The Effectiveness of Employing Exclusive Advance Care Planning (ACP) Clinicians The Effectiveness of...
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The Effectiveness of Employing Exclusive Advance Care Planning
(ACP) Clinicians
Kasey Wallis, Karen Detering, Kathy Whiteside, Daveena Mawren, Rebekah Sjanta, Dorothy Campbell, William Silvester
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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
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A Large Health Care Provider
Primary catchment area 118km2
Extended catchment area 1800km2
Under Here
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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)
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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
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The statistics: 2010-2011 Service Delivery
1580 referred 1463 (93%) had ACP• 79% acute hospital
• 20% sub-acute hospital
• 1% other
454 (31%) died
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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%)
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Referred Patients: Primary Admission Diagnosis
23%
10%
18%12%9%
28%
Primary Admission DiagnosisCancer Cardiac Renal Respiratory Orthopaedic Other
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Designation of referrer n %Nursing staff 530 36Medical staff 109 7Allied health staff 56 4RPC initiated 541 37Other 228 16
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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).
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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
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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%)
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Resuscitation Preferences by Primary Diagnosis
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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%)
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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
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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
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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
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Many thanks for your time today and to the
Austin Health RPC Team