title: Improving care for patients whose recovery is uncertain. The AMBER care bundle: design and implementation.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Palliative Care, Guy's Hospital, London, UK.
authors.forename: Irene
authors.initials: I
authors.lastname: Carey
authors.affiliation: Guy's & St Thomas' Foundation Trust, London, UK.
authors.forename: Susanna
authors.initials: S
authors.lastname: Shouls
authors.affiliation: King's College London Cicely Saunders Institute, London, UK.
authors.forename: Katherine
authors.initials: K
authors.lastname: Bristowe
authors.affiliation: Department of Palliative Care, Guy's Hospital, London, UK.
authors.forename: Michelle
authors.initials: M
authors.lastname: Morris
authors.affiliation: Guy's & St Thomas' Foundation Trust, London, UK.
authors.forename: Linda
authors.initials: L
authors.lastname: Briant
authors.affiliation: Harris HospisCare, Kent, UK.
authors.forename: Carole
authors.initials: C
authors.lastname: Robinson
authors.affiliation: Guy's & St Thomas' Foundation Trust, London, UK.
authors.forename: Ruth
authors.initials: R
authors.lastname: Caulkin
authors.affiliation: Guy's & St Thomas' Foundation Trust, London, UK.
authors.forename: Mathew
authors.initials: M
authors.lastname: Griffiths
authors.affiliation: Department of Palliative Care, Guy's Hospital, London, UK.
authors.forename: Kieron
authors.initials: K
authors.lastname: Clark
authors.affiliation: King's College London Cicely Saunders Institute, London, UK.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Koffman
authors.affiliation: Guy's & St Thomas' Foundation Trust, London, UK.
authors.forename: Adrian
authors.initials: A
authors.lastname: Hopper
mesh_terms: D000066491:Clinical Decision-Making; D003643:Death; D006801:Humans; D017063:Outcome Assessment, Health Care; D010166:Palliative Care / Q000379:methods*; D064872:Patient Care Bundles / Q000379:methods*; D011787:Quality of Health Care; D035501:Uncertainty
keywords: Clinical decisions; Communication; Cultural issues; Education and training; Hospital care; Transitional care