The Gold Standards Framework developed directly from the need to prevent out of hours crises in primary care, which were causing most of the inappropriate hospital admissions. The out of hours periods occupy about 75% of the week and improving anticipatory in-hours care, planning and communication can greatly reduce the chance of out of hours crises.
Many areas have developed local Out of Hours protocols, improved access to drugs out of hours and training and advice to on-call doctors and nurses. However there have been several significant changes in the provision of out of hours care which have led to a perceived deterioration in care, with dying patients being seriously affected in some areas. This therefore means there is even more need for good proactive in-hours care to prevent these out of hours calls being inappropriately dealt with. This includes reducing 999 calls, reducing un-needed hospital admissions, reducing inappropriate resuscitation attempts, improving the handling of such patients by ambulance and A&E staff, and improving symptom relief.
Out of hours emergency care includes many elements:
- Communicating with the carers about what might go wrong, what to do if it does and who to contact. This can include use of GSF Home Pack, Patient Held Record / Care Plan, Contact Cards
- Communicating with the OOH providers with handover information eg SCR2, locality registers to enable appropriate response
- Passport Information - ensuring there is some mechanism for patients to be able to show basic information about their condition to anyone involved in their care. Informing ambulance service and others of Advance Care Plans and Do Not Attempt Resuscitation (DNAR) requests
- Leaving anticipatory drugs in the home, with nurses authorisation forms eg a set of drugs for 4 common symptoms in the 'Just in Case' boxes.
- Providing the OOH on call doctor / nurse with palliative drug bags available in the on call car or at base.
- A&E staff trained in use of guidance for palliative care patients, access to specialist advice or following of guidance. A&E staff / others to 'hold' patients and provide some emergency treatments to avert admission eg ambulatory care centres.
- Case Managers / Advanced Nurse Practitioners / Community Nurses to contact patients to prevent admissions or speed discharge
- Rapid discharge from hospitals for those wishing to get home quickly
- Mobilising alternative care providers to avoid admissions or facilitate early discharge.
REFLECTING on un-necessary admissions, or all admissions in the last months of life to understand the factors involved can help teams pre-plan to avoid future crises and admissions. The GSF Significant Event Template using the Traffic lights approach can be a useful way to approach this in a non-judgemental way.
More details are available from the National GSF Centre, but some resources are given below.
For more information on out of hours prescribing:
Development of Just in Case Boxes
The information below includes some guidance on developing Just in Case Boxes in a local area and some established examples from different PCTs
