Care Home Deterioration Context There is pressing need to develop - - PowerPoint PPT Presentation

Care Home Deterioration

Context There is pressing need to develop best & appropriate care practices within the Care home population that account for the personalised care & support planning, vulnerable residents require. Contents

• 2. Care home deterioration tool (ReSTORE2)
• 3. Care home assessment pathway
• 4. Personalised care and support planning
• 5. Optimal care for care home residents with dementia
• 6. Care home COVID virtual ward
• 7. Explanatory text re: the virtual ward & diary

8-9 Emergency palliative oxygen prescription (to be abbreviated & linked to other policy docs)

DRAFT

Care home staff e learning resources https://www.youtube.com/playlist?list=PLr VQaAxyJE3cJ1fB9K2poc9pXn7b9WcQg

https://westhampshireccg.nhs.uk/wp-content/uploads/2020/02/CS49286-RESTORE2-full-version.pdf

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MILD (Cat 3) O2> 94%

Or any of RR ≤ 20, HR ≤ 90 ≈ NEWS2 0-2

MODERATE (Cat 2) O293-94%

Or any of RR 21-24, HR 91-130 ≈ NEWS2 3-4

CARER CONCERN

pulse oximetry +/- NEWS2

Medical Referral Home Oxygen and/or palliative Care where appropriate - coordinated via the virtual ward

CARE HOME COVID ASSESSMENT PATHWAY

BREATHLESSNESS Myalgia Chill Severe Fatigue

Sputum Dizziness Cough

Nausea/vomiting Diarrhoea Headache Sore throat Nasal Congestion Loss of taste/smell

COVID Symptoms ranked by severity predictiveness

Face to face or Virtual Assessment

With knowledge of pre existing TEP if available

Shared Decision-making Points

SEVERE (Cat 1) O2< 93%

Or any of RR ≥ 25, HR ≥ 131, new confusion ≈ NEWS2 ≥ 5

C L I N I C A L J U D G E M E N T

COVID VIRTUAL WARD

GP issues COVID Virtual Ward Diary (incl. admission/CPR status) Monitoring – Symptoms & Trend of O2 saturations

Consider exertional saturations e.g. 40 step walk/stairs Modality & frequency of monitoring as directed by GP Some patients may be suitable for purely verbal/written safety netting, others may require calls

Watch for ‘silent hypoxia’

Asymptomatic presentations with low O2 sats (often with normal RR, HR & other obs)

Appropriateness for admission/CPR Determined on an individual basis

Soft signs of deterioration

1-2l/min as required up to 24 hrs a day

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Personalised care and support planning

• Ideally, residents should have personalised care and support plans that reflects

their preferences and priorities. These may include a combination of:

• one page profiles
• advance care plan
• emergency care plan
• advance decisions to refuse treatment (which may or may not include DNACPR)
• In the context of COVID, treatment escalation plans should include:
• discussions about potential benefit and burden of different treatment options
• documentation of the resident’s views about these options, and their preferences and

priorities in the light of COVID infection (important not to assume that prior expressed views in the context of progressive life limiting condition will remain unchanged in the context of COVID as an acute infectious illness)

• plans about treatment escalation steps and limits, and how to optimise symptom relief,

care and support wherever the person chooses to be

• who else should be involved in these discussions, including whether or not the resident

has authorised a Lasting Power of Attorney for Health and Welfare

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Three quarters of care home residents live with dementia Presentation – people with dementia may have difficulties in communication affecting expression of the symptoms

so awareness of the signs of COVID is important (“look beyond words”) (1,2)

Management – people in the later stages of dementia may have challenges in understanding the reason for

isolation and handwashing practices (3,4)

Person Centred Care – be aware of the resident's past history by, for example, the “This is me” document (5) Practical steps caring for residents while wearing PPE and during COVID testing (6)

• Have your name and picture clearly visible on clothing;
• Laminate a smiley face and flowers on PPE
• Use tone of voice and open body language to demonstrate warmth
• Draw or use written words to communicate where appropriate
• Explain why you are taking a sample - these may need to be repeated
• Play some favourite music to aid relaxation
• Ensure hearing aids and glasses are worn and working

Sedation – should be avoided if possible to manage purposeful wandering (7) Delirium – people with dementia and more likely to become delirious which can be prolonged (8) Advance Care Plans and Powers of Attorney can guide treatment plans End of Life Care – residents may have been there for some time so that end of life can be particularly stressful for

carers who often say “it’s like losing a member of our family” (9)

COVID 19 and Dementia in care home residents

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COVID VIRTUAL WARD

COVID Virtual Ward

Monitoring at clinician’s discretion Focusing on old, frail & challenged

Severe <93% Moderate 93-94% Mild > 94%

Are you Better/worse?

• Shortness of breath?
• Function (ADL)?
• What are your Oxygen

saturation trends? Consider Admission

• r Home O2

/palliation Consider Monitoring Or Admission Consider Monitoring or Discharge

Suspected COVID patient In the Care home

COVID Virtual Ward Referral form

Info / summary / symptoms O2 sats frequency at clinician’s discretion Function Treatment escalation planning

Time stamps of patients who deteriorate

Days 5-7 Silent hypoxia Days 7-11 Significant breathlessness Beware of a reduction in O2sats

SAFETY NETTING

If patients meet any of the following criteria, they need 999 Severe breathlessness

• Unable to complete sentences
• Rapid, significant deterioration in breathing in the last hour
• New breathlessness at rest
• Sudden onset of breathlessness

Shock or peripheral shutdown

• New confusion or reduced level of consciousness
• Extremities – cold and clammy to touch
• Pallor – skin colour is mottled, ashen, blue or very pale
• Reduced urine output – little or no urine in last 24 hours

Functional impairment

• Inability to self-care/ perform ADLs

All patients will be monitored with oximeters

In the majority, full recovery is usual within 10-14 Days

Suspected COVID patient

In own home, discharged from hospital Non-conveyed by ambulance

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COVID VIRTUAL WARD

For Follow up of suspected or confirmed COVID-19 patients with oximetry monitoring on patients:

• In own homes or care homes
• For monitoring in the community, discharge from the hospital, non-conveyance from ambulances

Clinician determined frequency (TDS or if feels worse) of diarising of oxygen levels/function, using the virtual ward diary Surveillance of patients in the community at the discretion of the clinician- frequency/modality Patient diary to monitor trends. Clear directions for patients to call back if deteriorating.

• Symptoms

Feeling better/worse/same Breathing better/worse/same

• Oximetry

O2 Saturations Heart Rate / Temp

Coordination role for community home oxygen/palliation

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Emergency oxygen provision in Care homes

https://player.vimeo.com/video/283011112

Covid HOOF Questions Response Where does COVID get documented? No 11- additional information write “Covid patient short term install” Box No 3 Clinical Code If clinical code 21 available tick this if not 20 and any other co morbidities e.g. COPD is 1 What do I request? Current advice is 1 static concentrator 1-2l/min 24 hrs tick nasal cannula How Do We get equipment removed Single use for patient and then securely removed by supplier care home will be instructed of process How quickly can the oxygen be delivered For emergencies, oxygen can be installed within 4 hrs Patient is not coping on 2l/min Discuss with Home Oxygen team / GP/ Hospital next steps Who do I phone to organise this urgently Links to the form and guidance is on the supplier page. What electronic forms do I have to fill in, and in what order? 1. IHORM (Initial Home Oxygen Risk Mitigation Form) 2. HOCF (Home Oxygen Consent Form) and then

• 3. HOOF (Home Oxygen Order Form)

https://www.england.nhs.uk/coronavirus/publication/home-oxygen-order-form-hoof-letters-and-guidance/

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HOOF and IHORM can be downloaded from this site

https://www.dolbyvivisol.com/services/healthcare-professionals/home-oxygen-services/england/ihorm-and- hoof-part-a/

Region you work in O2 Supplier and ordering details

• South West
• London
• North West
• East Midlands

Air Liquide Healthcare

Oxygen must be ordered through the portal https://www.airliquidehomehealth.co.uk/hcp Prescriber Support Team is on 0808 202 2099 (24/7)

• Yorkshire and Humber
• West Midlands
• Wales

Baywater Ltd

Oxygen must be ordered through the portal https://apps.baywater.co.uk/onlineportal/Account/Register Clinical Support 01270 218050 (24/7

• East of England

(excluding Milton Keynes)

• North East

British Oxygen Company (BOC)

Oxygen must be ordered through the portal https://www.bochealthcare.co.uk/hop/ Clinician Registration: https://www.bochealthcare.co.uk/hop/RegisterAsNHSStaff.aspx Clinical Support 0845 609 4345 (24/7)

• South Central

(INCLUDING Milton Keynes)

• South East Coast

Dolby Vivisol

Oxygen must be ordered by sending a HOOF by email from an NHS.net personal email account to Email: hoof.dv@nhs.net DO NOT send from generic nhs.net accounts. Clinical Support 0800 917 9840 option 5 (24/7)

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