Improving the use of treatment escalation plans: a quality-improvement study.
OBJECTIVES
Treatment escalation plans (TEPs) are vital in communicating a ceiling of care. However, many patients still deteriorate and die without a pre-established ceiling of care for attending clinicians to rely on. We aimed to increase the proportion of suitable patients that have TEPs in place in a rural district general hospital.


METHODS
We undertook three 'Plan-Do-Study-Act' (PDSA) cycles between 1 December 2016 and 9 June 2017. These cycles aimed to assess the problem, implement a solution and monitor its sustainability. We sampled all acute medical admissions at different time points, focusing on the acute medical unit. We identified patients requiring TEP forms using SupportiveandPalliative Care Indicators Tool. Stakeholders were surveyed during the project, and a process communication map was developed to understand the human interfaces that occur when producing a TEP.


RESULTS
We sampled a total of 323 patients (PDSA 1, n=128; PDSA 2, n=95; PDSA 3, n=100). Following implementation of a 'talking to your doctor about treatment' leaflet, the proportion of patients who did not have a TEP but required one fell from 43% (n=38, PDSA 1) to 27% (n=20, PDSA 3) then to 23% (n=77, PDSA 3) (CI 0.6631 to 39.917, p=0.028).


CONCLUSIONS
This study highlights the challenges of TEP form completion. The impact of our intervention appeared to raise awareness of advanced care planning. The information contained in our leaflet could be distributed in more innovative ways to ensure patients unable to access textual information are able to receive this message.
['Sayma|Meelad|M|http://orcid.org/0000-0002-4635-6390', 'Nowell|George|G|', "O'Connor|Aedamar|A|", 'Clark|Gemma|G|', 'Gaukroger|Andrew|A|', 'Proctor|Dominic|D|', 'Walsh|Jamie|J|', 'Rigney|Brian|B|', 'Norman|Storm|S|', 'Adedeji|Andrew|A|', 'Wilson|David|D|', "O'hagan|Darren|D|", 'Cook|Victoria|V|', 'Carrington|Robbie|R|', 'Sekaran|Preshgena|P|', 'Wehbe|Maya|M|', 'Paterson|Duncan|D|', 'Welchman|Sophie|S|', 'Over|Jay|J|', 'Payne|Sheila|S|']
D016223:Advance Directives D057286:Electronic Health Records D006801:Humans D005791:Patient Care D010347:Patient Care Planning D010353:Patient Education as Topic D010934:Planning Techniques D017064:Process Assessment, Health Care D058996:Quality Improvement
adult palliative care quality in health care