Background Treatment Escalation Personalised Plans (TEPPs) were introduced across the Trust in 2014 to record ceilings of care for patients who fulfil specified criteria. TEPPs aim to encourage clinical decision making by senior clinicians familiar with the patient, in discussion with the patient and/or their next of kin (NOK). An initial audit was completed in 2015.
Methods We performed a re-audit of case notes on 12 medical, surgical and oncology wards over 5 weeks in early 2017. The criteria for a TEPP were: patients with a DNACPR, those meeting poor prognostic criteria for long-term conditions, or those deteriorating despite active treatment. Documentation of TEPP discussions with patients and/or NOK was also examined.
Results Of 268 notes reviewed, 126 met criteria for a TEPP (47.0%). Of these, 59/126 (46.8%) had a TEPP, and a further 6 had ceilings of care documented in their medical notes. 75% of TEPPs were completed within 48 hours of admission. Appropriate completion of TEPPs varied between specialities, from 80% in Stroke to 0% in Surgery. Evidence of TEPP discussion was present for 93% of patients with capacity and 89% of those without (discussed with NOK).
Conclusions Completion of appropriately indicated TEPPs was stable across audit cycles. Documentation rates of TEPP discussions with relatives had improved, but the extent of documentation varied significantly. The variable rate of TEPP completion between specialties is worthy of further investigation. Further work is required to reinforce the indications for TEPPs, raise awareness of formal poor prognostic indicators and emphasise the importance of full documentation of discussions in medical notes. Information obtained from this audit will help guide development and implementation of new, combined DNACPR/TEPP forms in relation to new nationwide schemes.
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