Presentation on theme: "Nurse Consultant in Emergency Care Imperial College NHS Trust"— Presentation transcript:
1Nurse Consultant in Emergency Care Imperial College NHS Trust Mary Dawood RNNurse Consultant in Emergency CareImperial College NHS TrustnhsManagers.net
2Management of Emergency Care for frail older people Mary DawoodNurse ConsultantImperial College NHS Trust
3Definition of FrailtyIncreased vulnerability to insult or challenges resulting from impairments in multiple domains that compromise compensatory ability
4Frailty Challenges Multiple interacting medical and social problems Impaired functionAltered pharmacokinetics and pharmacodynamicsPolypharmacyAtypical disease presentations
5Context of the Emergency Department The Emergency Department is the most common point of access for frail elderly to the hospitalOlder people particularly those with dementia are heavy users of emergency servicesA poor ED experience can effect the entire hospital experience for the person both physically and mentallyThe ED is a very busy place which is frightening and much too fast for the older patient …..
8WhereTry to find a quieter place (sometimes better to examine in short stay wards)Draw curtains/close doors to reduce visual distractionKeep lights on – less shadow the betterDon’t try to compete with loud noises, wait until they are over before trying to communicateDiscourage loud chatting outside the cubicleIf you can find a second person will be easier, or family member to stay in while examining.
9Clear Signposting in the ED Signposting needs to be bold ,visible and multicueIt should be at eye level as the older person can easily loose their balance if they have to crane their neck
10Communication- What you need to know (in a short time) Used name (often different from given one)What the person does/did – helps to connect / helps with language recognitionWhere the person is originally from – will help with languageFamily/ Carers – who’s key and the first names – talk about ‘Margaret’, not ‘your daughter’What is the person’s home situation – who’s caring?Who was with the person last?
11Nursing Assessment Age, Date Place (name of the hospital or building), In addition to routine recordings of vital signs the AMT4 may be useful in the initial assessment of cognition in elderly patients.Helps early recognition and documentation of cognitive impairmentAge,DatePlace (name of the hospital or building),Current year
12Key Issues for People with Dementia in the ED Unsuitable environment – noise/activityFear / anxietyIllness / pain will make cognition worseNot good at waitingWill often struggle to contextualise what is happeningMight react negatively to perceived threatsWill forget injury/incident/reason for admissionHigh risk of deliriumWill come as a package- family/carer (most people with a diagnosis of dementia will have some level of care)
13Communication - What the Person with Dementia Needs to know You might think it’sobvious who you areNo white coatsPoor visionPoor hearingDifficulty reading IDbadges
14Communicating Context Every interaction should have:Who you are (using the word Dr/Nurse)Where you both areWhy the person is hereThat the person is safe / you can be trustedWhat’s about to happen (in the next minute)Repeat it every time.
17Poly-pharmacyInappropriate prescribing is a common problem in older peopleAdverse drug events account for 6.5%of all admissions but more in older people leading significant morbidity and mortalityIncreased pharmacist support is recommended for the elderly with medication
19Be Alert High degree of vulnerability Sometimes hard to separate unusual living situations from abusive onesOften involves financial abuseRecurrent attendances need to be investigatedEasy to get it wrong
20Safeguarding “No Secrets Policy” All services should have a nominated lead whilst accepting that safeguarding is everyone’s responsibility
21Mental HealthDepression is the commonest mental health problem in old age and is often undiagnosedThe Geriatric Depression Score -5 is a useful screening tool for depression
22Managing Challenging Behaviour It should be remembered that the elderly may react negatively to unfamiliar surroundingsUnwell older people will not always be able to articulate the reasons for their distress and it is always important to establish whether pain, constipation, urinary retention or psychosis lie behind disturbed behaviourMedication should only be used where it is the safest and least restrictive way of managing behaviour, which is a serious risk to other patients, the staff or other people in the emergency setting, or to patients themselves.National guidance on rapid sedation can be found at:
23Discharge PlanningEarly attention to discharge planning is essential as older people have complex needsThey should only be discharged from hospital with adequate support and respect for their preferencesAvoid discharging from the ED at night unless they are accompanied by family /carers
24Major Incident Planning Major incident plans and disaster preparedness plans need to include explicit contingencies for the management of multiple casualties of frail older peopleEach area/region needs to have up to date lists of named key clinicians and social care personnel with contact numbers, who have specific responsibilities for older people in the event of a major incident
25Hurricane KatrinaIt is notable that of the 1,330 people known to have perished in Hurricane Katrina in New Orleans in 2005, 71% were over the age of 60 and 47% were older than 75 years and at least 68 people died in nursing homes.
26Simple Recommendations to improve the Emergency Department Environment The assessment area for older people should be located in a quieter area of the department where observation is possible but noise, interruptions and over stimulation is minimised.Not be close to an exit.Cubicle/rooms large enough to accommodate family member/caregivers;Food and drink should be readily availableCreate an ambience consistent with the age of the patient eg older type prints on the wallsLarge ClockSofter lighting to prevent glareSuitable comfortable chairsNon shiny /Non slip flooringTrolleys with mattresses that are thicker to accommodate the frailty of the older patient
28Golden Rules for the ED Privacy and dignity must be respected Carers and/or family members should be involved if possibleAlways consider pain as a cause of agitation/confusionTwo health care professionals need to be involved in procedures one to monitor, comfort and distract, and the other to undertake the procedure;Intra and inter-hospital transfers of older people at night, should be minimised as it increases the risk of deliriumKeep safeguarding in mindPut a name bracelet on patientPrioritise assessment if at all possible
29SummaryThe ED represents a key point in the health and social care system where older people with health & social crises can be managedCreate a “frailty friendly front door” if we get it right for the elderly it will be right for allFocus on the needs of the patient, respond to the needsThink creatively – challenges are new, traditional approaches will not be enoughCommissioning the right model relevant to the needs of the local population
30It is hoped that the Silver Book will be a valuable resource and be the Silver lining in the care of our frail older patientsThank you for listening
31Medical management of frailty: confessions of a gnostic Recommended reading !Medical management of frailty: confessions of a gnosticKenneth RockwoodCAN MED ASSOC J 1997;