Holistic Assessment of Concerns (HAC) Audit Teesside Hospice 2011 Dr Lucy Roth

1. Holistic Assessment of Concerns (HAC) Audit Teesside Hospice 2011 Dr Lucy Roth Consultant in Palliative Medicine

2. Background Teesside Hospice Audit Group has been looking at ways of measuring patient outcomes for a number of years. This is becoming increasingly important as organisations like the CQC and commissioners become involved in monitoring our care and demand evidence of a patient centred and effective service.

3. Background The North of England Cancer Network Holistic Assessment of Concerns (HAC) or “Distress Thermometer” has now been in use on the inpatient unit at Teesside Hospice for about 18 months. More recently it has been introduced in Day Care. The aims of its introduction were: To provide evidence of benefit to patients of our management To improve our holistic care of patients by eliciting what matters to them rather than us.

4. Background The HAC is given to Day Care patients in the first few weeks of attendance, when it is felt to be appropriate. It is then revisited as part of the six weekly review. We aim to offer this assessment tool to all patients admitted to the inpatient unit and then review patients concerns with the tool prior to discharge or earlier if appropriate.

5. Daycare Audit • The audit was designed to assess: • Whether the HAC had been completed within the first few weeks of attendance • Whether the HAC was subsequently reviewed • The number and type of concerns elicited • Any change in score for highlighted concerns

6. Method The Day Care audit population was selected by taking alternate sets of notes from the filing drawers in Day Care. 17 sets of patients’ notes were analysed using an audit tool devised after a pilot audit in 2010.

7. Results 10 patients had an initial HAC completed. 2 patients chose not to complete one. 5 patients had only attended Day Care once and so HAC was not yet deemed appropriate.

8. Results 6 of the patients had a follow-up HAC completed. 1 patient had refused follow-up. 3 patients were not yet due for review.

9. The number of concerns elicited varied from 3 to 25 (maximum possible was 45).Concerns chosen as one of the three most important to the patient were: • Pain – 3 • Fatigue – 3 • Anxiety – 2 • Forgetful – 2 • Nausea • Appetite loss • Weight loss • Constipation • Diarrhoea • Dysphagia • Fear • Anger • Mobility problems • Loss of independence • Emotional problems • Insomnia • Sexual problems • Numbness

10. Results The highest distress score was 10/10 The average distress score was 5.7/10 The change in distress score varied from +3 (problem got worse) to -7 (problem got much better) The average change in score was -1.5

11. Results – score change for first concern for the 6 patients completing follow up assessments

12. Results – score change for second concern

13. Results – third concern

14. What we did well:

15. What we did not manage to improve:

16. Inpatient Audit • The audit was designed to assess: • Whether the HAC had been completed on admission • Whether the HAC was subsequently reviewed prior to discharge • The number and type of concerns elicited • Any change in score for highlighted concerns

17. Method The IPU audit population was selected by taking the notes of 20 consecutive admissions from March 1st 2011. All 20 sets of notes were analysed using an audit tool devised after a pilot audit in 2010.

18. Results • 8 patients had an initial HAC completed. • 2 patients had an initial HAC partially completed. • 7 of these patients had a follow-up HAC completed.

19. Results Patients without completed HAC • 2 patients were unable to complete due to dementia • 1 patient did not want to complete • 1 stayed less than 24 hours • 2 respite admissions • 3 had previous HAC completed in day care but not reviewed on IPU

20. The number of concerns elicited varied from 5 to 21 (maximum possible was 45).Concerns chosen as one of the three most important to the patient were: • Pain – 4 • Fatigue – 4 • Weight loss – 3 • Mobility - 2 • Nausea – 2 • Sleep - 2 • Worries re family -2 • Bathing • Mouth Ulcers • Urinary urgency • Finances • Worry re managing at home • Sadness and stress • Fear of dying • Toileting

21. Results The highest distress score was 10/10 The average distress score was 7.85/10 The change in distress score varied from 0 (problem remained the same) to -9 (problem got much better) None of the problems identified got worse The average change in score was -2.85

22. Results – score change for first concern for the patients completing follow up assessments

23. Results – score change for second concern

24. Results – third concern

25. What we did well:

26. What we did not manage to improve Weight loss Fear of dying Mouth ulcers Sleep

27. Case Study

28. Conclusions The HAC has allowed us to demonstrate that our interventions benefit patients admitted to the inpatient unit and those attending day care. It gives us good evidence that our work is effective. The areas we did not improve were those we would expect to be difficult to change – but now we know where we may need to concentrate our efforts. Completing the HAC has been reasonably easy and most patients and staff were happy to use it. We feel the recording sheet could be made more user friendly.

29. Plan We will continue to use the HAC on the inpatient unit and in day care as part of our assessment and planning of each patient’s care. We will update the recording sheet to make it easier to use. On IPU we will offer the HAC to respite patients and review the assessment on admission with patients who have previously completed one in day care if they wish. We will re-audit in12 months time.