Article Text

Download PDFPDF
Improving the use of treatment escalation plans: a quality-improvement study
  1. Meelad Sayma1,
  2. George Nowell1,
  3. Aedamar O’Connor1,
  4. Gemma Clark1,
  5. Andrew Gaukroger2,
  6. Dominic Proctor2,
  7. Jamie Walsh2,
  8. Brian Rigney1,
  9. Storm Norman1,
  10. Andrew Adedeji1,
  11. David Wilson1,
  12. Darren O’hagan1,
  13. Victoria Cook1,
  14. Robbie Carrington1,
  15. Preshgena Sekaran1,
  16. Maya Wehbe1,
  17. Duncan Paterson3,
  18. Sophie Welchman3,
  19. Jay Over3,
  20. Sheila Payne4
  1. 1Faculty of Medicine, Peninsula College of Medicine and Dentistry, Truro, UK
  2. 2Faculty of Medicine, Exeter Medical School, Truro, UK
  3. 3Divisions of Medicine and Surgery, Royal Cornwall Hospital, Truro, UK
  4. 4International Observatory on End of Life Care, Lancaster University, Lancaster, UK
  1. Correspondence to Dr Meelad Sayma, North Middlesex University Hospital, London, N18 1QX, UK; meeladsayma{at}


Objectives Treatment escalation plans (TEPs) are vital in communicating a ceiling of care. However, many patients still deteriorate and die without a pre-established ceiling of care for attending clinicians to rely on. We aimed to increase the proportion of suitable patients that have TEPs in place in a rural district general hospital.

Methods We undertook three ‘Plan-Do-Study-Act’ (PDSA) cycles between 1 December 2016 and 9 June 2017. These cycles aimed to assess the problem, implement a solution and monitor its sustainability. We sampled all acute medical admissions at different time points, focusing on the acute medical unit. We identified patients requiring TEP forms using SupportiveandPalliative Care Indicators Tool. Stakeholders were surveyed during the project, and a process communication map was developed to understand the human interfaces that occur when producing a TEP.

Results We sampled a total of 323 patients (PDSA 1, n=128; PDSA 2, n=95; PDSA 3, n=100). Following implementation of a ‘talking to your doctor about treatment’ leaflet, the proportion of patients who did not have a TEP but required one fell from 43% (n=38, PDSA 1) to 27% (n=20, PDSA 3) then to 23% (n=77, PDSA 3) (CI 0.6631 to 39.917, p=0.028).

Conclusions This study highlights the challenges of TEP form completion. The impact of our intervention appeared to raise awareness of advanced care planning. The information contained in our leaflet could be distributed in more innovative ways to ensure patients unable to access textual information are able to receive this message.

  • quality in health care
  • adult palliative care

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors GN and MS take responsibility for the integrity of data, overall design of the project and write up of the work, they also participated in data collection. JO, DP and SW were part of the conception and design of the project. AO, AG, AA, BR, DW, DP, GC, JW, MW, PS, RC, SN, DO and VC took part in study design and were responsible for data collection. GN and MS are joint first authors of this paper. SP aided with synthesis and interpretation of results and completion of the final paper. All authors were involved in drafting and approved this version of the work.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval This project was classified as Quality Improvement, therefore ethical approval was not required. Despite this, we registered and approved the project with our Hospital Research and Audit Department. We ensured all data we recorded were anonymised. For follow-up data (to identify what proportion of patients were deceased), we stored a list of patient numbers on a secure National Health Service computer. Once these patients were followed up, these data were deleted.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Presented at Part of this work was presented as a poster in the National Clinical Fellows conference 2017.