From infection control and palliative care to diabetes and medication management, Australian Ageing Agenda presents expert advice on the latest evidence and resources for frontline staff.
Infection control
Judy Forrest
Significant changes have been made to the original criteria for infection surveillance in facilities, writes Judy Forrest.
The infection surveillance definitions for long-term care facilities, the McGeer Criteria, were originally published in 1991 and had not been updated until recently.
At the time the McGeer Criteria were developed, long-term care facilities rarely provided intravenous therapy or laboratory or radiology services and other investigative services for the diagnosis of new clinical problems.
Now, 20 years later, it is still important that clear definitions for infection surveillance are applied in residential care facilities that care for the post-acute and frail older age populations, as well as for those in other long-term residential care environments such as disability services, rehabilitation units and other facilities that deliver medical and skilled nursing services. New definitions have now been published to encompass all these areas.
The existing McGeer definitions were reviewed and updated late in 2012 by an expert consensus panel in the US. Led by Nimalie D. Stone and Suzanne F. Bradley, together with leaders in infectious diseases, epidemiology, and long-term care, the modified definitions have been based on a structured review of the evidence and literature.
Significant changes have been made to the original criteria and all those responsible for infection surveillance in residential care facilities should be cognisant of the new information. Changes in the new definitions include new criteria for urinary tract and respiratory tract and influenza infections. New definitions have also been added for norovirus gastroenteritis and Clostridium difficile infections. Additional information regarding scabies definitions has also been included. And, in an effort to standardise terminology across the clinical syndromes, common definitions for fever, acute change in mental status, and acute functional decline have also been outlined.
Many organisations are not aware of the revised definitions. To enable valid infection surveillance data to be produced from the residential care sector it is vital that there is accurate reporting of infections according to the recommended criteria. It is important that all residential care facilities review and update their documentation and infection surveillance criteria in line with the revised definitions of infection for surveillance in long-term care facilities.
Click here to access the full criteria
Judy Forrest is managing director of Bug Control Australia.
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Diabetes
Trisha Dunning
New guidelines are helping professionals care for the growing number of older people living with diabetes, writes Professor Trisha Dunning.
Diabetes is a common problem in older people. Statistics show that diabetes and dementia are both increasing in Australia and the two conditions are linked. Some 16 per cent of older Australians have diabetes, while a further 16 per cent have undiagnosed diabetes, and many also have a diabetes complication when they are diagnosed. One in four older Australians living in residential aged care has diabetes.
In addition, older people often have other problems such as heart diseases, high blood pressure and kidney problems and are at increased risk of developing dementia. However, every older person is an individual so their care plans need to be personalised and developed with the individual and sometimes their family. Until recently there were very few guidelines that described how to develop care plans for older people with diabetes.
New guidelines, The McKellar Guidelines for Managing Older People with Diabetes in Residential and Other Care Facilities, launched in 2013, were designed in collaboration with experts in aged care and older people with diabetes living in residential aged care and in the community. The guidelines set the standard of care older people with diabetes can expect.
The philosophy behind the guidelines is that care of older people with diabetes needs to suit the individual’s health status, their ability to look after themselves and their diabetes, and their social situation including access to support.
The guidelines were evaluated in one large and four small rural aged care facilities in Victoria. The evaluation showed the guidelines helped aged care staff learn more about how to care for older people with diabetes; make decisions about individual older people’s care need; discuss important information about older people’s health and wellbeing with their GPs; and identify risks for the older person such as falls, pain, medicine side effects, low blood glucose and high blood glucose and how to plan care to reduce the risks.
The McKellar Guidelines are being implemented in a range of aged care facilities and will have an important role in the care of older people with diabetes in the future.
Click here to access the guidelines
Professor Trisha Dunning is Chair in Nursing (Barwon Health) at Deakin University and co-author of the McKellar Guidelines.
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Medication management
Andrew Boyden
Any symptom can be a medicines-related problem until proven otherwise, says Dr Andrew Boyden.
While modern medicines have contributed to longer life spans, improved health and better quality of life, sometimes medicines can make patients feel worse. This can be a result of medicines-related problems (MRPs) including over-dosage, inappropriate medicines use, drug interactions, medication errors, and non-adherence.
MRPs may occur with all types of medicines including prescription, over-the-counter (OTC) medicines and complementary therapies. It’s important that consumers are made aware that safety also needs to be considered for medicines that can be purchased without a prescription.
It is common for older people to have multiple health conditions and comorbidities and accordingly, to be taking multiple medicines. A consequence of more frequent medicines use is a higher risk for developing MRPs.
Reducing the risk of MRPs and optimising medicine use can be achieved by adopting the following principles and through use of evidence-based training and resources.
Watch for signs and symptoms of medicines-related problems: When assessing patients it can be useful to remember that any new symptom in an older patient should be considered a MRP until proven otherwise.
While many MRPs are predictable, they can also be hard to differentiate from underlying conditions particularly in older people (e.g. confusion caused by benzodiazepines may be mistaken for cognitive decline). It is therefore useful to know which MRPs might be predicted from the known pharmacology of the medicines and their known interactions.
Avoid ‘problem’ medicines and monitor use: A number of criteria are available to assist in the identification of potentially inappropriate medicines in older people. For example, The American Geriatric Society Beers Criteria 2012, which has been tailored to a pocket card format for use by health professionals.
Given the significant variability in response to medicines that is often observed amongst older people, it is important to monitor their situation so that treatment can be appropriately individualised over time.
Check if the benefits of current medicines outweigh the risks: Although in many cases clear benefits can be realised, due to limited efficacy data for many medicines in older people, it can be difficult to determine the likely benefit of a medicine in an individual patient. Apart from considering the potential benefits of a medicine, consider whether the patient is at risk of developing a MRP, for example by using the Medicines Risk Screen, a self-screening tool comprising of ten ‘yes/no’ questions.
Record any decisions agreed with the patient and provide them with a medicines list: Document any plans to help manage a person’s medicines (e.g. a tapering plan when stopping medicines) and keep an updated medicines list to help prevent medicine errors associated with the handover of care and to maintain continuity of care. Provide patients or carers with an updated list when medicines are changed and encourage them to maintain their medicines list.
Consider a medicines review: Residential Medication Management Review (RMMR) and Home Medicines Review (HMR) involves a pharmacist reviewing a patient’s medicines on request from the general practitioner. Identify which patients are at risk of MRPs and recommend that these patients have a RMMR or HMR.
Click here for more information or call NPS Medicines Line 1300 633 424
Dr Andrew Boyden is clinical adviser with NPS MedicineWise.
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Palliative care
Liz Reymond
The national rollout of new resources will support the capacity of facilities to provide high quality palliative and end of life care, writes Professor Liz Reymond.
The Palliative Approach Toolkit for residential aged care facilities (PA Toolkit) is an innovative set of clinical, educational and management resources designed to guide and support residential aged care staff to deliver optimal resident-centred palliative and end of life care in a sustainable and evidence-based way.
The use of a palliative approach enhances residents’ quality of life and the care provided by residential aged care facilities. There is no fixed ‘best time’ to commence a palliative approach. In general, a palliative approach is started when aggressive curative treatments are no longer appropriate for the resident and the focus of care is on symptom management, quality of life and comfort.
The model of care underpinning the PA Toolkit uses a resident’s estimated prognosis to trigger three key processes that are central to the successful implementation of a palliative approach: advance care planning, palliative care case conferences and use of an end of life care pathway.
Benefits of implementing a palliative approach using the resources in the PA Toolkit include: improvement in the care of residents; increased family satisfaction with resident care; increased workforce capacity to deliver high quality, evidence-based palliative and end of life care; and alignment of facility practices with Australian aged care and palliative care standards.
Focused around these key processes, resources in the PA Toolkit provide evidence-based and up-to-date information, tools and templates that will assist facility managers, clinicians, educators and care staff to undertake, review and continuously improve their palliative and end of life care practices.
As part of the national rollout, over 900 facilities have participated in free one-day workshops facilitated by experts in the implementation of a palliative approach in residential aged care. These workshops focus on the three key processes and 10 key steps for implementing a palliative approach in residential aged care and how PA Toolkit resources can be used to support each of these steps. (Refer to the Workplace Implementation Guide in the PA Toolkit for detailed information on each of these steps.)
By increasing access to the PA Toolkit and supporting the development of new clinical, educational and management resources to enhance its use in the residential aged care sector, the national rollout will further strengthen the capacity of Australian facilities to provide high quality palliative and end of life care for their residents.
Click here to access the PA Toolkit
Professor Liz Reymond is clinical director of Metro South Palliative Care Services, Metro South Health Queensland.
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