Analysis

Older people with urgent care needs: new advice will aid nurses’ clinical decision-making

Updated guidance aims to help minimise hospital stays and spot the signs of frailty

British Geriatrics Societys Silver Book II guidance aims to help prevent or minimise hospital stays, reduce unnecessary interventions and spot the signs of frailty

  • Focus is on the first 72 hours after an urgent care episode, with the need for more skills and training highlighted
  • Nurses need to be able to form balanced decisions on care required by older people, minimising investigations and interventions
  • Advice is to look holistically at the presenting complaint, the psychological aspect, and functionality and movement

Nurses across emergency, community and surgical care need to be able to unpick the complexity of non-specific presentations in older people living with frailty who have urgent care needs, according to new

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British Geriatrics Society’s Silver Book II guidance aims to help prevent or minimise hospital stays, reduce unnecessary interventions and spot the signs of frailty

  • Focus is on the first 72 hours after an urgent care episode, with the need for more skills and training highlighted
  • Nurses need to be able to form balanced decisions on care required by older people, minimising investigations and interventions
  • Advice is to look holistically at the presenting complaint, the psychological aspect, and functionality and movement
Picture: Charles Milligan

Nurses across emergency, community and surgical care need to be able to unpick the complexity of non-specific presentations in older people living with frailty who have urgent care needs, according to new clinical guidance.

With a focus on the first 72 hours after an urgent care episode, updated best practice guidance on improving care for older people aims to equip healthcare professionals to do just this.

The Silver Book II, published by the British Geriatrics Society (BGS), replaces the original 2012 version. Its ambition is to prevent hospital admission or, where it is needed, to minimise stays while reducing unnecessary interventions, particularly at the end of life.

Nurses should consider the underlying causes of common illnesses and injuries

The UK’s ageing population means that almost all health and social care professionals will be encountering older people living with differing levels of frailty on a daily basis. Around 10% of over 65s are living with frailty, rising to between 25% and 50% for the over 85s.

10%

of over 65s live with frailty
Source: British Geriatrics Society (2020)

There is a clear focus on emergency department (ED) settings, but the guidance also targets teams in other parts of the hospital, from surgery to cardiology, as well as in the community and care homes.

It highlights the need for comprehensive assessments to unpick what is happening by looking beyond the immediately obvious to often overlooked issues such as mood disorders, substance misuse and elder abuse.

Nurses should also consider the underlying causes of common illnesses and injuries such as falls, which may be linked to issues that can easily be overlooked – problems such as those with eyesight or balance.

Picture: iStock

Silver Book II is important as COVID-19 has made things worse and people’s health has deteriorated

The goal should be to generate a well-informed and well-balanced decision about their care, which includes minimising investigations and interventions that do not add value, it says.

Recognising and being able to unpick the complexity of non-specific presentations is a particular skillset over which professionals should seek to develop mastery, it says. ‘Skilful management of delirium, falls, silver trauma, continence and skin integrity issues is likely to improve patient experience and outcomes,’ says the guidance.

Lucy Lewis
Picture: British Geriatrics Society

Nurses and Allied Health Professionals Council chair Lucy Lewis wants nurses in all disciplines to read the guidance – including GP practice staff and hospital-at-home teams. ‘COVID-19 has made things worse. People's health has deteriorated because they have not been able to access the support they normally would or they may have been socially isolated,’ she says.

‘It’s easy to read – you can do it on your phone. It’s been designed so you can dip in and out of the chapters. It will help keep people out of hospital, and if they need to be admitted ensure they get the right support and interventions so they can leave as soon as possible.’

Develop a care plan after a comprehensive assessment identifies frailty

Ms Lewis, a consultant practitioner in a community frailty support team, says for most patients that should mean no more than 48 hours in hospital, or 72 hours at most. ‘The longer a person living with frailty is in hospital the more they will deteriorate,’ she says.

25% to 50%

of over 85s live with frailty
Source: British Geriatrics Society (2020)

The need to identify patients living with frailty by using a tool, such as the Clinical Frailty Scale recommended by NHS Improvement and others, is highlighted. Such a scale may consider aspects such as weight, self-reported exhaustion, slow gait speed and weak grip strength.

Silver Book II recommends a comprehensive assessment where frailty is identified, followed by the development of a care plan. Although a formal comprehensive geriatric assessment led by consultants is seen as the gold standard, Ms Lewis says this should not stop nurses from carrying out their own assessments.

Be alert to the signs that can be missed

Non-specific presentations

Delirium and depression

Substance misuse

Pain

Stealth trauma

Initial triage is essential to identifying the right care, whether that is being done in the ED, on a surgical ward or in the community. ‘What is important is that as part of that triage you look holistically,’ Ms Lewis says. ‘There are some important basic principles. First, look at the presenting complaint and the history of the presenting complaint.

‘Second, you need a mini-systems review. If they’ve fallen, could the individual have an infection or pneumonia as the cause? Assess cognitive abilities – talk to the person and their family to find out if they are more confused than normal.

Taking time to do an assessment is essential to get the right support, actions and care in place quickly

‘Consider the psychological aspect – is the person's mood low? Are they depressed? Could chronic pain be causing that?

‘Then you need to look at functionality and movement, and finally the environment and social network the person has at home. This can be done in 45 minutes in hospital – at the person's home you may want to take a little longer. But taking that time is essential in terms of getting the right support, actions and care in place quickly.’

Dawne Garrett
Picture: David Gee

RCN professional lead for older people and dementia care Dawne Garrett agrees this initial assessment is crucial: ‘There is a temptation to order too many tests and interventions or not coordinate those that need to be done. If you are moving really frail people around it can be distressing and confusing.

‘There is a real skill in being able to combine assessments, for example a cognitive assessment while taking blood or washing someone. It is also important to take the person’s wishes into account. They will have multiple conditions and not all of them need an intervention.

‘A patient with a possible fracture who has heart failure and breathlessness may be happy managing their heart failure. Older people’s nurse consultants and advanced nurse practitioners are great at this. They know how to do it.

£5.9 billion a year

Cost of frailty in terms of hospital admissions in the UK
Source: Silver Book II

‘But there are other nurses and staff, working in EDs and surgical units, for whom Silver Book II will be an important guide. In 2019 we had a real momentum on frailty, but that has been lost with COVID-19. This hopefully can help us to start to get some of it back.’

Need for development across three domains – skills, knowledge and attitudes

A need for more skills and training is also highlighted in the guidance. Assessing and caring for older people living with frailty is often not reflected in education and training programmes for those working in the urgent care system, meaning there is a potential mismatch between population needs and the capability of the system to meet them.

Silver Book II stresses the need for development across three domains:

  • Skills – including hard skills such as being able to transfer a person from a wheelchair to a bed, and soft skills such as reading facial expressions and body posture.
  • Knowledge – such as knowing how to carry out comprehensive assessments and how to interpret what the normal blood pressure range is for older patients.
  • Attitudes – including the need for positive behaviour towards older people, with openness to collaborate more intensively with family members and interdisciplinary colleagues.

Communication is a key area requiring improvement

But the greatest area of improvement is needed in communication, it says. Effective communication decreases error, enhances safety and improves outcomes – critical when working with people with cognitive impairment and dementia.

People with altered mental states are likely to require second source accounts from families and carers or confirmation to ensure accurate communication.

Neal Aplin

RCN Advanced Nursing Practitioner Steering Committee member Neal Aplin says this focus on competencies is important. He wants to see the NHS providing extra training to nurses given there is an increasingly older population who are living and presenting with a wide range of conditions and co-morbidities.

Quality training regarding frailty and signs of deterioration is important

Mr Aplin, who works as an advanced clinical practitioner at Swindon’s Great Western Hospital, says the skills and knowledge of nurses in this area will vary.

'As an advanced practitioner, this is included in my training to assess, diagnose and manage autonomously. Experienced ED staff are likely to have developed many of the skills required, but for junior staff further training could be required.

‘Quality training regarding frailty and specifically signs of deterioration in older patients is important. This is because older frail people can present atypically, and recognising signs of deterioration in older people promptly can help to improve outcomes.’


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