Integrating palliative care into an acute teaching hospital and cancer centre in a publicly funded national health service

Introduction

Palliative care in the UK has traditionally been community focussed, and based in independent or NHS funded hospice institutions, which are physically separate from acute hospitals. Palliative care services have struggled to keep pace with increasing need. Most acute hospitals have an advisory service – some have hospice wards. But there is an increasing need to meet the palliative care needs of those patients having “active” treatment. Palliative care therefore must be integrated into the core hospital activity and work alongside other hospital specialities.

Ninewells Hospital in Tayside has provided an advisory service since 1998. Tayside Health Board approved the development of an acute palliative care unit in 2007. We agreed to a one year pilot 2009 – 2010 to demonstrate the benefits for the hospital.

Description

• Three beds [single rooms] were identified in an acute surgical ward.
• Round the clock staffing was delivered by 7.6 seconded nurses - some of whom had specialist palliative care experience.
• Medical staffing included 1 full time consultant who was also medical consultant to the hospital palliative care advisory service for 700 bed hospital.
• An additional 0.6 WTE consultant with extensive experience in teaching to develop the hospital education programme.
• Patients seen by the advisory service, and who had the most complex symptoms or needs were admitted to the APCU.
• Data was prospectively collected : Daily ESAS, daily distress measurement, percentage patients seeing appropriate disciplines in 2 working days, family meeting achieved within 2 working days, discharge as planned achieved, satisfaction [patient, family and staff] and patient story.

Results

51 patients were admitted during the first 6 months of the pilot. Pain was reduced from a median of 7 to 3.5 [p< 0.001] within 48 hours. Distress was reduced from 7.5 to 3.0 [p< 0.001]. There were also significant reductions in: anxiety [p=0.01], poor appetite [p=0.02], loss of well being [p=0.046] and overall symptom burden [p=0.001]. There was no significant increase in any symptom [Mann-Whitney U test]. The median length of stay was 4.5 days and the mortality was low for a palliative care setting. [29%] 60% of patients were discharged directly from the APCU, with 33% being discharged home.

Summary

• We had hoped for a dedicated unit but got three pilot beds instead.
• Symptoms and distress can be tackled rapidly and effectively in a hospital setting – despite the “ordinariness” of the pilot beds.
• Culture change can occur quickly “I never knew someone so ill could go home” – consultant surgeon