The Free - Standing Inpatient unit / Hospice

A ‘free-standing’ unit is one not within a general. It may be in the grounds of a hospital or totally separate from a hospital, even miles away. Whether it is called a palliative care unit or a hospice is a decision that must be made by the Trustees when establishing it.

What makes any palliative care unit or hospice different from a hospital is not its size (although most hospices are small units with around 20- 30 beds), but the holistic, personalized, flexible programme, and the attitude of the staff.

When planning to open /build a free standing in-patient unit one has to address the following questions.

Why is a free-standing inpatient unit thought to be needed?

There must be an identified need for care in a hospice according to the pattern of death, and the structure of the society. There must be good reasons why the palliative care unit cannot be within a hospital or palliative care be provided by a hospital palliative care team (HPCT)

A well conducted needs assessment is essential to define the target population, the major clinical problems, the existing services and networks in the community to be served

Mortality statistics are the starting point:

 If it is a culture where family bonds are strong and families feel that it is their duty their to care for the patients no matter whatever the cost to them, and the patients want to die in their own beds than maybe it is better to have a second thought and ask if a community palliative care team might be more appropriate or a unit for short stay, for “acute problems” combined with a such a community team.

If numerous young couples have to emigrate to find better jobs and there is shortage of “lay carers”, no nursing homes and little development of community services then a long-stay unit is the best solution for offering palliative care.

ill it be a demonstration unit?

If you work in areas where palliative care is in the pioneering stage it might be necessary to demonstrate to the authorities the benefits of hospice, the costs associated with it, the impact of care on the patients and the families in order to convince them to accept the model and to integrate it into the existing health care system.

Will the unit engage in professional education and training?

When training others in palliative care the most difficult task is to change attitudes and to acquire the right communication and practical skills. So practical training is a vital part of the education project and an in-patient unit is the place where this can best be achieved

Will an existing building be donated or become available for purchase?

Sometimes buildings become available when hospital re-organization takes place and some buildings are found to be redundant. They may be offered for emerging palliative care services sometimes with the idea of keeping the workplace for staff that would otherwise be made redundant. Think of all the implications when accepting such an offer. It might not be the best decision for all concerned

If it is a hospital you could be assimilated with, would you be obliged to give up some important things like number of staff, or accepting staff into the interdisciplinary team? If yes then this is not an option and you must find a way to convince your authorities that hospices are well recognized in the world and back up your case with recommendations made by international professional associations or official bodies like European Union, World Health Organization. (WHO)

How is the new hospice going to fit in to the existing health system or collaborate with a nearby hospital?

In your country are hospices recognized as health care facilities? If not what is the closest type of medical unit that your hospice could be associated with? What are the legal requirements for a unit to operate like a hospice or as health care unit? Are there special services that need to be put in place (e.g. laundry, kitchens, food stores, pharmacy, etc,) Find out now and discuss them with your architect.

What other things need to be considered at the planning stage?

If it is to be a short stay hospice (most being discharged within 14 days)  what is going to happen to the patients when they leave the hospice.? Are the community services well enough developed to take over the care of the discharged patients? Are there other services with which you can establish links?

What about diagnostic and pharmacy services?

Can you make arrangements for investigations: radiology, laboratory or for receiving such further treatments as radiotherapy, surgery, chemotherapy? Will it have units own pharmacy and how / where will drugs be procured?

Will the hospice have its own mortuary or can you use the facilities of a neighbouring hospice. Depending on the law in your country will you need to plan a “cold room” in your hospice if you can not issue the death certificate within24 hours and you are not allowed until then to transport the patient?

What can you learn from others?

In the planning period it is good to visit other similar facilities existing in the country and to learn from their success and failures. If you are the first to open a hospice in your country and maybe you have been abroad and have been impressed with one specific hospice and have learnt about its functioning, policies and operational procedures be realistic in what you can use in your specific situation, what needs to be adapted and what needs  to be left out. Do not try to clone a unit that has impressed you!

Go on the Internet if you have access and look for palliative care sites and official documents regarding palliative care like Rec (24) 2003 of the European Council. Doing work in advance might save you from ending with a building that can not be registered in your country and is not suitable for the needs of the needs of the patients.

What characteristics do you want your hospice to have?

Is the hospice going to be for adults, for children or for both? If you plan to open a children’s hospice you have to be aware that for children there is a longer dying trajectory and that children might be reluctant to come because a hospice, as homely as friendly it might be, remains an institution and the best place for a child remains the family environment. If children area to be cared for in a ‘mixed unit’ there will need to be special rooms set aside for them and nurses trained in paediatric care.

 It must be decided at the planning stage which patients the unit will cater for. Will they all be in the terminal stages of illness or might some have chronic, not-life-threatening conditions.  Possible eligible patients are listed in Clinical Practice Guidelines for Quality Palliative Care National Consensus Project). p.4   For example will the unit accept :

One has to decide if the unit is going to be for long stay or short stay patients admitted, for example, for 10-14 days to control severe symptoms or psychosocial problems or for terminal care. (In most units in the West the average length of stay is 11-14 days)

It has to be decided if patients will be admitted for respite care to offer families a break from exhausting care.  If so, will such stays be booked in advance or be offered as the need arises?  The need for respite care is greatest when the unit is associated with a community palliative care service.. One problem is that many such patients do not return home but stay and die in the unit.

Once the unit is well known in the community there will soon be a waiting list for admission so apart from establishing in your admission criteria you have to establish the priority criteria for admission. It is useful to have a team responsible for the admissions so as not to put too much pressure on one individual

How many beds will be needed?

For administrative / economic / efficiency  reasons a unit smaller than 10 beds is not cost efficient unless catering, stores, supplies, central heating, security, pharmacy etc are available on site in an adjacent unit / hospital

It is generally accepted that in a population of 1,000,000 the number who will need a palliative care bed is

The numbers with non-malignant disease in the population who might need palliative care (but not necessarily a hospital bed) are :

The average statistics for hospices in the West are

Is the hospice going to have an incorporated outpatient / ambulatory clinic or maybe a day hospice / unit or other palliative care services? If so this will affect the number and type of rooms, toilets, ambulance and car access, wheelchair access, the need for activity rooms, treatment rooms and equipment.

Will there be an educational programme? (See separate section)

If so there will need to be a seminar room for teaching, space for a library, storage space for equipment, toilets nearby, access separate from the in-patient unit as well as major staffing and therefore financial implications

How will drugs be procured and stored?

A free-standing unit may need to have its own pharmacy or contract with another one in a local hospital. Arrangements will need to be made in advance - before any building is done - to comply with national legal requirements related to “ controlled drugs / dangerous drugs “ their procurement, storage, dispensing, administration to patients, secure trolleys. secure cupboards, drug registers, inspections, appointment of staff qualified to handle them etc.-

Staffing the unit

If you work in a country with a tradition of palliative care then staff recruitment is no problem but if you come from a country where palliative care is in a developing phase then you might encounter difficulties in the sense that you will not have a pool of trained staff from which to select your people and also there might be little interest from health care professionals to move into palliative care jobs. It has to be remembered, however, that excellent staff do eventually come forward, as seen in so many countries.

If there is a good training programme in your country, ask if they would be interested in doing multidisciplinary disciplinary training. This will help also build up your team.

Pre-service training as well as orientation are essential and must be budgeted for. There might be there a possibility for some staff from another unit in your country or from a unit with which you are twinned to come and work for a month or two as volunteers at the beginning alongside your staff as role models

Nursing staff

A good rule is to aim for a nurse/patient ratio of not less than nurse:1.5 patients throughout 24 hours. Put another way aim for 13-18 nurses per 10 beds. At least 50% of nurses on duty at any one time should be registered ( ie trained)nurses.) Most experienced units do not use student nurses rotating through different specialties, but have a permanent, designated palliative care staff, instead.

Medical staff

How many depends on:

A rule of thumb is that one full time physician can look after 10-15 beds, provide the medical input into a community palliative  care service caring for 40 patients at any time, plus a day unit, and spend up to 3 hours/week on education.

Extensive experience in the United Kingdom shows that units with full-time physicians have a higher admission and discharge rate of patients, and provide more education, than units served by part-time visiting physicians.

Junior doctors who rotate through the unit for experience should not be regarded as service providers because they require so much of the senior physician's time in supervising and teaching. A critical issue is "out-of-hours" cover. For the sake of patients and nurses, it should not be provided by a doctor (senior or junior) lacking experience in hospice/palliative care. This cannot be overstressed.

Social work staff

It is essential that every comprehensive palliative care service (which may include in-patient unit, community care, day care and even hospital palliative care team ) has an experienced social worker on staff. It is, however, recognised that in many countries there are few, if any, social workers and even fewer with training / experience in palliative care Their work will usually focus as much on staff as on patients and relatives, and be concerned with coping strategies, loss and personality problems.

The "simpler " tasks of a social worker, such as facilitating discharge, arranging help in the home, obtaining financial assistance, making special holiday arrangements etc. can usually be dealt with by someone appropriately trained, though not necessarily accredited as / paid as much as a social worker.

Professionals allied to medicine

Any in-patient unit with more than 15 beds, regardless of other services it provides, will need a physiotherapist on staff. Units with 30+ beds need a full-time one. Good palliative care involves rehabilitation, not simply the aim of getting patients back to their homes and loved ones. For this a physiotherapist and, if possible, an occupational therapist are essential

Pastoral care staff

It is axiomatic that a hospice/palliative care service and its team pay due and equal attention to the spiritual needs of the patients as well as to their physical and psycho-social needs. This generally means that a priest, clergyman or someone trained in pastoral care should be on staff, or be readily available. Larger units (of> 25 beds) need a full time pastoral care worker if possible. Others may use local clergy. It must be remembered that this "chaplain" will also support staff and volunteers, contribute to and organize educational courses, and conduct many funerals.

Volunteers (see separate section)

Volunteers are used in a variety of ways in different countries. They do not replace professional staff nor are they used to reduce costs in the long established units in the United Kingdom. They do work which would not normally be done by staff, and in many general hospitals, work which might never be done at all. For example, they arrange flowers, staff cafeterias, man switchboards "out of hours", read to patients or play games with them, transport patients and relatives to the Day Unit or other hospitals, sit in the homes of the elderly and lonely, staff charity shops and other fund-raising enterprises, play a major role in fund-raising etc.

It is absolutely essential that volunteers are carefully selected, skilfully led and organised, and have a very clear, unambiguous job description with well-defined lines of communication and accountability.

Administration and Management

From the earliest planning stage of an in-patient unit there needs to be: a planning group composed of mature people familiar with (though not necessarily expert in) hospice/palliative care, able to contribute experience and skills in management, building, law, health care administration, medicine, nursing and spiritual care. Once the unit is operational this group may stand down.

They should ideally be responsible to, but separate from a trustee group who is legally responsible for the affairs of and operation of the unit.

The third group needed, preferably from the early planning stage is a professional advisory committee, non-executive but immensely important and influential, reporting directly to the Trustees. Much of the efficiency and credibility of the unit will flow from this committee and its influence and guidance. Its membership should be representative of specialist hospice/palliative care (both medical and nursing), general medicine, oncology, hospital and community nursing, social work, education and research, as well as representatives of the church, and professionals allied to medicine. As with any committee much depends on the authority of the chairperson who must be able to meet regularly with the senior hospice staff

Its responsibility is to advise on all aspects of the professional work of the unit, including staffing levels, recruitment, documentation, protocols, audit, curricula, relations with other clinical services, research and possibly ethics etc.

Appointment of senior staff

Provided there is a Professional Advisory Committee and the Trustees, the order in which senior staff are appointed hardly matters, though logically the senior administrator/chief executive should be given priority, followed by the senior medical and nursing staff, each of whom will then share in the recruitment and appointment of their own staff members.

It cannot be over-emphasized that even the smallest hospice/palliative care unit must be run on business-like lines, with well defined lines of accountability and communication, written down procedures and protocols, review systems in each department, clinical and organizational audit systems which operate from Day 1, and a defined public relations policy.

Being well-meaning and compassionate (as are all people in hospice/palliative care) is essential, but this can never substitute for clinical and organisational efficiency, however small or large the in-patient unit.

What financial resources are available?

Experience suggests that raising capital for hospice/palliative care is relatively easy when people already know what it is and how it can help them. The bigger challenge is raising sufficient revenue to maintain the service, particularly if there are in-patient beds.

The most expensive item is salaries, usually accounting for 80-85% of costs. Though hospice/palliative care beds are certainly slightly more economical than beds in acute or even long stay hospitals, they are still very expensive. A good rule, when planning an in-patient service is to budget for revenue requirements only 10 % less than current costs in local acute units.

It is a mistake to depend too heavily on unpaid volunteers as a means of reducing costs. Unquestionably volunteers play a major role in this type of care, but should not be regarded as cheap replacements for paid staff.

As with all of the models there are advantages and disadvantages related to it.

Advantages of a free-standing unit

Disadvantages of a free-standing unit

Audit

From Day 1 every aspect of the work of a free-standing unit must be audited, records kept of audit meetings, and all procedures – clinical and organisational - reviewed at frequent regular intervals.

Previous Page     Main     Next Page