Claire Read speaks to Rachel O’Donnell from Buckinghamshire Healthcare Trust’s palliative care in-reach nursing team
Helping patients get the right care at the right time
When Rachel O’Donnell begins her working day, the first item on her to do list is always the same. She logs straight onto her trust’s electronic database of recent admissions and starts to look for a very specific type of patient – namely anyone who would benefit from the involvement of palliative care.
Ms O’Donnell is a member of Buckinghamshire Healthcare Trust’s palliative care in-reach nursing team, created in 2015 with a specific desire to ensure patients with incurable disease receive the right care at the right time.
“As a hospital palliative care team, we were very aware that we were getting referrals quite late in the day for people,” remembers Ms O’Donnell, who has been a palliative care clinical nurse specialist for the past 15 years. To avoid that situation, staff at the hospital approached Macmillan Cancer Support with a view to funding a more proactive setup.
“The in-reach service covers the acute hub in the hospital, so we do see patients in accident and emergency but primarily we cover the acute medical unit and Ward 10, which is a short stay ward – so two wards that people go to very quickly after being admitted from A&E,” Ms O’Donnell explains. “We are screening for people [with incurable disease]; proactively looking for people who have come into hospital,” she says.
Having reviewed the admissions database, and cross-referenced with medical history, “we go out onto the wards to review the patients we’ve identified. We review those patients to see if there’s a need for us to be involved, and also we talk to staff on the wards to see if they have any patients they’re worried about and want to identify to us,” she added.
In many instances, patients will have a specific issue which can be treated. “So even though they’ve got an advanced disease, they may have come in with a chest infection, urine infection, so it’s appropriate they’re treated with antibiotics,” says Ms O’Donnell. She and her colleagues can help ensure that happens quickly, and that any other appropriate support is in place.
In some instances, however, it will be clear a patient is close to the end of life. “Usually a crisis has happened at home that’s brought them in, but actually hospital might not be the best place for them because these patients are unfortunately nearing end of life,” she says. “So for these patients it would be very important that we try to achieve a rapid discharge to their preferred place of care, whether that’s hospital or home.”
Establishing those preferences early on is also a key part of the in-reach team’s work. “It’s all very patient-centred,” notes Ms O’Donnell. “We have care plans that are specifically designed for people who are [at the] end of life, so we can document all their preferences.
“Then for example if they do go home for end-of-life care, we can liaise very closely with our colleagues in the community [to make clear] that perhaps they may not want to be readmitted to hospital if anything was to further deteriorate at home.”
The evidence is that the team’s work is making a difference. “The data that has been collected shows that we’ve shortened length of stay for people in hospital, and that’s purely just because we’ve identified them earlier in their hospital admission,” explains Ms O’Donnell.
“We’re achieving preferred place of care for these patients about 70% of the time, but that includes hospice as well as home. And we’re obviously able to manage their symptom control earlier as well, so that puts people in a better position to be able to be discharged if the symptoms have been addressed,” she says.
Ms O’Donnell emphasises that much of the success comes down to having “a very good working relationship” with the health professionals on the wards. She firmly believes that nurses have an intuition when it comes to their patients’ needs, and encourages colleagues to speak up if they believe someone may be nearing the end of life.
“Nurses are working in a very busy environment, and the culture is active treatment”, she says. “But I think nurses are very good at realising when perhaps the priority should be to keep them comfortable. And I think you shouldn’t be afraid to speak up and say something – you’re acting in the patient’s best interest.”
She also encourages nurses in these situations to liaise with their palliative care colleagues. “I think contacting us and saying ‘can I talk to you about my patient?’ is the best starting point,” she says.