Improving care for patients whose recovery is uncertain. The AMBER care bundle: design and implementation Irene Carey, 1 Susanna Shouls, 2 Katherine Bristowe, 3 Michelle Morris, 1 Linda Briant, 2 Carole Robinson, 4 Ruth Caulkin, 2 Mathew Griffiths, 2 Kieron Clark, 1 Jonathan Koffman, 3 Adrian Hopper 2 1 Department of Palliative Care, Guy’s Hospital, London, UK 2 Guy’s & St Thomas’ Foundation Trust, London, UK 3 King’s College London Cicely Saunders Institute, London, UK 4 Harris HospisCare, Kent, UK Correspondence to Dr Irene Carey, Department of Palliative Care, Guy’s Hospital, Ground Floor Borough Wing, Great Maze Pond, London SE1 9RT, UK; irene.carey@gstt.nhs.uk Received 2 December 2013 Revised 16 June 2014 Accepted 13 August 2014 Published Online First 2 September 2014 To cite: Carey I, Shouls S, Bristowe K, et al. BMJ Supportive & Palliative Care 2015;5:12–18. ABSTRACT Introduction Despite preferences to the contrary, 53% of deaths in England occur in hospital. Difficulties in managing clinical uncertainty can result in delayed recognition that a person may be approaching the end of life, and a failure to address his/her preferences. Planning and shared decision-making for hospital patients need to improve where an underlying condition responds poorly to acute medical treatment and there is a risk of dying in the next 1–2 months. This paper suggests an approach to improve this care. Intervention A care bundle (the AMBER care bundle) was designed by a multiprofessional development team, which included service users, utilising the model for improvement following an initial scoping exercise. The care bundle includes two identification questions, four subsequent time restricted actions and systematic daily follow-up. Clinical impact This paper describes the development and implementation of a care bundle. From August 2011 to July 2012, 638 patients received care supported by the AMBER care bundle. In total 42.8% died in hospital and a further 14.5% were readmitted as emergencies within 30 days of discharge. Clinical outcome measures are in development. Conclusions It has been possible to develop a care bundle addressing a complex area of care which can be a lever for cultural change. The implementation of the AMBER care bundle has the potential to improve care of clinically uncertain hospital patients who may be approaching the end of life by supporting their recognition and prompting discussion of their preferences. Outcomes associated with its use are currently being formally evaluated. INTRODUCTION There is increasing recognition of the challenges experienced by patients, their families and professional caregivers when admitted to hospital with an acute exacerbation of an underlying life- limiting condition, frequently facing an uncertain outcome. Acute hospital treat- ment tends to focus on the immediate clinical problem with less effective case management such as recognition of tran- sitions between clinical phases. 1 A struc- tured approach to intrateam consensus is rarely evident, and prognosis is often not discussed with patients. 2 Particular diffi- culties are associated with the heteroge- neous presentation of clinical uncertainty —the spectrum ranges from those patients with more predictable progres- sive disease (typically advanced cancer), to those with a less predictable course sometimes characterised by episodic acute deterioration (typified by frail older patients). The result can be delayed rec- ognition that a patient may be approach- ing the end of life, and a consequent failure to provide high-quality care and convey information that gives the opportunity to focus on patient choice in the face of uncertainty and possible approaching death. 3 In England, currently 53% of all deaths occur in hospital, 4 despite research sug- gesting that most people would prefer to die at home. 5 On average, 29.7 days are spent in hospital in the last year of life with repeated hospitalisations which can be a cause of distress among patients and their families. Recent reports have sug- gested that only 25–42% of deaths in Editor’s choice Scan to access more free content Features 12 Carey I, et al. BMJ Supportive & Palliative Care 2015;5:12–18. doi:10.1136/bmjspcare-2013-000634 group.bmj.com on January 5, 2017 - Published by http://spcare.bmj.com/ Downloaded from