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Phil’s Story
Why information sharing really matters
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Phil
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January 2015
62 years old
Living at home with wife
Heart failure
End stage, on maximum tolerated therapy
He is aware that he is deteriorating
No idea of prognosis
If asked, would like to die at home
Problems
• Physical:
• Swollen , painful legs
• Leg ulcers
• Chest pain
• Breathlessness
• Psychological:
• Anxiety, frightened
• Social/family:
• Social isolation
• Impact on family
Healthcare professionals involved
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Community matron
GP
District nurses
Cardiology OPA
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March 2015
Bloods
Clinical examination
Follow up 1 year
Admission
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March 2015
Chest pain
Wife dials 999
Seen in A&E
Transferred to ward
Heart attack excluded
on post take ward round
Treated for chest infection
Transferred to medical ward
Admission
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Deteriorating renal function
Cardiac function worse
Therapies input
Discharged after
10 days
• Standard discharge
paperwork sent to GP
Follow up
• June 2015
• Cardiology outpatients post discharge from hospita
• Continued improvement
• Follow up six months
Second admission
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August 2015
Chest pain
Wife dials 999
Seen in A&E
Transferred
Diagnosed musculoskeletal
chest pain on post take WR
Transferred to medical ward
Second admission
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Antibiotics for legs
Worsening renal function
Medications adjusted
Physio and OT
• Discharged after 10 days
• Standard paperwork sent to GP
Outpatients
• October 2015
• Did not attend
• Too unwell to make the journey
Third admission
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Chest pain and breathlessness
Wife dials 999
Seen in A&E
Transferred
• Intravenous antibiotics, oxygen, diuretics
• Transferred to medical ward
Third admission
• November 2015
• 4 weeks in hospital
• DNACPR form completed
• Some discussion around
• acknowledging limited
prognosis
• Discharged with a package of
care
• Standard discharge paperwork
• sent to GP
Deterioration at home
• November 2015
• Agitated, confused
• Not eating, drinking little
• Wife calls GP
• GP attends but has not seen paperwork
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from recent hospital stay
• GP arranges admission to hospital
Fourth and final admission
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Admitted
Dehydrated, end stage heart failure, sepsis
Receives IV antibiotics and fluids
Transferred to medical ward
Treatment discontinued after 48 hours
Fourth and
final
admission
• December 2015
• Personalised Care Plan for the Last Days of
Life commenced
• Family informed that he is dying
• Phil dies two days later in hospital
Timeline – Phil’s last year of life
January
December
Outpatients
Communication on transfer
Deteriorating
Unstable
Dying
Benefits of better
information
• To Phil:
• Improved pain and symptom management
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Choice, giving back some control
Better informed, opportunity to prepare
Greater chance of dying at home
Less time spent in hospital
Benefits of better
information
• To Phil’s wife:
• Improved support in the community
• Involvement in decision making
• Better informed, chance to prepare
• More quality time available with Phil
• Supported in achieving Phil’s wishes to die at
home
Benefits of
better
information
• To the Trust:
• Better quality of care
• Financial implications
• Improved patient flow
• Reduced intervention at end of life
• Reduced admission
• Improved patient experience, fewer
complaints, more compliments
• Reduced length of stay
• Reduced readmission at end of life
• Improved staff morale
• Opportunity to demonstrate high standards
and meet contractual expectations
Resources
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53 bed days
2 OPA (1 DNA)
24 blood tests
1 CTPA
1 echocardiogram
1 renal USS
3 CXR
4 ECG
2 courses IV antibiotics
IV fluids
Oxygen
£12,585
£5,034,000
Risk
• A third of 10,000 patient safety incidents reviewed by the National Reporting and
Learning System were due to poor information sharing on discharge.
• Half of medication errors and 20% of serious reactions to drugs are due to poor
information sharing in patient care records.
• A National Audit Office (NAO) review identified poor record keeping by NHS
bodies as a contributory factor in over 40% of medical negligence claims.
• Poor record keeping is a common reason that nurses become involved in
disciplinary hearings.
What are we doing about this?
Record standards developed by the Professional Record Standards Body (PRSB) are endorsed by
the Academy of Medical Royal Colleges.
They support electronic transfer of information between systems (interoperability) by ensuring
information is consistently recorded and coded across Trusts and disciplines.
The electronic discharge summary headings standard should be used by December 2016 with coded
messages in 2018
We can start to use headings without new IT systems
We need to work with local clinicians to ensure that we introduce the headings in a way that works
for frontline staff
The use of standard headings and clearer records will help our staff support people like Phil in future
For discussion
How could you contribute to introducing standards and improving information
sharing?
How might we best involve the public and patients in developing this programme?
How does this fit into the Trust’s Five Year Plan?
How can we ensure that the need for information sharing, record standards and
changes in practice are recognised and appropriately prioritised?
With acknowledgments to
The Professional Record Standards Body
and to
Dr Amy Pharaoh
Consultant in Palliative Medicine,
Poole Hospital Foundation Trust
who developed the original concept of Phil’s story
How long does it take?
Cambridge University Hospitals found that using the agreed headings for their edischarge summary meant they took on average:
 3-4 minutes for a routine simple admission (eg day case)
 7 minutes for a routine surgical admission
 9 minutes for a routine general medical admission (5-8 days) including medicines
reconciliation
 15 – 20 minutes for a complex discharge after an inpatient stay of several weeks.
Perhaps a better question is: How long should a good discharge summary take?
Resources
Nuffield Trust. Exploring the cost of care at the end of life:
http://www.nuffieldtrust.org.uk/publications/exploring-cost-care-end-life
NHS England Patient Safety Alert: Alert reference number: NHS/PSA/W/2014/014 based on
information from the National Reporting and Learning System, 2014: https://www.england.nhs.uk/wpcontent/uploads/2014/08/psa-imp-saf-of-discharge.pdf
UK National Audit Office Report: Handling Clinical Negligence Claims in England, May 2001:
https://www.nao.org.uk/wp-content/uploads/2001/05/0001403.pdf
The Professional Record Standards Body: www.theprsb.org.uk/projects
NHS Digital: http://systems.digital.nhs.uk/interop