# Improving the Use of Treatment Escalation Plans in Geriatric Medicine: A Quality Improvement Project

## TL;DR

This study shows how targeted interventions can improve the use of treatment escalation plans in geriatric medicine, leading to better patient-centered care.

## Contribution

The study introduces a quality improvement approach to increase TEP completion rates and timeliness in geriatric wards.

## Key findings

- TEP completion rates increased from 28% to 58% after two cycles of interventions.
- Median time to TEP documentation decreased from 10.5 to 5 days.
- Consultant involvement rose from 12% to 27%, linked to faster TEP completion.

## Abstract

Background

Treatment escalation plans (TEPs) support patient-centered decision-making by documenting individualized goals of care during clinical deterioration. Despite national guidance, TEP completion remains inconsistent, particularly in geriatric medicine, where frailty and multimorbidity complicate escalation decisions. Our audit aims to improve the uptake and timeliness of TEP completion in geriatric medicine wards of a tertiary hospital in Glasgow through targeted quality improvement interventions.

Methodology

A two-cycle quality improvement project was conducted between April and August 2025. Only patients admitted during the study periods and meeting predefined TEP criteria were included. Interventions included a paper-based admission checklist (Cycle 1) and a multidisciplinary teaching program (Cycle 2). Outcome measures included TEP completion rates, time to documentation, decisions regarding Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), and consultant involvement.

Results

A total of 275 patients were included (baseline: 75; Cycle 1: 75; Cycle 2: 125). TEP completion rates improved from 21 of 75 patients (28%) at baseline to 32 of 75 (43%) in Cycle 1 and 72 of 125 (58%) in Cycle 2. Median time to TEP documentation decreased from 10.5 days (interquartile range (IQR) 7-14) to 5 days (IQR 3-8). DNACPR documentation increased from 55% to 73%, with a significant association between DNACPR completion and TEP completion (P = 0.01). Consultant involvement increased from 12% at baseline to 27% and was associated with earlier TEP completion (median 4 vs. 7 days, P = 0.03).

Conclusions

This audit demonstrated an initial approach to improving TEP uptake and timeliness in geriatric medicine. While targeted interventions showed measurable benefits, formal TEP education and ongoing strategies are required to support sustainable use and strengthen patient-centered decision-making.