosis of dying – without this ‘it deprives the dying of their autonomy, leading to questions such as “Whose death is this?” We actually found that residents knew any way and often were trying to tell staff – but staffs’ ears had grown deaf through fear of not knowing whether it was OK to talk about death or not knowing what to say. There was a change of attitude from being REACTIVE to being PROACTIVE. The LCP helped them to MARK THE PROCESS OF DYING. Nurses became more aware of their responsibility to the dying. Because the culture was so closed many hadn’t realised the importance of their role. The LCP document gave them confidence. McCue (1995) stresses the importance of making a diagnosis of dying – without this ‘it deprives the dying of their autonomy, leading to questions such as “Whose death is this?” We actually found that residents knew any way and often were trying to tell staff – but staffs’ ears had grown deaf through fear of not knowing whether it was OK to talk about death or not knowing what to say. There was a change of attitude from being REACTIVE to being PROACTIVE. The LCP helped them to MARK THE PROCESS OF DYING.

17. Improving Teamwork “…The pathway – it draws everybody together, everybody is going in the same direction, everybody is doing the right thing and it makes a huge difference…” [SN. NH.C] “Communicating better with the doctors & being a bit up front about what we might need before we need it, we didn’t do that before.” [NHM. NH.D]

18. Critically using palliative care knowledge to influence practice “…if one of the carers comes and says he sounds a bit funny, you know, you won’t say, ‘Well, they always sound a bit funny when they are dying’. You say well OK, we’ll go and have a look at them.’ You know so you’re getting all the information from everybody and you’re acting on what you are getting… I think it’s been really good.” [KC. NH.A]

19. Deeper more meaningful communication “…not sort of brushing it off with a throw away comment…she’ll be fine tomorrow, but actually taking the time to sit and say ‘well what is it that is making you feel that way? There’s a lot more of that stuff that is happening, an awful lot more..” [KC. NH.C] “Accepting that death is a natural process [in older people] …..I didn’t know how to deal with death myself but this has enlightened me, made me accept death as a natural thing..” [KC. NH.A]

20. “..it’s a lot more relaxed and people aren’t so frightened…it’s been a really successful thing in bringing death and dying to the fore and not to be so frightened of it.” [SN3.NH.H – final evaluation]

21. References: Riley W (1998) Paving the way. Health Service Journal, 108: 30-31 Overill S (2003) The development role and integration of integrated care pathways in modern day health care. In: J Ellershaw & S Wilkinson (eds) Care of the Dying: a pathway to excellence. Oxford University Press: Oxford Ellershaw J & Wilkinson S (2003) Care of the Dying: a pathway to excellence. Oxford University Press: Oxford Zander K (1992) Critical Pathways. In: M. Minerva Melum & M. Kuchuris Sinioris (eds) Total Quality Management: the health care pioneers. American Hospital Publishing: Chicago. pp305-314 Hockley J, Watson J, Dewar B (2004) Implementing an integrated care pathway for the last days of life into 8 nursing homes. Bridges Initiative Report. St Columba’s Hospice