Primary care rapid response assessment of dysphagia in end of life care Provided by: Sandwell Community Healthcare Services

Transcription

1 Primary care rapid response assessment of dysphagia in end of life care Provided by: Sandwell Community Healthcare Services Summary Sandwell Community Healthcare Services improved dysphagia management and piloted a community dysphagia rapid response assessment service. Quality was improved by allowing more patients to be managed at home for terminal illnesses, and increasing empowerment for patients, their carers and staff. Productivity has been improved by reducing hospital referrals and admissions. Evidence summary Yes Yes Yes The intervention has been successfully implemented The intervention is linked to standards or guidance An evaluation of the effects of the intervention has been carried out The proposal Proposal description Acute hospital attendance, length of stay and repeat admissions will be reduced by: 1. community rapid response dysphagia assessments for patients at risk of aspiration; and 2. training of primary care staff in the management of patients with dysphagia There are three components to this proposal: Responsiveness A rapid response dysphagia service in the community, where urgent patients will be assessed within 4 working hours, reducing hospital admissions. Prevention Extensive training to community staff to enable frontline dysphagia management 24 hours, 7 days a week long term. Strategy Develop and implement a palliative feeding Care Pathway to ensure patients with dysphagia related end of life conditions are managed by community services, ensuring patients die in their place of choice whilst they, their relatives and carers feel Page 1 of 6

2 supported. Purpose of change Evidence suggests that 45% of patients with palliative care needs report communication or swallowing (dysphagia) problems (Communicating Quality 3, Royal College of Speech & Language Therapists 2007). Therefore, based on current palliative care figures within Sandwell, 1,388 patients each year will expect to have problems with swallowing and communication at the end of their life and would benefit from Speech and Language Therapy (SLT). There are a range of aetiologies where SLT would be involved including: progressive neurological illnesses (Parkinson's disease, motor neurone disease, multiple sclerosis, dementia); respiratory disease; elderly frail; and cancer (brain, lung, head & neck, upper digestive tract). Patients were seen by primary care SLT but they were not able to provide a rapid response service or training to primary care staff in the early identification and management of dysphagia or end of life related difficulties. 37% of hospital SLT referrals were for palliative feeding and could have been assessed and managed at home with the right resources and support. Relatives and staff caring for patients with dysphagia are often anxious around dysphagia management, when this is associated with the end of life. Patients were repeatedly admitted to hospital or referred to community SLT where there was unclear decision making around end of life and feeding at risk. Pathway group Type of change Related standards and guidance End of life care Service redesign to provide a primary care rapid response speech and language therapy service in end of life care to avoid unnecessary admissions to secondary care This service development supports 'Care closer to home', 'Admission avoidance' and ensures that the patient has choice over their preferred place of death. It would target older people, neurological conditions & palliative care. References National Service Framework for Long Term Conditions (2005) End of Life Care Strategy - promoting high quality care for all adults at the end of life (2008) Report from West Midland End of Life Clinical Pathway Group NHS Operating Framework 2009/10 Page 2 of 6

3 Our care our health our say, Darzi (2008) General Medical Council (GMC) (2002) Withholding and Withdrawing Life-Prolonging Treatments: Good Practice in Decision-Making. London: GMC The British Psychological Society & The Royal College of Psychiatrists, (2007). A NICE-SCIE Guideline on supporting people with dementia and their carers in health and social care. Published by The British Psychological Society and Gaskell. ISBN: Other information Patients will be identified with dysphagia earlier; therefore ensuring they receive immediate management of their difficulties, advanced care planning regarding feeding and monthly reviews, by competent primary care key workers. There will be rapid access (four working hours response time) to a specialist speech and language therapy assessment for more complex dysphagia, avoiding the need for hospital admission and ensuring the patient has choice over their preferred place of death. Fewer hospital admissions thus reducing the risk of acquiring a hospital related infection and allowing patients to die in their place of choice. Rapid assessment, advice and management of acquired communication difficulties enabling patients to continue to express their wishes regarding intervention, consent and preferred place of death. Health benefits for the above include: maintained function; reduced risk of choking; reduced anxiety and distress for patients, families, carers and health professionals; and prevention of complications. Clinical Outcomes Data (East Kent Outcomes System) from 2006 supports the above health benefits and indicates that there was a positive outcome for 83% of the episodes of care for patients with end of life feeding related to dementia. The 17% with a poor outcome were either admitted to hospital or died before the episode of care was completed. This proposal would increase the number of positive episodes of care. Evidence of implementation Organisations where the proposal has Sandwell Community Healthcare Services Page 3 of 6

4 been implemented Effect on quality of care Safety 75 staff have been trained across institutions and primary care. Refresher training has been carried out for 5 homes where turn over of staff is high. Effectiveness 480 urgent contacts have taken place with 80 episodes of care completed in the 6 months from April 09 - August admissions have been avoided following an urgent assessment. 47% reduction in the number of ward referrals within Sandwell Hospital for dysphagia related end of life dementia. (N= 50). 42 patients with end of life dysphagia have been transferred to community service from secondary care for follow up and support. Patient experience Nursing homes: Following training there has been an increase in the number of community referrals, but fewer admissions to hospital. It has also increased awareness of the rapid response service and improved the relationship between the SLT and nursing teams. Nursing home staff are more likely to phone for a second opinion, to discuss whether or not a referral is appropriate and to problem solve over the telephone. This has meant that inappropriate referrals have been avoided, freeing up time, so SLTs can focus on appropriate complex cases. Nursing Home staff have fed back that they are now more confident in managing dysphagia, e.g. end of life care in advanced dementia, including feeding at risk. Family and carers: Comments have included 'brilliant, responsive service'. 'Feel reassured and empowered.' Nursing Home & SLT staff have reported an outcome as positive, even when the client died, because they were able to stay in their own bed, surrounded by their relatives and staff they knew, rather than being admitted to hospital and dying in a strange environment with unfamiliar staff. Clients have been helped to have a 'good death'. This fits in with a palliative model of care and is also consistent with the national agenda of increasing care in the community rather than secondary care. Effect on productivity The average length of stay for each end of life admission is 10 days at a cost of 300 per day. Avoiding 75 admissions so far this financial year has saved 225,000. Timescales for The data relates to the period from April 09 to the end of Page 4 of 6

5 realisation of benefits September 09. Additional costs One band 5 speech and language therapist and travel costs Further evidence Evaluations Number of referrals, nursing home staff confidence in dysphagia management, number of avoided admissions, family and carer satisfaction with end of life care, end of life feeding pathway. Please see above for initial data. Implementation advice Implementation guidance One additional Band 5 speech and language therapist was employed. This was supported by an existing Band 7 to provide leadership and operational management. The therapists sit within Sandwell Community Healthcare Service s Primary Care Rehabilitation Team. The expected time frame of the initial project was 12 months. The project is now in it's second year. There is a 50% training component to this post providing targeted training to meet the varying needs of course participants. The training modules delivered range from awareness raising of dysphagia to palliative care and feeding, depending on the band of staff attending. Further considerations For this to have succeeded locally we had to restructure the department and ensure routine appointments were dealt with in a timely way, this was achieved over a year by the implementation of appointment slots and no waiting lists. Urgent appointments are now just that, urgent, as all other appointments are seen within 5 working days. There needs to be collaborative working with the private sector i.e. nursing homes to receive the training and support from palliative care services in community to support diagnoses that are not normally supported by end of life care e.g. dementia. There needs to be a willingness of the speech and language therapy team to challenge tradition and work to the same vision. Contacts and resources ruth.williams2@nhs.net Rehabilitation Service - Sandwell Community Healthcare Services ID: 1178 Page 5 of 6

6 Page 6 of 6