News

The Treatment Escalation Plan (TEP), the signature project for NIHR CLAHRC Theme 6 project is gradually moving forward.  Treatment Escalation Plans are essentially the summary record of a conversation between a patient (and next of kin) and a clinician on treatment preferences and options in case of an emergency.  It is a subject that has a far-reaching impact on health and social care practice, that cuts across clinical specialisms.

Change in this area is complex and challenging to deliver, and understanding the barriers and facilitators to successful implementation is the main focus of the research.

The summary below comprises a reminder of the goals of the project, who is involved, progress with our working groups, what is happening with the national working group and what we expect to deliver as a result of the project over the next 2 to 3 years.

What is a Treatment Escalation Plan (TEP)?

A system of recording decisions about treatment preferences, when a patient is unwell or their health is at risk of serious deterioration. Discussion and decision about resuscitation (DNACPR) is usually incorporated in this process.

The goals of the TEP Project

Our overall aim is to evaluate the implementation of an evidence-informed Treatment Escalation Plan to support improved decision-making in a number of healthcare organisations in the Wessex Region, and to inform theory that pertains to implementation and can be generalised to complex healthcare systems.

In terms of service development, we want to improve communication and decision-making around at times of acute clinical deterioration. The aim is to develop a set of tools and resources to support patients, carers and professionals as they experience and respond to clinical deterioration at home, in the community or in hospital. 

These tools and resources will comprise:

• A workable TEP/s (locally or nationally produced)
  
• A clear account of barriers and facilitators to TEP implementation
  
• A generic implementation plan
  

Who is involved?

• A team of researchers and clinicians based at the University of Southampton, funded by the National Institute for Health Research Collaboration for Leadership in Applied Heath Research and Care (NIHR CLAHRC) Wessex.
  
• Partner organisations, specifically University Hospital Southampton NHS Foundation Trust, Hampshire Hospitals NHS Foundation Trust, Salisbury   Hospital NHS Foundation Trust, Stoneham Lane Surgery, Southampton, and Colten Care care homes.
  

Working Group progress

Of the five working groups established, four have done some pilot testing (some with, some without patients) using a variety of forms.  Early learnings have been generated regarding usability of forms, as well as anticipated barriers and facilitators to implementation.  Two trusts (HH and UHS) have conducted staff surveys to support engagement and assess readiness for implementation.  There has been sharing of ideas and best practice between the groups as the different organisations decide on how to proceed.

The national working group (ECTP to ReSPECT)

Here is a link to the latest bulletin on the developments of the national working group; the name of the form and process being developed has changed from Emergency Care and Treatment Plan (ECTP) to ReSPECT (Recommended Summary Plan for Emergency Care and Treatment).  The ‘launch’ and issue of the form and supporting materials (educational, implementation guidance etc.) are expected in February 2017.  Our team contribute to the work of the National Group through representation on the Committee; hosting a PPI (Public and Patient Involvement) event to review the ReSPECT materials, contributing to implementation guidance and providing feedback from our working groups, including pilot testing of the ReSPECT form.

Expected outcomes from the project (2016-2018)

• Clinically useful tools for implementation
• Tools and insights that are practical and useful to clinicians that support implementation of TEP, but also provide a road map that could potentially be of use to local Service Improvement Teams and national bodies focused on improvement in all areas of healthcare.
• Generally applicable theories of implementation
  

A better understanding of how implementation works in complex systems and organisations and particularly in today’s NHS; theory that is based on real experience and data that can advance understanding of how to implement change successfully in the world of healthcare.  The work we are generating reflects the dynamic and ever-changing nature of modern healthcare, and builds in the assumption of local reinvention.

Main learnings anticipated from the project

• Barriers and facilitators to implementation of TEP
  
• Through considering TEP to be an example of implementing a ‘contentious intervention’ in healthcare, enable broadening of learning beyond the   specific context of TEP.
  
• A greater understanding of the process and outcome of clinical decision making in the context of patients facing clinical deterioration drawing on detailed data from one acute trust.
  
• A series of insights into the impact of TEP implementation generated through our work with our partner organisations.
  
• Understanding the nature and degree of local variation encountered across a range of healthcare settings whilst implementing a nationally     generated system of treatment escalation planning
  
• More generalisable findings that can be used to inform implementation efforts in complex healthcare systems.
  
  

How we intend to ensure the project and its findings make an impact on healthcare practice

• Disseminate findings from the project through our academic publications in relevant journals, communications, events and other stakeholder activities.
  
• Make available an e-facilitator toolkit for use across the NHS.
  

Contact email: Clahrc6@soton.ac.uk       Website: www.clahrc-wessex.nihr.ac.uk/theme/project/10