An All–Wales Audit of the Integrated Care Pathway for the Last Days of Life: Establishing the Audit Cycle

Since 2000, the Integrated Care Pathway (ICP) for the last days of life has been implemented mainly in secondary care and to some extent in primary care throughout Wales. The use of the document was monitored centrally. Analysis and feedback of the variance sheets demonstrated that looking at the ICP variances in isolation had limitations. In response to suggestions made by colleagues working with the ICP for the last days of life throughout Wales, an all-Wales audit of the pathway was initiated. At the close of the baseline audit (31 August 2006), data were analysed from 24 sites, which included four (of 5) hospices, three (of 5) specialist inpatient units, eight (of 28) community sites, eight (of 9) district general hospitals and one nursing home. These sites submitted data on 201 deaths managed using the ICP for the last days of life and represent a 77% response rate. Data arriving up to one week after the deadline were subsequently entered onto the database resulting in a response rate of 80%. The response rate from a concomitant staff survey sent out to district nursing teams, community hospitals, wards in district general hospitals and hospices was 48%. The findings of the audit indicate that standards were met in 62% of cases. Variance recording and reporting are misunderstood resulting in 34% underreporting of variances or changes to the expected course of care as detailed in the ICP. Ongoing training and ‘refresher’ sessions are indicated for new and existing staff. The outcomes of the staff survey endorse the findings of the audit and call for more training, although the pathway is recognized as a contributory factor in improving the care of the dying patient. Re-audit six months later showed an overall outcome of the ICP standards being met in 81% of cases. This second audit establishes the annual audit cycle for the pathway that will continue to monitor quality of care and contribute to the annual review of the pathway.