The Hornsby Ku-ring-gai Hospital (HKH) Palliative Care Service is a specialist inpatient consult team that directly supports people admitted to the hospital and provides advice to treating and admitting teams. The palliative care team collaborates with admitting or treating teams to:
Inpatient specialist multidisciplinary palliative care team
Screening and identification of patients whose recovery is uncertain
Shared decision-making and communication with patients and their families
End of life care provided during admission
The HKH palliative care team supports the use of the AMBER Care Bundle in the hospital, providing a systematic approach to assist the multidisciplinary team to identify when an inpatient’s recovery is uncertain. AMBER refers to Assessment Management Best Practice Engagement of patients and carers for patients whose Recovery is uncertain.
This bundle enables care planning conversations to be initiated with patients and families earlier and allows them to have a better understanding of their condition. It also promotes ongoing conversations and advance care planning with their community care providers if the person recovers to the point where they can be discharged.
Between 14 July 2020 and April 2021, 165 patients were identified as being suitable for the AMBER Care Bundle. Of these, 49 died in HKH, 16 were transferred to the Neringah Hospital Palliative Care Unit where they subsequently died and 3 died at home. The remaining 116 patients were discharged to their usual place of residence or placed in a Residential Aged Care Facility (RACF). Only 32 patients experienced an inpatient readmission.
“The AMBER care bundle allows all multidisciplinary team members to have a voice and a role in care planning for patients. At HKH, medical teams rotate through inpatient services every 12 weeks, whereas nursing staff and allied health are based permanently on the various wards. As HKH serves an elderly population, nurses and allied health staff will often see the same patient over multiple admissions and are well placed to identify any ongoing functional decline or changes in the care needs of these patients. Medical staff find their input with the AMBER Care Bundle supportive and helpful, and feel it is a useful tool in identifying patients whose recovery may be uncertain.
The AMBER care bundle is empowering for all staff. It helps with decision making and plans.”
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