‘PICD’ – an integrated end of life care pathway

Dr Michael Franco – Palliative Medicine Physician & Medical Oncologist, Southern Health, Christine MooneyChristine Mooney, Palliative Care Nurse Consultant; , Palliative Care Nurse Consultant; Gabrielle OGabrielle O’’ConnorConnor, Palliative Care , Palliative Care Nurse Consultant (Manager); Nurse Consultant (Manager); A/Prof Kate JacksonA/Prof Kate Jackson, Director Supportive and Palliative , Director Supportive and Palliative Care; Care; Dr Dr LeeroyLeeroy WilliamWilliam, Palliative Medicine Specialist; , Palliative Medicine Specialist; Ben EvansBen Evans, Palliative Care , Palliative Care Consult Nurse; Consult Nurse; Kaye WalshKaye Walsh, Palliative Care Consult Nurse; , Palliative Care Consult Nurse; Pam HoskingPam Hosking, Palliative Care , Palliative Care Consult Nurse; Consult Nurse; Peter Peter PoonPoon, Palliative Medicine Specialist, Palliative Medicine Specialist

• A very wise man once said…“I still don't know what I was waiting for, And my time was running wild. A million dead-end streets, Every time I thought I'd got it made, It seemed the taste was not so sweet……Ch-ch-ch-ch-Changes …Turn and face the strain Ch-ch-Changes Just gonna have to be a different man Time may change me But I can't trace time”

• Created in 2007

• Aim was to create an End of Life Pathway for non-palliative care specialist staff to use at Southern Health• Four main campuses• Over 1000 beds

• Used the Liverpool Care Pathway as a starting point• Aimed for brevity• To be fully integrated into patient’s history and used at the bedside as the

nursing care plan

• With support and input of senior medical and nursing staff of General Medicine

• Initial project funding through a training and development grant from the Department of Health

• Funding used for a project officer• One of Southern Health’s existing Palliative Care Nurse Consultants

• Already well known to the staff on wards and understanding of the Southern Health system

• Funded for 0.5EFT to audit, then implement and trial PICD

• Initially to four general medical wards

• Project manager:• Performed an audit of all deaths for two months prior to implement• Ran education sessions to a total of over 200 staff members• Provided ongoing support to each of the wards during trial of PICD• Performed a second audit after the first two months of PICD

• Great results!!• Examples (pre vs post-PICD):

• Pastoral Care involvement – 0% vs 70%• Social Worker involvement – 40% vs 75%• Medications appropriately ceased and prn charted – 70% vs 100%

• No more funding for project manager

• Repeat audit at 12 months

• Not Great Results!!

• A significant amount of the initial gains were given back:• Examples (pre vs 2 months post-implementation vs 24 months post-

implement):• Pastoral Care involvement – 0% vs 70% vs 48%• Social Worker involvement – 40% vs 75% vs 61%• Medications appropriately ceased and prn charted – 70% vs 100%

vs 93%

• Twelve months of intensive, aggressive education and training was not long enough to ingrain cultural and system change

• On review with the wards, it was found that it was the lack of an ongoing education and mentoring that was the key component in losing the initial gains

• Ideas for improvement• Rotating junior medical staff• New nursing staff• Refresher courses for permanent staff

• Some more funding gained from the Department of Health used to reinstitute Project Officer

• Project Officer concentrated on education sessions and promotion of use of PICD rather than getting involved at the level of individual patient

• Improved results on repeat auditing

• Renewed enthusiasm from Health Service, other wards, doctors and nurses

• Rollout to other sites, in particular Oncology

• Easier than other wards• Experienced in working in a multidisciplinary team• Used to having family meetings and discussions regarding

prognosis, limitation of treatment, death and the dying process

• Gains made on the pre vs post audits smaller, as baseline statistics good already• E.g. Discussion goals of care: 87% pre- & post-implementation

• Worked as an affirmation of current practices more than changing patient care

• PICD instituted:• Stroke Unit• Dandenong Hospital General Medical Wards

• Interest from ED and ICU

• More enthusiasm!

• Small palliative care consult service stretched thinner and thinner for resources with increasing demand for PICD

• Involving Medical Unit Heads and Nurse Unit Managers empowering them to take responsibility for PICD in their unit

• Nurse Champions

• Large nursing education program

• Repeated education programs to rotating junior medical staff

• Developing a DVD to enable online training with our unit doing the initial training and then providing subsequent advice and support

• PICD used on 650 patients so far in the acute hospital setting

• Hospital Executive instituting a policy for end-of-life care• Therefore, PICD has high level support and is mandated for use with all

dying patients across Southern Health• Available on hospital intranet and on wards• Some extra resources may become available

• The successful implementation of a pathway requires very different strategies and foci in the initial stage vs the ongoing sustenance of the protocol

• Hands on involvement at a ward level is the key component of initial success of instituting the rollout of a new pathway• Builds a ‘grass roots’ knowledge base to handle the basics of using the

pathway• Allows development of enthusiasm in staff• Leads naturally to the emergence of ward champions

• Ward Champions• Benefits for the champions:

• Professional development• Valuable additions to their CV• Job satisfaction

• Benefits for the protocol• Provision of the hands-on support to free up the time of the project

manager• No funding needed

• Education and mentoring, rather than involvement at the ward level is the key component of ongoing success of instituting the rollout of a new pathway

• Get support on three levels• Executive level• Unit level• Ward level

• Funding helps!

• It is easier to establish an end-of-life pathway in wards that are experienced in dealing with these issues• Inpatient Oncology Unit• ? Inpatient Palliative Care Units

• We did not encounter the problem of:• “We’re already doing this well – we don’t need new unnecessary

paperwork to tell us how to do it”

Many thanks for your attention