27 A COLLABORATIVE QUALITY IMPROVEMENT PROJECT BETWEEN AN NHS TRUST AND INDEPENDENT PROVIDER TO DEVELOP A CARE-HOME SPECIFIC TREATMENT ESCALATION PLAN

Abstract

BackgroundThe COVID19 pandemic highlighted deficiencies in information exchange around treatment escalation plans (TEP) in an intermediate care unit, based in a 30 bed independent care home, into which the hospital organisation assigns medical, pharmacy, physiotherapy, occupational therapy and social work teams to provide post-acute care rehabilitation for adults. Mean length of stay is 20 days and > 75% return home. Weekly bed turnover is approximately 15%.TEP documentation is a component of RESTORE2 use, as recommended in the British Geriatric Society Good Practice Guide for Managing COVID19 in Care Homes.MethodsSemi-structured interviews with nursing leaders and a weighted questionnaire for the whole nursing team were used to determine baseline levels of confidence around aspects of TEP.An Ishikawa diagram analysed factors contributing to poor documentation and communication. The ‘Chain Of Care’ vision for care home environments incorporated the need for a TEP. Three iterations occurred. A post-implementation weighted questionnaire collated qualitative information on confidence change.ResultsAreas of greatest ‘swing’ towards INCREASED or SLIGHTLY INCREASED confidence around...: 90%, Cardiopulmonary Resuscitation (CPR) status clarity; 90%, treatment ‘ceiling of care’ e.g. ‘conveyance to the Emergency Department in any situation that the clinical team deem necessary’; 40%, conversations with out-of-hours services/external clinicians around appropriate actions; 30%, conversations with nominated persons around appropriate actions.ConclusionThe TEP incorporates more than just CPR status and contributed to increased nursing team confidence in responding to the acutely deteriorating adult appropriately in a care home environment. Clear documentation of: capacity assessment; patient prioritisation (using ReSPECT principles); and agreed treatment escalation and limitation, enabled information exchange. Standardisation of language, and cross-fertilisation with Nursing Handover, facilitated conversations with external clinicians and nominated persons.Tailoring the TEP to the care-home environment and rendering it generalisable to non-intermediate care, non-geriatrician supported care home microsystems was considered in the iterations.