Background Treatment escalation plans (TEPs) document decisions around levels of care. In April 2020 during the first wave of the Covid-19 pandemic 90–100% of TEPs were completed in our health board, falling to 12–82% by September 2020. We aimed to increase the percentage of inpatients with a TEP that was completed, and discussed with the patient or relative. Our secondary aim was to explore barriers to TEP completion.

Method All doctors working in one large acute teaching hospital were invited to complete an online questionnaire, identifying barriers to completing TEPs. Two medical and two surgical wards were selected for study. One of each were selected at random to receive a teaching intervention focused on the rationale and practical application of TEPs. TEPs were audited on all wards pre and post intervention.

Results The doctor’s survey had 40 responses. In medicine and surgery the main barrier was ‘time pressures’. In trauma and orthopaedics (T&O) it was ‘unable to find a TEP form in the notes’.

14 doctors, 32 nurses and 4 healthcare support workers attended the teaching intervention. We also provided teaching during the T&O clinical governance meeting. In medicine, numbers of completed TEPs decreased from 20 (80%) to 12 (52%) on the non-intervention, and from 9 (30%) to 5 (19%) on the intervention ward. In surgery, numbers of completed TEPs increased from 1 (3%) to 2 (7%) on the non-intervention ward and from 0 to 3 (12%) on the intervention ward. Of the 30 patients who were not for full escalation, 8 (4 pre-intervention, 4 post-intervention) did not have a documented discussion with the patient or relative.

Conclusion The teaching intervention is not clearly effective in isolation. This may in part be because it did not address the major barriers to TEP completion, as identified in the survey.