ENGAGEMENT WITH PROGNOSTICATION. INCORPORATING THE GOLD STANDARDS FRAMEWORK INTO DISCHARGE PLANNING

Background The GSF was developed in 2000 to improve palliative care in primary care by improving :- 1. Quality of care 2. Co-ordination and communication 3. Patient outcomes and cost effectiveness. Acute hospitals have been described as the missing link, providing seamless, co-ordinated high quality End of Life care. Enabling staff to identify patients in the last 12 months of life in a systematic sustainable way and linking this into discharge planning proves difficult. There has been no experiences in implementing GSF in Tertiary Cancer Centres, this causes many challenges; around communication with multi-disciplinary teams across a large geographical area. Aim To improve engagement of staff in identifying patients in the last 12 months of life. Method RAG is a tool used for highlighting patients needs, referrals and outcomes to aid in a safe/timely discharge. RAG (Red/Amber/Green) boards have been implemented as part of the discharge planning. It9s regarded as a good way of engaging colleagues in the identification of patients within the last twelve months of life. Results A weekly meeting is held on all wards. Staff discuss and agree the expected prognosis for individual patients. Each category is linked to specific needs which are addressed. Blue=Stable disease Green=Less than twelve months Amber=Weeks prognosis Red=Days prognosis The visual aide memoir assists all health care professionals to review the needs of individual patients ensuring appropriate support is in place for both patients and carers at the time of discharge Conclusion The GSF can be linked with the discharge planning process in an acute hospital setting. This facilitates discussion and ensures the needs of patients are addressed and met in a timely manner. Appropriate communication with primary healthcare teams is achieved with collaboration and seamless care across healthcare settings becomes a reality.