Improving documentation of treatment escalation decisions in acute care.

The aim of this project was to improve the documentation of treatment escalation decisions at a district general hospital in southwest England. A pilot "Ceiling of Treatment" proforma was trialled on the care of the elderly wards at the Royal United Hospital (RUH), Bath. Successive PDSA cycles enabled revision of the proforma for use across the Trust. Data were collected on the proportion of patients with a documented treatment escalation decision. Formative feedback was collected via questionnaire from trainees and discussion with special interest groups of consultants within the hospital. This approach involved collaboration between acute medicine, intensive care, elderly care, the resuscitation department, palliative care and the legal department. Documentation of ceiling of treatment decisions rose from 30% to 90% during the study. A survey of medical trainees showed 67% (n=36) had seen the ceiling of treatment form, of which, 100% found it useful on on-call shifts. Initiating a proforma to record treatment escalation decisions and combining this with the existing 'Do not attempt cardiopulmonary resuscitation' (DNAR) paperwork, increased decision making and documentation. This intervention ensures patients receive the appropriate level of care, as indicated by their consultant, and reduces anxiety for junior doctors during on-call shifts.