AMBER Care Bundle Research Articles

Communication is key: implementing the AMBER care bundle

Communication is key: implementing the AMBER care bundle

117 Hospital @Home and the Amber Care Bundle: Introducing the Concept of Uncertainty of Survival to Improve Advance Care Planning

Abstract Introduction GSTT@home is a hospital@home providing multi-disciplinary acute care in peoples’ homes throughout Lambeth and Southwark. AMBER is an internationally recognised care bundle to improve care for hospital inpatients where survival is uncertain. The bundle prompts recognition of survival uncertainty, communication and advance care planning (ACP)- principles relevant to many hospital@home patients. This quality improvement project aimed to embed these principles into GSTT@home by adapting AMBER to this community setting. Methods Cycle 1 Plan- Determine whether @home patients might benefit from principles of AMBER. Do and Study- Audit patients >80 years that died within a 3-month period after @home admission (January–June 2018); one in 10 patients died (10.9%), median age 82 and median CFS 8. Act- Inpatient AMBER bundle adapted for @home setting to systemically identify and prompt ACP. Cycle 2 Plan and Do- AMBER@Home bundle formally introduced and piloted with @home, education using posters and lanyard cards. Study Audit use of AMBER@Home for patients >80 years who died within three months of discharge from @home (August–October 2019). Act- AMBER@Home incorporated into daily handover document. Cycle 3 Plan and Do- Further education embedded AMBER@Home, increased consultant and GP support. Study- Use of AMBER@Home re-audited as above for November 2019–January 2020. Conclusions Using AMBER@Home appears to have changed practice without the AMBER bundle being formally used. Throughout 3 audit cycles there was a steady increase in ACP. Future planned interventions include appointing a frailty nurse to @home team to further embed AMBER@Home, distributing lanyard cards more often and using “Coordinate My Care” to improve accessibility to ACP decisions including PEACE.

Seeing is believing – healthcare professionals’ perceptions of a complex intervention to improve care towards the end of life: A qualitative interview study

Background: Methods to improve care, trust and communication are important in acute hospitals. Complex interventions aimed at improving care of patients approaching the end of life are increasingly common. While evaluating outcomes of complex interventions is essential, exploring healthcare professionals’ perceptions is also required to understand how they are interpreted; this can inform training, education and implementation strategies to ensure fidelity and consistency in use. Aim: To explore healthcare professionals’ perceptions of using a complex intervention (AMBER care bundle) to improve care for people approaching the end of life and their understandings of its purpose within clinical practice. Design: Qualitative study of healthcare professionals. Analysis informed by Medical Research Council guidance for process evaluations. Setting/participants: A total of 20 healthcare professionals (12 nursing and 8 medical) interviewed from three London tertiary National Health Service hospitals. Healthcare professionals recruited from palliative care, oncology, stroke, health and ageing, medicine, neurology and renal/endocrine services. Results: Three views emerged regarding the purpose of a complex intervention towards the end of life: labelling/categorising patients, tool to change care delivery and serving symbolic purpose indirectly affecting behaviours of individuals and teams. All impact upon potential utility of the intervention. Participants described the importance of training and education alongside implementation of the intervention. However, adequate exposure to the intervention was essential to witness its potential added value or embed it into practice. Conclusion: Understanding differing interpretations of complex interventions is essential. Consideration of ward composition, casemix and potential exposure to the intervention is critical for their successful implementation.

Patient and carer experiences of clinical uncertainty and deterioration, in the face of limited reversibility: A comparative observational study of the AMBER care bundle

Background: Clinical uncertainty is emotionally challenging for patients and carers and creates additional pressures for those clinicians in acute hospitals. The AMBER care bundle was designed to improve care for patients identified as clinically unstable, deteriorating, with limited reversibility and at risk of dying in the next 1–2 months. Aim: To examine the experience of care supported by the AMBER care bundle compared to standard care in the context of clinical uncertainty, deterioration and limited reversibility. Design: A comparative observational mixed-methods study using semi-structured qualitative interviews and a followback survey. Setting/participants: Three large London acute tertiary National Health Service hospitals. Nineteen interviews with 23 patients and carers (10 supported by AMBER care bundle and 9 standard care). Surveys completed by next of kin of 95 deceased patients (59 AMBER care bundle and 36 standard care). Results: The AMBER care bundle was associated with increased frequency of discussions about prognosis between clinicians and patients (χ2 = 4.09, p = 0.04), higher awareness of their prognosis by patients (χ2 = 4.29, p = 0.04) and lower clarity in the information received about their condition (χ2 = 6.26, p = 0.04). Although the consistency and quality of communication were not different between the two groups, those supported by the AMBER care bundle described more unresolved concerns about caring for someone at home. Conclusion: Awareness of prognosis appears to be higher among patients supported by the AMBER care bundle, but in this small study this was not translated into higher quality communication, and information was judged less easy to understand. Adequately powered comparative evaluation is urgently needed.

Supporting patients with uncertain recovery: the use of the AMBER care bundle in an acute hospital

ObjectivesPatients who are deteriorating, with uncertain recovery and with a short prognosis often have complex needs. The AMBER care bundle systematically manages these patients by promoting consistent communication and care...

Improving care for patients whose recovery is uncertain. The AMBER care bundle: design and implementation

IntroductionDespite preferences to the contrary, 53% of deaths in England occur in hospital. Difficulties in managing clinical uncertainty can result in delayed recognition that a person may be approaching the...

Improving care for patients whose recovery is uncertain. The AMBER care bundle: design and implementation.

Despite preferences to the contrary, 53% of deaths in England occur in hospital. Difficulties in managing clinical uncertainty can result in delayed recognition that a person may be approaching the end of life, and a failure to address his/her preferences. Planning and shared decision-making for hospital patients need to improve where an underlying condition responds poorly to acute medical treatment and there is a risk of dying in the next 1-2 months. This paper suggests an approach to improve this care. A care bundle (the AMBER care bundle) was designed by a multiprofessional development team, which included service users, utilising the model for improvement following an initial scoping exercise. The care bundle includes two identification questions, four subsequent time restricted actions and systematic daily follow-up. This paper describes the development and implementation of a care bundle. From August 2011 to July 2012, 638 patients received care supported by the AMBER care bundle. In total 42.8% died in hospital and a further 14.5% were readmitted as emergencies within 30 days of discharge. Clinical outcome measures are in development. It has been possible to develop a care bundle addressing a complex area of care which can be a lever for cultural change. The implementation of the AMBER care bundle has the potential to improve care of clinically uncertain hospital patients who may be approaching the end of life by supporting their recognition and prompting discussion of their preferences. Outcomes associated with its use are currently being formally evaluated.

IMPLEMENTATION OF THE AMBER CARE BUNDLE: A WAY TO MANAGE UNCERTAINTY

BackgroundWarrington and Halton NHS Foundation Trust is a part of Transforming End of Life Care in Acute Hospitals. The Transform programme advocates the use of tools and enablers to standardise...

LAST YEAR OF LIFE PROJECT: BRADFORD TEACHING HOSPITALS FOUNDATION TRUST

Aimto improve care of patients identified in their last year of life by increasing the number of patients identified in their last year of life; recording patients' Preferred Place of...

AN INNOVATIVE DEVELOPMENT APPROACH FOR ACUTE HOSPITAL SENIOR CLINICIANS TO IMPLEMENT THE NATIONAL EOLC STRATEGY 2008

BackgroundApproximately half the annual 600,000 deaths in England occur in acute hospitals although research indicates that most would choose to die elsewhere. The National End of Life Care Strategy encourages...

Collaborative services show positive outcomes for end of life care

The authors outline the benefits of participating in the Transforming End of Life Care in Acute Hospitals Programme. The article describes the introduction at Worcestershire Acute Hospitals NHS Trust of the amber care bundle, an approach used in hospitals when clinicians are concerned that patients are acutely unwell and their potential for recovery is uncertain. The bundle is supported with staff education and carer feedback using the VOICES questionnaire, which carers or relatives fill out post-bereavement. The authors also discuss the potential to measure outcomes to indicate quality, by linking the amber care bundle quality audit and the adapted VOICES questionnaire to demonstrate the impact of the introduction of the amber care bundle.

010 Inspiring compassionate care in an acute hospital setting – the power of QELCA

Transforming the traditional delivery of specialist end-of-life care education and training for nursing staff in acute hospital settings through the Quality End of Life Care for All (QELCA) education and...

Bringing in care planning conversations for patients whose recovery is uncertain: learning from the AMBER care bundle

60 per cent of people in our inner city area die in an acute hospital. The hospital provides good care to patients known to be dying through the Liverpool Care...