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129 Implementation of treatment escalation plans (TEP) and DNACPR decisions at St George’s university hospitals NHS foundation trust
  1. Amy Hawkins and
  2. Megan L Papworth
  1. St George’s University Hospitals NHS Foundation Trust


Introduction Treatment escalation plans (TEP) are a tool to promote advance care planning, appropriate decision making and good communication between professionals, patients and carers, in line with national guidelines.1 2 In 2018, this Trust introduced guidance that all patients at risk of acute deterioration and/or with a National Early Warning Score (NEWS) of 5 should have a TEP.

Aim To assess the proportion of patients on the palliative care caseload with a TEP and/or DNACPR decision in place over a three-month period.

Methods The palliative care caseload was reviewed weekly between December 2018 and March 2019. Two audit standards were set with a target of 100% compliance:

  1. Completion of a TEP

  2. Documented decision regarding CPR

Results The total sample size was 545 patients. Whilst the mean compliance with the audit standard for TEP was low (40%), over the three-month audit period there was an increase from 25% to 50%. Medical wards had a higher proportion of patients with a TEP (43%), compared with surgery (35%), ITU (33%) and oncology/haematology (31%). The proportion of patients with a documented decision regarding CPR status was high throughout (98%).

Conclusions Reasons for the increase in uptake of TEP may include increased awareness resulting from the audit process, and the focus on TEP as a priority within the Trust. The results were disseminated at divisional level and to the Deteriorating Adults Governance Group. Recommendations include TEP ‘champions’ to share examples of best practice, targeted education sessions, adopting appropriate use of TEP as a key quality indicator for the Trust and replacing the paper TEP form with an online version as part of the electronic patient record system. The audit will be repeated in 9–12 months to assess the impact of these interventions.


  1. Bailey S and Cogle K. Talking about dying. Royal College of Physicians. October 2018.

  2. National Palliative and End of Life Care Partnership. Ambitions for palliative and end of life care: a national framework for local action 2015–2020. 2015.

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