title: Supporting patients with uncertain recovery: the use of the AMBER care bundle in an acute hospital.
abstract: OBJECTIVE
  Patients who are deteriorating, with uncertain recovery and with a short prognosis often have complex needs. The AMBER care bundle systematically manages these patients by promoting consistent communication and care planning. To describe how the AMBER bundle is applied in a UK hospital. To identify factors affecting the use of the AMBER bundle in patients who subsequently died. To gain preliminary data with regard to potential markers of deterioration in groups less frequently supported by AMBER METHODS: Retrospective review of electronic case notes for all deaths over 11 months on five inpatient wards where AMBER was implemented.
  
  
  RESULTS
  N=149. Median age 80, IQR 72-87. Admission diagnoses: cancer (25%), non-cancer (31%), multimorbidity (44%). 38% were supported by AMBER. Patients with cancer were more frequently supported by AMBER (62% vs 30% p<0.001). Illness trajectory was defined a priori as 'predictable gradual' (40%), 'predictable rapid' (22%), 'unpredictable' (21%) or 'sudden death' (17%). 'Predictable gradual' deterioration resulted in more frequent support by AMBER (62% vs 21%, p<0.001). Patients were supported by AMBER after median 10 days of admission (IQR 5-17 days), and died median 9 days later (IQR 3-15 days). Patients with multimorbidity or unpredictable deterioration were less frequently supported by AMBER. Potential markers of deterioration were acute kidney injury, delirium, falls and comorbidity.
  
  
  CONCLUSIONS
  The use of the AMBER care bundle is affected by illness trajectory and diagnosis. Future work should clarify predictors of deterioration in patients with an unpredictable course.
authors.affiliation: King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, London, UK.
authors.forename: Simon Noah
authors.initials: SN
authors.lastname: Etkind
authors.affiliation: King's College Hospital NHS Foundation Trust, London, UK.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Karno
authors.affiliation: King's College Hospital NHS Foundation Trust, London, UK.
authors.forename: Polly M
authors.initials: PM
authors.lastname: Edmonds
authors.affiliation: Guy's and St Thomas' NHS Foundation Trust, London, UK.
authors.forename: Irene
authors.initials: I
authors.lastname: Carey
authors.affiliation: Department of Palliative Care, Policy and Rehabilitation, King's College London, Cicely Saunders Institute, London, UK.
authors.forename: Fliss E M
authors.initials: FE
authors.lastname: Murtagh
mesh_terms: D032722:Advance Care Planning / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D004608:Eligibility Determination / Q000379:methods; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D064872:Patient Care Bundles / Q000706:statistics & numerical data*; D011379:Prognosis; D012189:Retrospective Studies; D035501:Uncertainty; D006113:United Kingdom
keywords: Clinical decisions; Communication; Hospital care; Service evaluation; Transitional care; Uncertainty