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Aged Health Network
Key principles for individual patient specials in hospital Aged Health Network
Key principles for additional supervision and individual patient specials in hospital
Aged Health Network Key principles for individual patient specials in hospital i
AGENCY FOR CLINICAL INNOVATION
Level 4, 67 Albert Avenue Chatswood NSW 2067
PO Box 699 Chatswood NSW 2057 T +61 2 9464 4666 | F +61 2 9464 4728 E [email protected] | www.aci.health.nsw.gov.au
SHPN (ACI) 180210, ISBN 978-76000-852-9
Produced by: Name of Network, Institute or Taskforce if applicable.
Further copies of this publication can be obtained from the Agency for Clinical Innovation website at www.aci.health.nsw.gov.au
Disclaimer: Content within this publication was accurate at the time of publication. This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the Agency for Clinical Innovation.
Version: 01 Trim: ACI/D15/2379
Date Amended: 2016
© Agency for Clinical Innovation 2016
The Agency for Clinical Innovation (ACI) works with clinicians, consumers and managers to design and promote better healthcare for NSW. It does this by:
• service redesign and evaluation – applying redesign methodology to assist healthcare providers and consumers to review and improve the quality, effectiveness and efficiency of services
• specialist advice on healthcare innovation – advising on the development, evaluation and adoption of healthcare innovations from optimal use through to disinvestment
• initiatives including guidelines and models of care – developing a range of evidence-based healthcare improvement initiatives to benefit the NSW health system
• implementation support – working with ACI Networks, consumers and healthcare providers to assist delivery of healthcare innovations into practice across metropolitan and rural NSW
• knowledge sharing – partnering with healthcare providers to support collaboration, learning capability and knowledge sharing on healthcare innovation and improvement
• continuous capability building – working with healthcare providers to build capability in redesign, project management and change management through the Centre for Healthcare Redesign.
ACI Clinical Networks, Taskforces and Institutes provide a unique forum for people to collaborate across clinical specialties and regional and service boundaries to develop successful healthcare innovations.
A priority for the ACI is identifying unwarranted variation in clinical practice and working in partnership with healthcare providers to develop mechanisms to improve clinical practice and patient care.
www.aci.health.nsw.gov.au
Aged Health Network Key principles for individual patient specials in hospital ii
Acknowledgements
The Key principles for individual patient specials in hospital were developed by a working group of the Nurses Subgroup, Aged Health Network. The working group would like to thank the directors of nursing for their valuable feedback.
Name Position
Lorraine Lovitt Nurses Subgroup Co-chair and Leader, Lead, NSW Falls Prevention Program, Clinical Excellence Commission (Working Group Co-chair)
Drew Kear Program Manager, Geriatric and Ambulatory Medicine, St Vincent's Hospital (Working Group Co-chair)
Kerry Bartlett Clinical Nurse Consultant, Coffs Harbour, Mid North Coast Local Health District (LHD)
Jenene Bell Manager, Nursing & Midwifery Workload Unit, Ministry of Health
Carol Burfoot Clinical Nurse Specialist, Coffs Harbour, Mid North Coast LHD
John Dobrohotoff Clinical Advisor, Older People’s Mental Health Policy Unit, Mental Health Drug and Alcohol Office, Ministry of Health
Debra Donnelly Clinical Manager Aged Care, Rehabilitation, Chronic & Ambulatory Care, Endocrinology, General Medicine & General Practice, Andrology & Clinical Genetics, Sydney LHD
Trudie Duiveman Clinical Nurse Consultant, Aged Care, Rehabilitation Aged Care Services, Central Coast LHD
Sandy Everson Clinical Nurse Specialist, Aged Care Medical Unit, Coffs Harbour Hospital, Mid North Coast LHD
Kelli Flowers Nurses Subgroup Co-chair and Clinical Nurse Consultant, Aged Care, Liverpool Hospital, South West Sydney LHD
Jamie Gills Clinical Nurse Consultant, Dementia/Delirium, Central Coast LHD
Catherine Lothian Clinical Nurse Educator, Division of Rehabilitation and Aged Care, Central Coast LHD
Colleen McKinnon Clinical Nurse Consultant, Dementia/Delirium, South Eastern Sydney LHD (2013)
Catherine McPhail Clinical Nurse Consultant, Aged Care, Shellharbour Hospital, Illawarra Shoalhaven LHD
Gai McPherson Clinical Nurse Consultant, Dementia/Delirium, Port Macquarie, Mid North Coast LHD
Trish Merchant Clinical Nurse Consultant, Orange Base Hospital, Western NSW LHD
Anne Moehead Nurse Practitioner Psychogeriatrics / Dementia Northern NSW LHD
David Nielsen Clinical Nurse Consultant, Dementia Community, Murrumbidgee LHD
Dwight Robinson Project Officer, Emergency Care Institute, Agency for Clinical Innovation
Jenny Rodwell Nurse Manager Special Initiatives Nursing and Midwifery, Mid North Coast LHD
Sue Schasser Clinical Nurse Consultant/Coordinator, Aged Care Services Emergency Team Concord & Canterbury Hospitals, Sydney LHD
Aged Health Network Key principles for individual patient specials in hospital iii
Name Position
Colette Scott Transitional Nurse Practitioner, Psychogeriatrics, Port Macquarie Base Hospital, Mid North Coast LHD
Cathy Sendlhofer Acute to Age Related Care Services Coffs Harbour, Bellingen and Dorrigo
Joan Stort Nursing and Midwifery Unit, NSW Ministry of Health
Sharon Strahand Acute Care of the Elderly Clinical Nurse Consultant, Hornsby Kuringai Hospital Northern Sydney LHD
Sharon Sutherland Clinical Nurse Consultant Aged Care Facility Outreach, Blacktown Hospital, WLHD
Lee Taylor Emergency Department Aged Care Co-Ordinator, The Maitland Hospital
Jan- Maree Tweedie Executive Director of Nursing and Midwifery Central Coast LHD
Jason Viney A/Nurse Manager Special Initiatives Nursing and Midwifery, Mid North Coast LHD
Secretariat
Name Position
Glen Pang Network Manager Aged Health, ACI
Anthea Temple CHOPS Project, Aged Health Network, ACI
Aged Health Network Key principles for individual patient specials in hospital iv
Contents Acknowledgements ...................................................................................................................... ii
Introduction ................................................................................................................................... 5
Purpose ................................................................................................................................. 5
Scope .................................................................................................................................... 5
Out of scope .......................................................................................................................... 5
Describing the role of an individual patient special ................................................................. 6
Key Principles ........................................................................................................................ 7
Other key strategies ............................................................................................................... 7
Aboriginal Health Impact Statement ....................................................................................... 8
Particular considerations for specific populations ................................................................... 9
Principle 1: Supportive care for people ..................................................................................... 10
Principle 2: Staff education on caring for people ..................................................................... 12
Principle 3: Individualised assessment and care planning of patients ................................... 14
Considerations for a successful IPS role .............................................................................. 15
Principle 4: Communication processes to support person-centred care ............................... 17
References .................................................................................................................................. 18
Collaboration. Innovation. Better Healthcare.
Introduction Patients may require additional or enhanced supervision during their admission in acute, sub-acute care and Multi-Purpose Service (MPS). This may be for behavioural and safety needs or other clinical conditions such as the management of cognitive impairment; the need for complex nursing care; high fall risk; potential for absconding; observation of adverse effects due to medication. Additional supervision may be delivered by the colocation of two, three or four patients in a ward area with a nurse providing supervision and care3,4,7 (often called high acuity care/observation units). Some patients may require one-on-one supervision provided by an individual patient special 3,4,7. These Key Principles for additional supervision and Individual Patient Specials have been developed to provide guidance for staff to deliver one-on-one observation and supportive clinical care. It is important to note that not all patients who have clinical and behavioural needs will require one-on-one care, as good clinical assessment in many cases should lead to appropriate intervention3,4,7.
Other key strategies should also be employed to support additional observation, supportive and clinical.
Purpose The Key principles for additional supervision and individual patient specials in hospital aim to improve the care for those patients who require one-on-one or high levels of supervision during their admission in acute care, sub-acute care and MPS settings. These patients may be agitated, disorientated or confused and/or at risk of harm to self and others. The key outcome for the implementation of an enhanced supervision or IPS is to provide safe patient care delivered by appropriately skilled staff. These principles focus on patients with cognitive impairment. However, they are applicable to other patients who may require one-on-one supervision. Throughout the remainder of the document, the term IPS will be used to describe the role for providing supervised care and adapting components of the skills can also be used for enhanced supervision options.
Scope These key principles are applicable to inpatients in: acute care, sub-acute care and MPS settings, including emergency departments (EDs). They are for staff involved in the clinical assessment, planning, implementation, evaluation and documentation for the provision of an IPS.
Out of scope 1. Patients in intensive care/high dependency.
2. Patients in specialist mental health units.
3. The use of volunteers, a security officer or a health & safety security assistant as an IPS as they do not have the skill set required.
4. Children and adolescents
Aged Health Network Key principles for individual patient specials in hospital 6
Describing the role of an individual patient special The term individual patient special, or IPS, refers to a clinician with skills to provide one-on-one observation, supportive and clinical care to one patient who may have clinical and behavioural disturbance such as: • unsettled (wandering, aggression, restlessness) behaviours resulting from delirium and/or
dementia1,7 • the potential to abscond1 • the potential to cause harm to self or others • the need for observation due to potential adverse effects of medication1,5.
The role of the IPS is to enhance patient safety and provide quality care to ensure the best outcome for the patient/family and carer. This clinician may be an assistant in nursing (AIN), an enrolled nurse (EN) or a registered nurse (RN). In some settings, an allied health assistant may be appropriate in this role. The clinical and care needs of the patient are to be assessed in consultation with other members of the health care team to: • minimise the risk of harm to self to staff or others • observe and document behaviours7,10,3 • provide early notification of possible adverse events1 • engage the patient/family/carer2 • provide non–pharmacological management and person-centred approaches to care. 5,9 There will be patients with mental health needs (detained or not detained under the Mental Health Act 2007) admitted to general care hospital settings. The management of these patients should be determined at a local level.
Aged Health Network Key principles for individual patient specials in hospital 7
Key Principles
Other key strategies Other key strategies should be employed to support additional observation, supportive and clinical care such as: • assessing the patients level of cognition, risk and causes of delirium and implementing
treatment3,4,7 • assessing for pain and implementing treatment4 • implementation of fall prevention strategies • requesting family/carer to stay with the patient11,6 • completing the TOP 5 – carer's tips for effective communication to promote personalised care2 • relocating a patient to where they are able to be observed more closely7. There are also a range of strategies and resources in relation to the management of patients with behaviours of concern that could reduce the requirement for an IPS. These include:
• Management of older person with confusion as described in the Key Principles for the Care of Confused Hospitalised Older Persons (CHOPs), Principle 4,
• TOP 5: - Carer's tips for effective communication to promote personalised care, Partnering with Patients, Clinical Excellence Commission
• Assessment and management of people with behavioural and psychological symptoms of dementia (BPSD): A handbook for NSW clinicians, Ministry of Health
• Aggression, seclusion and restraint in mental health facilities in NSW,
• The ways of working team approach
Principle 1: Supportive care for patients NSW hospitals will have systems in place to support staff in caring for patients requiring an IPS.
Principle 2: Staff education on caring for patients Staff are supported through training, education and leadership to enable them to deliver skilled, timely and knowledgeable care.
Principle 3: Individualised assessment and care planning of patients A patient who requires an IPS will be assessed and individualised care will be implemented.
Principle 4: Communication processes to support person-centred care Carers and families will be supported and informed of the patient’s care plan and needs while requiring one-on-one care.
Aged Health Network Key principles for individual patient specials in hospital 8
• Key Principles for Improving Healthcare Environments for People with Dementia
• The HETI dementia and delirium online e-learning module, The NSW Health dementia care competency framework,
• The University of Tasmania Massive Open Online Course, Understanding dementia,
• NSW Falls Prevention Program, NSW Clinical Excellence Commission,
Aboriginal Health Impact Statement The prevalence rate of dementia among Aboriginal and Torres Strait Islander people is approximately three times that of the non-Indigenous Australians. Aboriginal and Torres Strait Islander people also experience a younger onset of dementia and consequently an increased risk of delirium compared to similarly aged non-Indigenous Australians. It is important that services ensure that IPS is delivered in culturally safe and competent ways. Consideration should be given to cultural differences, the use of liaison officers and greater involvement and communication with carers, family and their wider community. Service providers should particularly focus on:
• Ensuring Aboriginal are people are identified • The development of trust • Screening and assessment processes that recognise the holistic approach to health that is
shared by most Aboriginal people and communities • Education processes that will build the literacy, engagement and empowerment of
Aboriginal people • Referral processes to appropriate agencies with a particular focus on the unique role of
AMSs • Follow-up to ensure that Aboriginal people are receiving the services required and
supported to effectively manage their health.
The preceding dot points are further expanded in the Chronic Care for Aboriginal People Model of Care and services should familiarise themselves with that model to enable the development of culturally competent and safe services.
Collaboration. Innovation. Better Healthcare.
Considerations for specific populations Improved understanding and early identification and management of patients with cognitive impairment may reduce the requirement for an IPS. A patient with increased cognitive impairment (delirium and/or dementia), agitation or restlessness has an increased risk of an adverse event and in particular for falls. Often these patients require extra supervision and care because they are acutely unwell. They require physical, psychological, cognitive and behavioural assessment, care planning and intervention delivered by specially skilled clinicians. Individuals respond to confusion/dementia/delirium in different ways and there is diversity in perception and understanding of dementia and confusion across cultures. Ascertaining care requirements for the following groups may require the use of interpreters, social workers, access to specialist services and use of technology for consultation and liaison with support organisations. Some of these groups include: • culturally and linguistically diverse communities • rural and remote communities • people with younger onset dementia • people with intellectual disability • lesbian, gay, bisexual, transgender and intersex people • people with dementia in correctional centres • people with non-progressive cognitive impairment.
There is further information on the specific needs of these groups are outlined in the Dementia Services Framework 2010 – 2015. How to use this document The implementation of the four key principles will considerably improve the care and management of patients requiring an IPS. The principles are interlinked and the order in which they are listed does not indicate the level of priority. Health care facilities wishing to implement the IPS can utilise all principles within this document or focus on specific principles where gaps have been identified. Local Health Districts (LHDs) and healthcare facilities should consider how best to: 1. incorporate the key principles in local policies and procedures
2. incorporate the key principles in local initiatives to improve the care of confused older people in hospital
3. utilise their health professionals with expertise in the care of confused patients such as geriatricians, old aged psychiatrists, aged care specialist nurses, dementia and delirium clinical nurse consultants and senior allied health professionals.
Aged Health Network Key principles for individual patient specials in hospital 10
Principle 1: Supportive care for people NSW Hospitals will have systems in place to support staff in caring for people who require one-on-one care and supervision.
When a patient requires increased care, the need for an IPS should be determined by local processes including consultation with the nursing unit manager (NUM)/nurse in charge of the shift/after hours nurse executive and medical team (or in rural and remote areas the senior nurse). Choosing the staff to undertake the IPS role is important, and the person chosen may come from the nurses rostered on the shift or from additional staff, taking into account: • safety7 • the best outcome for the patient4 • the number of staff on the shift10 • the skill mix on the shift10 • the skills of the staff to take on the IPS role7,10 • the overall clinical workload on the ward at the time10. This decision should be made during the shift and may not necessarily require extra staff to be allocated. Consideration may be given to alternate models of care within existing staffing. When the NUM or nurse in charge considers that the IPS is unable to be resourced from the staff available on the shift, they should seek approval to engage additional staff in accordance with local policy. A governance framework is necessary to support the implementation of an IPS. Key components of the framework should include:
• Executive endorsement The executive has developed and endorsed a governance system and process to support enhanced and one-on-one care decision making. This should include the role of IPS, the process for approval and appropriate educaton3,4.
• Standardised process for requesting, authorising, continuing and ceasing IPS Systems are in place to establish the need for and authorisation of an IPS, including the role for the NUM/manager to approve, and a process for ceasing IPS when clinically considered as no longer required.
• A standardised tool is recommended for approval of an IPS3,4. This is to ensure that the care needs of the patient remain paramount and that thorough assessment and care planning has been undertaken.
• Regular review of the patient and their care requirements will contribute to a decision as to whether there is a need to continue with an IPS. A decision to cease an IPS could follow discussions with the staff member providing the special, any carers and any family members 1,2,10.
Aged Health Network Key principles for individual patient specials in hospital 11
• A process for assessing the patient’s decision-making capacity A person requiring an IPS may have diminished capacity for consent for care and treatment. If a patient is not capable of consenting to their own treatment, there should be consultation with and consent sought from the patient’s nominated person responsible8.
• Suitably skilled staff are identified and assigned to the IPS role3 A process is in place to ensure that staff assigned to the role of IPS receive training and education in the provision of one-on–one care.
• A procedure for supporting external staff in the IPS role3 If an IPS with the required skillset is not available and an agency or casual staff member is allocated to the role, they will require extra support by the NUM and/or the nurse in charge of shift and other members of the nursing team.
• An escalation procedure The IPS should be aware of the escalation process if the patient’s condition changes or deteriorates1. For example, the Between the Flags system is a 'safety net' for patients who are cared for in NSW public hospitals and health care facilities. It is designed to protect patients from deteriorating unnoticed and to ensure they receive appropriate care if they do.
• Support for staff in the role of IPS The nurse in charge of the shift and other members of the ward team are to provide support to the IPS and collaborate on care interventions and observations.
• Standardised data set for measuring/auditing. Collection of data on IPS use at a local level allows healthcare facilities to monitor current performance and drive improved patient care. This could include cost, hours, level of staffing, requirement and hours of IPS, patient outcomes and adverse events1. As health services become more skilled in the care of patients with confusion, it would be expected that the number of IPS employed will decrease.
• A process for identifying and acknowledging staff who have performed well in the IPS role Positive feedback and acknowledgement should be encouraged and supported for staff who are recognised as performing well in the IPS role.
Aged Health Network Key principles for individual patient specials in hospital 12
Principle 2: Staff education on caring for people Staff are supported through training, education and leadership to enable them to deliver skilled, timely and knowledgeable care.
The key focus for the IPS is to provide observation of the patient, appropriate clinical care and treatment according to the patient’s needs. The patient will require an individualised assessment in regards to their care requirements and IPS staff require the skills to provide that care3. This is a shift from the notion of ‘custodial’ care typified by staff being passive observers (sitting and guarding patients).
Staff undertaking the IPS role require specific skills, attitudes and knowledge. It should be noted that many nursing staff may have the skills and knowledge to undertake the role of an IPS. Decisions as to which nursing staff member is most suitable are made at a local level. It is recommended that there is to be a process in place for education3 of staff undertaking the role of IPS. This can be achieved by: • providing training for staff who may potentially fill the role of an IPS6,10 • liaising with external providers to ensure staff appointed to an IPS role have, as a minimum,
training to provide one-on-one care across the identified clinical areas10 • ensuring that other staff are aware of the role of the IPS and that they are an integral part of the
ward health care team10 • executive staff endorsement and understanding of the requirements of the role of IPS and the
care needs of a patient requiring an IPS3 • building workforce capacity (e.g. a pool of skilled staff) to undertake the role of IPS, that could
be either ward based or across the hospital6,10 • where an additional nurse is provided and this nurse is a casual or agency nurse, then
consideration that they be assigned to the ward and an appropriate member of the ward staff should undertake the IPS role6
• compiling a register of staff that have undertaken specific IPS training • informing ward nurses of their roles in supporting the IPS as part of the clinical care team6.
Education in providing direct patient care should include the following domains:
• Safety: minimising harm to the patient e.g. noting ‘high fall risk’, and implementing appropriate fall interventions and minimising pressure injuries.
• Behaviours: having knowledge about reducing the risk of self-harm and minimising aggression by implementing strategies such as therapeutic and diversional activities.
• Confusion: having knowledge and understanding of the older person with dementia/delirium. • Observations: monitoring and recording vital signs as indicated and reporting any variances
and reporting any changes in cognition e.g. increasing confusion, agitation. • Nutrition: ensuring adequate food and fluid intake. • Therapeutic and diversional activities: engaging the patient with suitable and stimulating
activities e.g. reading the newspaper, watching football on TV, playing cards. • Personal care needs: including supervised toileting and mobility.
Aged Health Network Key principles for individual patient specials in hospital 13
• Engaging with family and carers: asking about key interests and hobbies and recording e.g. TOP 5 communication strategies2.
Contributing to the multidisciplinary team • Planning: plan the patient’s care needs in liaison with other members of the health care team
and the patient’s family/carer where possible10. • Communication (patient): use communication skills that build rapport with the patient,
family/carer about care needs and plan of care e.g. orientating, reminiscing, engaging, validating3,4,10.
• Communication (health care team): liaise with other members of the health care team to arrange suitable meal breaks and provide a handover relating to care needs. Changes in the patient’s condition should be escalated using the appropriate methods according to local policy.
• Documentation: document all interventions and plan of care in the patient health record7.
Aged Health Network Key principles for individual patient specials in hospital 14
Principle 3: Individualised assessment and care planning of patients Patients who require an IPS will be assessed and individualised care will be implemented.
A patient considered as requiring an IPS must undergo a comprehensive clinical assessment that includes risk screening and clinical assessment for causes of the underlying condition, behaviours and presentation4. There should be clear criteria for determining the need for an IPS e.g. increased clinical care requirements when responding to behaviour needs, agitation and high falls risk and when other strategies have been considered and or unavailable. Consultation with other members of the health care team may assist in providing guidance for intervention and management. Consider talking to a geriatrician or psychogeriatrian, where available, as well as senior clinical nursing staff and Clinical Nurse Consultants or Clinical Nurse Specialists who are experienced in the management of behavioural disturbance and/or dementia /delirium3. These assessments and management plans must be clearly documented in the patient’s health record and care plan with regular review to facilitate the continuing and/or ceasing of the IPS role. Tools should be available for the assessment and management of the patient at risk3,7. Screening or assessment for risk may cover falls, cognition (including delirium) mood, nutrition and hydration, adverse response to medications, pain, urinary tract infection, constipation and pressure injury. This may occur at any point of care during the patient’s hospital stay, including on presentation to ED. The assessment of risk should be completed by adequately skilled clinicians. The desired knowledge base will include clinical areas such as: • cognition –assessment of cognition including delirium and management of people with
dementia and delirium • fall risk and interventions • pain assessment and management • activities of daily living – requirements for personal care and mobilisation • continence and bowel management • nutrition and hydration • pressure injuries • behavioural management strategies that are non-pharmacological (e.g. diversional and
recreational activities). Review of the patient and of the need for the continuation of the IPS should be at least daily, and ideally every shift. If the patient has settled and if clinically appropriate the decision to remove the IPS should be made in consultation with the treating team.
Aged Health Network Key principles for individual patient specials in hospital 15
Considerations for a successful IPS role
define the capabilities and scope of practice of the IPS ensure the appropriateness of the nurse to the patient they are caring for – consideration
should be given to gender, cultural and social background, skills and training provide report updates and clinical changes to senior in charge of hospital or similar ensure observations/procedures are attended by an appropriately trained nurse ensure that the IPS has assistance from other members of the nursing team to assist with
observations and ADLs as required ensure the carer and family are informed of current treatment and involved in care where
appropriate provide a thorough clinical handover at change of shift.
In supporting the IPS, the following should occur:
the IPS is informed of the nominated RN who has overall responsibility for that patient and the ward team
the IPS is relieved for breaks during the shift when a patient requires tests and investigations that the IPS communicates with the
supervising RN when leaving and returning to the ward. handover between the IPS and supervising RN and incoming stall members at the completion
of the shift, including signs of escalating behaviours and management strategies implemented and documentation as required
The clinical care provided of the IPS may include but not limited to the following as determined by local arrangements and scope of practice:
deliver care outlined in the care plan and provide care within their scope of practice complete the patient observation chart and complete additional charts/assessments within
scope of practice inform the supervising RN responsible if the patient’s condition changes assist with the patients personal care, mobilising, assist with showering, toileting and meals interact with the patient, and take them for walks if appropriate provide written communication about the care provided during the shift in the patient health
care record notify the RN immediately if the patient’s condition or behaviour is such that there is a concern
they are unable to care for the patient safely continue to monitor and document any clinical observations including whilst the patient is
asleep engage with the patient, carer and family whilst providing care in a person-centred way carry/ or have access to a duress alarm.
Aged Health Network Key principles for individual patient specials in hospital 16
Patient care plan Formulation of the plan Based on assessment, a person-centred care plan to address the behaviour, safety and clinical condition should be developed by the clinical team, which includes the patients, family/carer where possible. These relevant inputs occur at different stages of the patient’s journey and a family meeting may be required3,4,7,10.
Key aspects of the patient care plan will include: • assess for delirium, pain, unmet needs or other physical problems • hydration, nutrition, elimination, meal requirements eg small frequent meals and fluids • safety (fall risk and minimisation strategies implemented and documented, mobilisation,
toileting) • communication (e.g. Sunflower, TOP 5) • environment (quiet, noise reduction, location with the ward, psychological symptoms • monitoring of behaviours and use of a behavioural chart if appropriate • medication (review and limitation on use of night sedation and appropriate use of antipsychotic
medication) • ongoing monitoring and assessment of vital signs as indicated, including level of cognition • communication of care details at clinical handover.
Aged Health Network Key principles for individual patient specials in hospital 17
Principle 4: Communication processes to support person-centred care Communication processes and tools will support person centred care for the person requiring IPS. Carers and families will be supported and informed of the persons care plan and needs while requiring one on one care.
• Provide supportive environments to engage with carers and families in planning care and responding to the needs and preferences of the patient4
• Key information obtained from family and carers can assist in having a better understanding of the patient and their needs. The CEC Top 5 Program is an effective communication tool that can be implemented to improve communication with a patient with dementia2. The CHOPs sunflower can be used to describe more details about the patient e.g hobbies, previous work, number of grandchildren, favourite movies and radio programs
• Communication between teams and at clinical handover is important. Complex care needs requires input and expertise from the multidisciplinary healthcare team which may also include consultation with the mental health consultation liaison service and other speciality services.
Aged Health Network Key principles for individual patient specials in hospital 18
References 1. Bartlett, K. (no date). Specialling in delirium and dementia: A cross-sectional cohort
study. http://www.heti.nsw.gov.au/Global/Rural/RRCBP/2012%20RRCBP%20Intake/K%20Bartlett%20-%20Final%20Report.pdf
2. Clinical Excellence Commission, 2014. TOP 5: Improving the care of patients with dementia 2012-2013, Sydney: Clinical Excellence Commission.
3. Dewing, J. (2012). Special observation and older persons with dementia/delirium: a disappointing literature review. International Journal of Older People Nursing, 8, 19-28. doi:10.1111/j.1748-3743.2011.00304.
4. Dewing, J., & Dijk, S. (2016). What is the current state of care for older people with dementia in general hospitals? A literature review. Dementia, 15(1), 106-124 doi:10.1177/1471301213520172.
5. Dolan, C., Omer, S., Glynn, D., Corcoran, M. & McCarthy, G. (2012). Benzodiazepine and Z-drug prescribing for elderly people in a general hospital: a complete audit cycle. Psych Med, 29 (2), 128-131.
6. Dick, A., La Grow, S., & Boddy, J. (2009). The effects of staff education on the practice of 'specialling' by care assistants in an acute care setting. Nursing Praxis in New Zealand, 25 (1), 17-26.
7. Kerr, M., Verner, Y. & Traynor, V. (2013). From darkness to lightness: developing a working definition of special observation in an acute aged care setting. International Practice Development Journal, 3 (Conference Suppl.), 6.
8. NSW Department of Attorney General & Justice. (2016). NSW Civil and Administrative Tribunal, Person responsible. NSW Department of Attorney General & Justice. www.ncat.nsw.gov.au/Documents/gd_factsheet_person_responsible.pdf
9. NSW Ministry of Health, Royal Australian and New Zealand College of Psychiatrists. (2013) Assessment and management of people with behavioural and psychological symptoms of dementia (BPSD): A handbook for clinicians.
10. Wilkes, L., Jackson, D., Mohan, S., & Wallis, M. (2010). Close observation by 'specials' to promote the safety of the older person with behavioural disturbances in the acute care setting. Contemporary nurse: a journal for the Australian nursing profession, 36 (1-2), 131-142. doi:10.5172/conu.2010.36.1-2.131
