Problem

Every patient admitted to the hospital should have a treatment escalation plan (TEP) form (see figure 1) filled out and placed in their medical notes as per our hospital’s policy. This should be done by the treating doctors, ideally by a registrar and countersigned by a consultant at the earliest opportunity. However, there is no clear consensus as to who specifically should take the responsibility to fill out the TEP form and when this should be done.

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Figure 1

Treatment escalation plan format at Northampton General Hospital NHS Trust.

Northampton General Hospital (NGH) NHS Trust is a district general hospital with 700 beds and an oncology service which provides both inpatient and outpatient care. Patients are admitted under the oncology team either via the emergency department or, more often, via the oncology emergency assessment bay (EAB). An acute oncology consultant reviews most patients the day after admission during the working week and that role is taken up by the on-call consultant during weekends. Patients are otherwise seen by their primary oncology consultant who would have allocated ward rounds during the week. It is the responsibility of the doctors looking after the patient to ensure there is a clear TEP form in their clinical notes and that this has been discussed with either the patient or their next of kin if they lack capacity.

Despite this, we had observed that when patients deteriorated out of hours on the oncology ward, often a TEP form had not been filled out. The on-call registrar or consultant may not know the patient very well and therefore deciding on the appropriate escalation of care for the deteriorating patient, while out of hours, was often difficult. In one instance, this led to a patient not being referred to intensive care when she deteriorated, while her primary oncology consultant would have wanted her to be referred. Thus, the proportion of patients having TEPs filled out seemed inadequate and was affecting patient care.

We decided to address this problem and increase the number of patients, admitted under oncology, with a valid TEP form filled out within 72 hours. We approached this using quality improvement methodology and aimed to achieve a rate of at least 80% of patients with a valid TEP form filled out within 72 hours of their admission.

Background

TEPs are used in some form across the NHS. It is either a specific inpatient TEP as in our trust, as advance care plans, as part of the 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) discussion or as part of a combined 'Recommended Summary Plan for Emergency Care and Treatment' (ReSPECT) form.1 The TEP form used at NGH is reproduced in figure 1.

Increasingly, in modern hospital medicine, it is seen as a positive process encompassing a range of treatments and not exclusively for a decision on cardiopulmonary resuscitation. The ensuing plan should outline what treatments should be offered (eg, intravenous fluids, blood products, antibiotics, nutritional support and renal replacement) as well as what may be inappropriate. This may or may not include escalation to critical care.2 3

TEPs which are clear, and initiated early in a patient’s admission, help facilitate and improve the care out of hours for patients who are unstable or at risk of dying.4 International prospective and retrospective studies of medical emergency team calls have also recommended improved advance planning of treatment escalation and limitation.5 Around a third of such calls resulted in end-of-life care discussions, the majority of which in patients with significant comorbidities.6

The National Confidential Enquiry into Patient Outcome and Death has consistently recommended that a clear escalation policy is in place, as well as a consultant-led discussion (including with the patient or their representative) around escalation and of what interventions are likely to be of benefit to the patient.7

Comparable studies in other hospitals, although in elderly and acute medicine, have improved implementation of TEPs from 30% to 90% and 57% to 77%.8 9 All medical trainees surveyed found a completed form useful during on-call shifts.8 We aimed for an improvement of similar magnitude in our project.

Baseline data

We collected a baseline measurement for the month of September 2021 to assess the percentage of patients who had a valid TEP form in place, and which of those had a TEP form filled out within 72 hours. We found that 37% of patients had a TEP form filled out and only 22% had one within 72 hours of their admission.

Design and measurement

The initial aim of the project was to increase the percentage of patients, admitted under oncology, who had a TEP form completed within 72 hours (our principal outcome measure) to at least 80% by March 2022. Following this, we aimed to ensure that this rate of completion persisted a year later despite a new junior and registrar-level workforce. An idealistic and more ambitious aim was not thought to be appropriate in view of the peculiarities of data collection and the admission process. This shall be discussed later in the Limitations section. Thus 80% was deemed both reasonable and achievable.

Data would be collected over a predetermined 1-month period to ensure a representative sample size and avoid selection bias. In practice, the sample varied from 27 to 71 patients with a mean of 40 patients per month surveyed.

We were to systematically record which patients were admitted from daily handover lists and clinical notes, identifying how many patients had a TEP form in place and how many had this within 72 hours of their admission. These included patients admitted to the ward, as well as those who were under the care of oncology team but were outliers on other wards. Thus, we minimised selection bias as no admitted oncology patients were excluded from the data.

Reflecting on what we had learnt from each month of data collection, we would make recommendations for change and spend the intervening months implementing these changes. We received feedback from many of those involved in patient care, including nurses, junior doctors and consultants. Numerous ideas were tested by completing five full Plan-Do-Study-Act (PDSA) cycles.

Strategy

Timeline

September 2021—baseline data collection

October 2021—initial interventions including posters, TEP discussions in board rounds and MDT meetings and blank TEP forms inserted into clinical notes

November 2021—cycle 1 data collection

January 2022—policy of TEP form completion on admission initiated

February 2022—cycle 2 data collection

August 2022—change-over for junior doctors and registrars

October 2022—cycle 3 data collection

November/December 2022—educational interventions and encouraging registrars to attend daily board rounds

February 2023—cycle 4 data collection

May 2023—cycle 5 data collection

Limitations

Significant improvements can be achieved via simple measures, such as those employed in cycle 1. Our findings suggest, however, that policy change may be required for more marked improvements. This was evident in the considerably greater number of TEP forms completed on admission by registrars. The improved communication between registrars and the consultants, under whom the patient is being treated, helped facilitate greater confidence in completing TEPs and having these discussions with patients and their families. Interestingly, discussing patients among the junior members of the medical team and nursing staff at board rounds had limited impact on TEP completion rates, as although it was discussed and highlighted, none of the members of the meeting were qualified to fill out the TEP form itself. This was exploited later in cycle 4 as the new registrars were encouraged to participate in board rounds, such that any member of the team would be empowered to highlight a lack of escalation plan directly to someone who could do something about it. Of course, a senior and specialist presence at board rounds has other benefits from improved patient safety to education, teamwork and morale.

Despite the progress made and the 80% target reached (91% in cycle 5), 9% of patients after the final cycle still did not have a TEP form filled out during their admission, and the reasons for this delineate the potential limitations in this project.

First, some registrars who were working in the EAB completed TEP forms for all of the patients they admitted. However, this was not universal, and the considerable change in registrars in the department was thought to be a key contributor to this inconsistency. As well as awareness of the form itself, registrars reported that being relatively new to the job meant they did not feel comfortable calling a consultant about a TEP form or making a decision at the time.

This was accentuated in October 2022 when a largely new junior and registrar-level team meant rates of TEP completion fell. However, we proved that with education and engagement, improved performance when it came to TEP form completion could be sustained.

Second, many of the patients who did not have a TEP form in their notes were those whose admissions in hospital were less than 72 hours in duration (13 of 14 patients in cycle 3, 6 of 7 in cycle 4 and all 3 in cycle 5). Registrars and consultants reported that, in certain patients who were only in hospital for a short period of time, having complex discussions about ceilings of care brought more distress to the patient than was felt to be appropriate. In view of their reason for admission and short turnaround time in hospital, they were thought to be very unlikely to deteriorate and therefore, the TEP form was not deemed to be necessary.

Our approach to data collection was not discriminatory in this regard and included all patients admitted under the oncology team, such that even patients who stayed just for a few hours overnight would be recorded as not having a TEP form if they were promptly discharged following a senior review in the morning.

Third, the oncology team is staffed by a junior doctor (typically a senior house officer or equivalent) during evenings and overnight, with a registrar and consultant available over the phone for advice if needed. Compared with registrars during working hours, the on-call junior doctors tended to proportionately admit more patients, perhaps owing to their reduced oncology experience, confidence and the level of acuity of those patients presenting overnight. Yet, these doctors are not qualified to complete TEP forms, so this is either done by a senior doctor in the morning or often not at all if the patient is to be discharged home. Their inclusion in the data considerably limits the target rate of TEP form completion we can aspire to.

An ad hoc spot check approach to data collection, such as assessing all oncology inpatients on one particular day, would be less skewed by this effect. However, our approach prioritised sample size, representativity and reduced selection bias.

Nevertheless, this quality improvement project has produced considerable and sustained improvement in the timely completion of TEP forms in oncology inpatients. It is evidence of the cultural change we have initiated that as an unintended consequence of the project, the oncology ward sister now emails senior doctors, the names of the rare patients who have not had a TEP form completed. This would be unimaginable when we started, when most (78%) of patients did not have a TEP form completed within 72 hours of their admission.

We know that patients care about receiving appropriate treatment and interventions, while not being subjected to those likely to be futile. However, in this quality improvement project, we did not survey patients on the extent to which they care about TEPs and about having these conversations with their doctors. This would enhance our understanding and inform any future development of this project.