Introduction

Communicating with older adults can sometimes be challenging for a number of reasons. Therefore, involving next of kin in decision-making is extremely important. The aim of this audit was to evaluate the quality of communication between doctors and a patient’s next of kin in a community hospital.

Objective:

  • To determine if consent was obtained from a patient prior to speaking to next of kin.
  • To determine if communication between doctors and next of kin takes place within the first 48 hours of admission on working days.
  • To determine if the discussions regarding the ReSPECT (Recommended Summary Plan for Emergency Care) form took place with a patient’s next of kin (should patient consent). This is a national patient-held document, completed following an Advance Care Planning conversation between a patient and a healthcare professional.
  • Should there be a deterioration in patient’s clinical condition (i.e. new infection, change in cognition, need to transfer to an acute hospital setting), has this been communicated to next of kin?
  • To determine if there is regular contact with next of kin of long stay patients in the community hospital.

Standards

 

 Criteria

 

Reference

 

Discussions around ReSPECT form should be discussed with patient’s next of kin if patient consents.

GMC (2014) Good practice in decision making1

CQC Protect, respect, connect – decisions about living and dying well during COVID-192 (2021)

 

Next of kin updated if patients deteriorate clinically, i.e. acute infections, decline in cognition or need for transfer to the acute hospital.

SIGN 139, Care of Deteriorating Patients (May 2014)3

BCHC (2018) Safe Transfer of Patients and Service Users Policy4

 

Regular contact with patient’s next of kin if patient has a long stay in community hospital.

No specific guideline regarding how often a family member should be updated during inpatient stay however as a team we believe it is best practice to give a medical update to patient next of kin at least once a week

 

NICE (2021): Patient experience in adult NHS services: improving the experience of care for people using adult NHS services5


Method

We performed a retrospective audit involving 22 patients who have been inpatients on a single Geriatric Ward at a Community Hospital for 21 days or more between the period of June and Mid October 2021 with documented next of kin details.

Given that we are a community hospital and most of our patients are here for physical rehabilitation, we looked only at those who had a long stay in hospital as this was likely due to a chronic medical condition. Following the first cycle, we analysed the data and presented the findings to the team during departmental teaching and recommended areas of improvement.

Following implementation of the recommendations, we completed a second cycle after two months that looked at a total of 12 patients in the same ward who had been inpatients for 21 days or more.

Results

First cycle

  • Mean inpatient stay of patients was 36 days.
  • No documentation of consent gained to speak to next of kin from 64% of patients.
  • Only 50% of the patients' next of kin were spoken to within 48 hours of admission.
  • 55% of the patients have had a collateral history taken from next of kin.
  • 59% of the patients' next of kin have not been informed of ReSPECT form status.
  • Only 5% of the patients' next of kin are being updated by a doctor regularly (at least weekly).
  • 68% of the patients' next of kin are not being informed of any deterioration in their clinical condition.

Recommendations and action plan

  • Create a flyer to use as communication checklist (Appendix 1).

 

  • Communication whiteboard on the ward (Appendix 2)
  • Re-audit to check for compliance in two months.

Second cycle results

  • Mean inpatient stay of patients: 33.5 days.
  • Six patients had consented to sharing information with next of kin, one patient did not want any information shared with next of kin, two patients had no capacity and this was documented and two patients had no documentation of consent to update next of kin.
  • 72.7% of patients' (eight out of 11) next of kin were spoken to within 48 hours of admission
  • All 11 patients had a collateral history taken from the next of kin.
  • Discussions regarding ReSPECT forms were held with three patient’s next of kin. Four of the patient’s next of kin were already aware and this was documented. Two patients did not consent for this information to be shared. One of them had no ReSPECT form in place.
  • 81.8% of patient’s next of kin (nine out of 11) were being updated regularly by a doctor (at least weekly).
  • Six patients had some form of clinical deterioration during their stay and this was communicated to their next of kin.


Conclusions

With Covid-19 and visiting restrictions meeting patients' relatives on the ward to update them about ongoing treatment/ management plans and escalation plans does not happen very often. The first audit cycle showed that the communication between doctors and next of kin as well as related documentation was not up to standards set by GMC’s Good Medical Practice.

Following the presentation of findings and implementation of recommendations there has been an improved compliance with the standards set out. This will also result in better patient and family satisfaction.


References

  1. GMC: Confidentiality domain of Good Practice. Available at: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/confidentiality/using-and-disclosing-patient-information-for-direct-care
  2. GMC Good practice in decision making. Available at: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life/cardiopulmonary-resuscitation-cpr
  3. CQC Protect, respect, connect – decisions about living and dying well during COVID-19. https://www.cqc.org.uk/sites/default/files/20210318_dnacpr_printer-version.pdf
  4. NICE (2021) Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. Available at: https://www.nice.org.uk/guidance/cg138/chapter/1 guidance#essential-requirements-of-care (Accessed 20 September 2021)
  5. Scottish Intercollegiate Guidelines Network (SIGN) 139 (2014) Care of Deteriorating Patients. Available at: https://www.sign.ac.uk/assets/sign139.pdf (Accessed 01 December 2021)Jones, D., Mitchell, I., Hillman, K., Story D. (2013) ‘Defining Clinical Deterioration’, Resuscitation, 84 (8), pp. 1029 – 34