Friday, 30 August 2013

Liverpool Care Pathway - It's A Green Light For The Way Forward

The lights are at amber;
They're all set to go.
The CQUINs are ready-
As if they didn't know!

This is the 'tool' they used to dig your grave; the LCP was the 'tool' they used to toss you in it.

If idle talk costs lives, this is going to cost plenty. There is much backchannel chatter on the network.

On the Twitter network:
Katherine Sleeman ‏@kesleeman -
"Twitter drs/nurses: can you help me w some research for a talk? Is #LCP still in use where you work? Or gone? Very grateful all responses :)"
Ellie ‏@ellieornot -
"@kesleeman Still used where I work. Rather not say where publicly. Only recently rolled out on some wards (last 6 months). Has meant"
"huge improvement in Pall Care delivery. Prior to that most nurses in gen wards had no training in EoL care, no familiarity"
"..with meds. Was real fear of EoL management. That has thankfully changed since LCP intro."
"My exp of it good. Only ever seen it used appropriately, after careful contemplation & where possible discussion with family."
susan nattrass ‏@NattrassSusan -
"@kesleeman still offically in use but drs saying for tlc and writing up drugs from lcp ... so still lcp but no paperwork nurses usual care"
Benjamin Bloch ‏@Bloch_ortho -
"@kesleeman Principles of LCP still being used but has a new name. Looks identical to me tho."
Katherine Sleeman ‏@kesleeman -
"@Bloch_ortho thank you. New name since review?"
Benjamin Bloch ‏@Bloch_ortho -
"@kesleeman Can't remember exactly; something like amber bundleAmber something, anyway. Looks exactly like LCP..."
Claire Dickens ‏@ClaireLDickens -
"@kesleeman we are recommending continuing use for now. Use def dropped off tho. Some wards still confident to use, some less so"
Kate Granger ‏@GrangerKate -
"@kesleeman We have been advised by SPCT to continue using pathway. In reality most of us in Elderly Med aren't & using principles instead..."
Nintendo Police ‏@Rhincodon_T -
"@kesleeman @GrangerKate the #LCP was withdrawn where I work as soon as the negative stories surfaced in the media."
bridget coady ‏@coady98 -
"@kesleeman @GrangerKate Consultants are now not happy to use LCP shame as when used well its so beneficial"
TryingtobeaJuniorDr ‏@tryingtobeaDr -
"@kesleeman @GrangerKate gone, under instruction of chief exec."
Heather Lewis ‏@heatherilewis -
"@kesleeman @GrangerKate Gone where I work. Stopped the week of the report by chief exec due to concerns of loss of confidence by public"
Phil ‏@NCFC1979 -
"@kesleeman @NurChat we use the LCP @CUH_NHS, however there does appear to be hesitance to start the LCP possibly due to bad publicity."
"what I like about the LCP as a nurse it provides guidance and reassurance, key element is to communicate to the NOK."
[My note: CUH = Cambridge University Hospitals = Addenbrookes]
Fabrizio Motta ‏@cinghio81 -
"@kesleeman still in use in our hospice ward; still in "experimental" phase its use in internal med wards. Yes we're running 10 yrs late..."
Katherine Sleeman ‏@kesleeman -
"@cinghio81 'experimental phase' suggests a test which can only be a good thing. Thanks."
Fabrizio Motta ‏@cinghio81 -
"@kesleeman we can only hope so as #hpm awareness is growing in Italy #hpmglobal"
[My note: hpm = hospice and palliative medicine]
laura vincent ‏@mrsbungy -
"@kesleeman still considered gold standard where I work but only following proper conversation with family"
Trisha Macnair ‏@bluebass2 -
"@ibundle @kesleeman Our guidance is to stand by general principles (simply good and frequent symptomatic care) without the formal LCP" 
Paula Tucker ‏@ibundle -
"@bluebass2 @kesleeman do you think care has changed as result of what's happened with #LCP ? Sounds like not"
 Trisha Macnair ‏@bluebass2 -
"@ibundle @kesleeman Not really. We have always individualised it and give plenty time to family, to explain approach and ask if they agree"
qp nell ‏@qpnell -
"@kesleeman much confusion in primary care. GPs no idea & nursing homes worried about implications of using LCP now."
wishiwasgold ‏@wishiwasgold -
"@kesleeman still there (ie not rescinded) but not used... #LCP"
Terri Freeburn ‏@terrifreeburn -
"@kesleeman @NurChat nope, I work in a specialist palliative care unit and lcp stopped a few weeks ago!"
Liz Sampson ‏@DrLizSampson -
"@kesleeman still using principles just with the name and documentation dropped. Refs to pall care gone up as gen staff confidence gone down"
Toby Hillman ‏@tobyhillman -
"@kesleeman not in use at my place. Mandated day after the report published. Alternative not widely publicised - not had need myself recently"
Katherine Sleeman ‏@kesleeman -
"@tobyhillman thank you. So, there is an alternative in place? Do you know what?"
Toby Hillman ‏@tobyhillman -
"@kesleeman I don't know if there is a specific replacement, more just generic principles. But not certain - (good eg of the problem!)"
Kate ‏@Knit1jog1 -
"@kesleeman we're not using the paperwork but very much the principled. (Palliative care huge part of Respiratory really)"
Elin Roddy ‏@elinlowri -
"@kesleeman We still using, but have (re) formed whole health economy EOL group and am writing new 'End of Life Plan' for use in all settings"
Katherine Sleeman ‏@kesleeman -
"@elinlowri thanks. Interesting. All settings as in community/CH/hosp? What will you do if/when national replacement comes out?"
Elin Roddy ‏@elinlowri -
"@kesleeman Yes all settings. If national replacement fits us will use, but we decided couldn't wait in limbo that long as EOL care wd suffer"
"Already reluctance to write up end of life meds if patients 'not on LCP' - we have become so used to it that need something to>>"
">>clearly signal to staff (and obviously pts & their families) what the focus of care is otherwise we risk (even more) confusion"
Shaun Lintern ‏@ShaunLintern -
"@kesleeman What are you doing with the info?"
Katherine Sleeman ‏@kesleeman -
"@ShaunLintern its for a talk to London Cancer Alliance. Want a feel for how many trusts following 6/12 guidance & how many have ditched it."

This is the Quality Account of the Burton Hospitals NHS Foundation Trust -

Pages 25 and 27 discuss The Amber Care Pathway or 'bundle'. Mr. Lamb said not to mention the Pathway... And they think they've got away with it.
During the year the Trust has undertaken an end of life audit, which has identified areas of improvement which have been implemented. This will assist with the work required in 2013/14, as the Trust participates in the national AMBER CARE bundle 
Page 27 of the Account discusses the CQUIN payments and provides a table of those schemes eligible to qualify for CQUINs.

Areas for CQUIN payment framework in 2013/14 -
The CQUIN schemes for 2013/14 have been determined following discussions with Commissioners and also through areas identified nationally as topics for further quality improvements. Some of the CQUIN topics have been carried over into the new operating year, but given renewed focus and further standards for achievement. The table below details the extensive set of CQUIN topics, along with their rationale for inclusion in this year’s contract.

'End of Life' is one of the areas carried over into the new operating year. 

The 'Rationale' is 'Implementation for patients in whom recovery is uncertain'.

Say that again?

"Uncertain"! They have actually broadened the scope of the Pathway Bundle! And the CQUINs are in place!

They're being paid to seek out the weak, the more frail and the vulnerable with a view to finish them off.

Why is not everyone up in arms who raised the hue and cry against the LCP? They're slipping this in under the radar.

Look, if you're going to have euthanasia, be honest and call it euthanasia. At least Philip Nitschke is straight about what he's about and actually points out the economic benefits of - well, to cut a long life short - limiting life!

And there's more...

This is from the Public Meeting of the Board of Directors of the Heatherwood and Wexham Park Hospitals NHS Foundation Trust -

The local CQUINs  have a higher contract value (bounty) than the national ones. There is also a focus on admission avoidance which will ensure the local EoLC GP Register is reinforced and palliative rather than curative options are adhered to.

The Deputy Director of Nursing noted that the local CQUIN programme for 2013/14 had a higher contract value than the national one. The local programme had two key areas; firstly end of life care which followed from the 2012/13 quality accounts and focussed on patients on the amber care bundle (patients at risk of dying in the next one to two months) and would audit if these patients had died in their documented preferred place of death. The second focus was around working with Berkshire Healthcare Foundation Trust on admission avoidance and patient flow and pathways.
The National CQUINs are 0.5% of contract value; the local CQUINs are 1.5% of contract value.
Key issues, risks and actions arising from this paper:
  • Risk of litigation if patient care falls below the required standard
  • Significant financial risk if CQUINs not met (anticipated £4.8M)
£4.8 million... Loadsamoney! 
2013/2014 sees the first year of a pre-qualification criteria for the National and Local CQUIN programme which requires 50% compliance to enable payment for any achieved CQUINs. It is anticipated that the value of the entire CQUIN programme will be worth approximately £4.8 million.
Loadsa, loadsamoney!
End of Life Care
The EOL care CQUIN will focus on patient choice around preferred place of death. A bi-annual audit will be utilised to determine the number of patients on the AMBER care pathway and determine whether preferred place of death was achieved or not and factors contributing to this. 
This will contrive to ensure patient admission and patient 'preference' requirements are complied with and also maintain CQUIN targets. Pack them off home and make them comfortable.

Here is the Guy's & St. Thomas' NHS Trust Board Quality Committee -

End of Life care - Sustain and roll out AMBER care bundle; all new referrals on GOLD register & training & education -
CQUIN indicators for the quarters in 000s - 
£146, £694, £146, £694

Important Note: 
LCP use may have increased with earlier recognition of dying following the AMBER care bundle implementation.
Reduced in-hospital mortality.
There is a trend identified which may be at least partly related to the AMBER care bundle i.e. a reduction in-hospital mortality associated with the bundle having been rolled out across key wards in the Trust.

The graph records the number of in-patient deaths across a six-year period from 2006/01 to 2012/01. A median figure of 91 is recorded for the period up to 2011/01. A median figure of 83 is recorded for the period 2011/01 up to 2012/01.

A median figure is exactly that; it is the ‘middle’ figure. Statistically, a median is useful for detecting a trend, but figures and statistics can be used to demonstrate something - anything - not inaccurate in itself, but by interpretation inaccurate.

It is difficult to accurately discern from the graph depicted the recorded mortality figures, month by month. However, a cursory glance at the graph suggests a significant median shift from the period 2006/01 to 2007/11, approaching 2008/01, to the next.

The graph appears to indicate a trend of higher in-patient mortalities with notable peaks above the median line during the period 2008/01 to 2011/01. What caused that..?

Was there a 'great leap forward' during this period to press ahead with Pathway implementation? Were Chairman Ellershaw's red guards Bee-ing ahead about their business?

The DoH had committed to investing 286 million pounds over the two years to 2011 to support implementation of its National End of Life Care Strategy.

This document was jointly written by the National Council for Palliative Care and the National End of Life Care Programme -
"The purpose of this briefing is to help you to identify the immediate priority actions to commission effective end of life care, focusing on steps which we believe will make the most difference initially and can be seen as ‘quick wins’."
"Quick wins". They're talking about people...
"We are investing £286 million over the two years to 2011 to support implementation of the End of Life Care Strategy to help improve end of life care for all adults, regardless of where they live.”The Telegraph
Loadsa, loadsa, loadsamoney...!

Responding to the apparent statistical median shift attributed to implementation of Amber, this is more to do with nursing staff paying attention than to the EoL pathway. As has been shown to be the case, better care means better outcomes and more attentive care is better care.

In addition, if it is policy to parcel them off home for 'comfort care' then, of course, you are going to see a reduction in in-patient deaths.
The AMBER CARE bundle
The AMBER care bundle was developed at Guy's and St. Thomas' through an initiative that was funded by the Guy's and St. Thomas' Charity. It was developed to improve the quality of care of patients who are at risk of dying in the next one to two months but may still be receiving active treatment.
AMBER is now ‘live’ on 21 wards at GSTT. We have seen the number of patients cared for on AMBER increase by over 150% in the past financial year (201 in 2010-2011, vs 543 in 2011- 2012). AMBER is also being rolled out to 25 Trusts nationally, through the national ‘End of Life Care Route to Success’ programme, with 15 further hospitals interested in becoming AMBER sites.
This is the Isle of Wight NHS Trust Quality Account 2013 -

Priorities for Improvement for 2013/14 and Development of the Quality Account

Priority 1: Reducing Mortality rates
Priority 2: Prevention of Pressure Ulcers
Priority 3: Improving Communication 
Priority 4: End of Life Care (AMBER Care Bundle)

The AMBER care bundle© was developed at Guy's and St Thomas' NHS Foundation Trust through an initiative that was funded by Guy's and St Thomas' Charity. It was developed to improve the quality of care of patients who are at risk of dying in the next one to two months but may still be receiving active treatment.

It has been noted elsewhere and previously that use of the Amber Pathway actually improved uptake by the Liverpool Pathway. We have been here before. It is not possible to 'diagnose' dying. And "here we are again, dying as can be...!"

The Isle of Wight NHS Trust is keen to implement the AMBER Care Bundle to make it easier for Nurses and Consultants to have appropriate planning conversations with patients whose recovery is uncertain, thereby enhancing the patient experience and care of patients with palliative care needs and enables patients to be involved in decisions about their care and where they wish to die.

With the LCP, they had 'that' conversation with patients who 'are' at risk of dying.

They are now going to have 'that' conversation with patients who 'may be' at risk of dying. This is not just seeing the glass half empty instead of seeing the glass half full; it is actually tipping the water out to half-empty the glass!

There is also a Priority of Care to reduce mortality rates. Well, that's handy, Harry. Put them on the pathway bundle and their backs are covered.

In many respects, this is worse than the LCP; it is more broad, more all encompassing; it is trawling the net 'wider than before, better than before...' This is the six million dollar plan!

Conceding a position on the field of battle has won them the war. NOT!
Key performance indicators for 2013-2014 
Implementation Number of agreed wards using the AMBER Care bundle – target  100%
Evaluation & Impact Audit of patients’ healthcare records in January 2014 – 60% of  patients audited have completed AMBER care bundle
Dementia is a significant challenge for the NHS with an estimated 25% of acute beds occupied by people with dementia, leading to increased length of stay due to delays in leaving hospital. It is for this reason that it is necessary to single these people out and find them and it has been made a Quality Account priority for 2012/13. Thus, there is a CQUIN or bounty in place in the dementia hunt for 2013.

The scheme includes all patients aged 75 and over admitted with a length of stay longer than 72 hours (excluding those with known dementia or clinically unfit for assessment). It requires that over 90% of these patients are asked the Dementia Screening Questions. Subject to the result of this screening process, the provider is then required to undertake an Abbreviated Mental Test score (AMT) on more than 90% of this cohort. Finally if the patient scores 8 or less on the AMT, then at least 90% of these should be referred to the Memory service (or other appropriate service).

The Isle of Wight NHS Trust needs to achieve the following as part of the FAIR (Find, Assess and Investigate, Refer) dementia process:
• Find - 90% or greater of eligible patients screened (75 and over staying greater than 72 hours) asked the dementia screening question.
• Assess and Investigate – 90% or greater for those patients identified as failing the dementia screening question as above, assessed using the AMT.
• Refer – 90% or greater of those with a score of 8 or less on the AMT referred onto the Memory or other appropriate service.
The above standards need to be achieved for 3 consecutive months in order to receive the associated CQUIN payment and for 100% achievement of the priority.

Everyone has memory problems and might fail that 'test', but the over-75's are singled out.

This is not diagnosis; this is categorisation.

Amber is taking off.

Recruiting at University College:
Audit of Acute Medical Unit and Care of the Elderly units in UCLH
ucl medical society
A medical student is required to participate in auditing the medical notes of clinically unstable patients from the Acute Medical Unit and Care of the Elderly units of UCLH. This is in preparation for the AMBER care bundle due to be introduced in UCLH from January 2014.

Using End of Life Care funding, Worcester Royal Hospital have rolled out AMBER across 12 wards and have spoken on a national platform about their work in this area. It is our intent to promote the adoption and spread of AMBER during 2013/14.
York Teaching Hospital recently appointed an EOLC Educator on a fixed term basis to focus on Amber and Advance Care Planning.

The team will implement the ‘Amber Care Bundle’ on 2 wards, the bundle is a tool to identify patients who are at risk of passing away during their hospital admission...
And half way across the planet in New South Wales. An Action Plan 2013-2018 reports that Amber is being trialled Statewide.

Amber is here.

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