The Effectiveness of Employing Exclusive Advance Care Planning (ACP) Clinicians The Effectiveness of...
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Transcript of The Effectiveness of Employing Exclusive Advance Care Planning (ACP) Clinicians The Effectiveness of...
The Effectiveness of Employing Exclusive Advance Care Planning
(ACP) Clinicians
Kasey Wallis, Karen Detering, Kathy Whiteside, Daveena Mawren, Rebekah Sjanta, Dorothy Campbell, William Silvester
What Does Austin Health Do?
97,501 inpatient admissions
170,497 outpatients
69,923 emergency presentations
Networked across 3 sites
>400 acute beds
$686M budget
> 900 beds
=Lots of ACP activity
A Large Health Care Provider
Primary catchment area 118km2
Extended catchment area 1800km2
Under Here
A Timely Review of the RPC Service
• Austin Health has a well established Respecting Patient Choices program since 2002
• Period of service development 2007-2012
• Equivalent of 2 full-time clinicians (1.6 acute / 0.4 sub-acute)
• Prospective audit of all patients referred to RPC program during 2010-2011
– Evaluate service effectiveness & inform service development
• Utilised RPC database & electronic hospital systems– Referral characteristics– Demographics of patients seen– ACP clinician activity & – frequency of Advance Care Directives (ACD)
An Overview of ‘Our’ ACP Process
Hi I’m Kathy
Supported by hospital policy
Patients referred to
RPC
Consultation with ACP Clinician
ACP outcome
Conversation no ACD doc
Completed≥1 ACD doc
Not completed
RTCSOC SDM (MEPOA)
Patient identified by
ACP Clinician Via EHR
The statistics: 2010-2011 Service Delivery
1580 referred 1463 (93%) had ACP• 79% acute hospital
• 20% sub-acute hospital
• 1% other
454 (31%) died
Are Patients Referred to ACP Clinicians Representative of Austin Inpatients?
Patients referred to RPC 2010-2011 Austin Hospital inpatients admitted in 2011
Median age (range) years 76 (18-102) 61 (0-105)
Male n (%): Female n(%) 801 (51%): 779(49%) 30,576 (53%): 26,843 (47%)
Referred Patients: Primary Admission Diagnosis
23%
10%
18%12%9%
28%
Primary Admission DiagnosisCancer Cardiac Renal Respiratory Orthopaedic Other
Designation of referrer n %Nursing staff 530 36Medical staff 109 7Allied health staff 56 4RPC initiated 541 37Other 228 16
Relationship Between Visits and ACD Completion
• Mean time for consultation 3 days (SD 11, range 0-236)
• Median (range) ACP visits: 2 (1-11)
• ACP clinician vists/discussions significant association with ACD completion (p<0.001).
ACP Activity: Total time vs. ACD Completion
Chi square = 129.752, p<0.001
Mean SD Median RangeTotal time (minutes) all patients 89 65 65 0,570Total time no ACD completed (minutes 67 47 47 0,360Total time ACD completed (minutes) 117 73 73 0,570
Proportion of Clinician Facilitated ACDsExisting ACD at time of referral n(%) Clinician facilitated ACD n(%) Total
Appointed a SDM 179 (11%) 408(26%) 587 (37%)SOC - competent 79(5.4%) 335 (22.9%) 514 (28.3%)SOC- non-competent 3 (0.2%) 35 (2.4%) 38 (2.6%)SOC total 82 (5.6%) 370 (25.3%) 452 (31%)RTC 9 (0.6%) 48 (3%) 57 (3.6%)
Resuscitation Preferences by Primary Diagnosis
Life Prolonging Treatment Preferences by Primary Diagnosis
Want LPT Want LPT if reasonable outcome Don't want LPT Delegate to SDM Missing/NA Total no of SOC'sAll SOC's 14(3%) 195(43%) 184(41%) 23(5%) 36(8%) 452(100%)Cancer 3(3%) 41(45%) 34(37%) 9(10%) 4(4%) 91(20%)Cardiac 1(3%) 9(26%) 15(44%) 4(12%) 5(15%) 34(8%)Renal 3(2%) 77(64%) 37(31%) 1(1%) 3(2%) 121(27%)Respiratory 2(4%) 22(39%) 24(43%) 3(5%) 5(9%) 56(12%)Orthopaedic 2(6%) 9(27%) 16(48%) 2(6%) 4(12%) 33(7%_Other 3(3%) 37(32%) 58(50%) 4(3%) 15(13%) 117(26%)
SOC: Undesired Medical Treatment Indicated
Clinician facilitated SOC n=370
Quality audit of 98 (26%) of these SOC’s
• 71 (72%) indicated undesired medical treatment
Are we targeting the right patients?RPC sample (2010/2011) Austin Health patients (2011)
n (%) 454 (31%) 1174 (1.2%)Male : Female 248(55%):206(45%) 674(57%):500(43%)Median age (range) years 79 (25-102) 79Median time ACP consult to death (range) weeks 6 (0-97) NAMedian time b/w selecting NFR -death (range) weeks 6 (0-79) NA
What makes Austin’s Service Model Effective?
• Dedicated and supported ACP clinicians
• ACP clinicians devoted to particular specialty areas
• Patient-centred approach
• Multi-staged approach across the continuum of care
• Processes and policy for recording/alerting clinicians to ACDs & executive support
• Systematic education of medical, nursing & allied health staff
Many thanks for your time today and to the
Austin Health RPC Team