Section Five - Clinical Information Sheets
List of Clinical Information Sheets and reference cards
Use of Clinical Information Sheets
Process used to develop clinical information sheets
List of Clinical Information Sheets and reference cards
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Clinical Information Sheet
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Reference Card
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Advance Care Planning to Improve End of Life Care
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GP Steps to Advance Care Plan Assessing a Patient’s Legal Capacity Advance Care Planning Discussion Guide Resident Information and Documentation for ACP including Refusal of Treatment for Competent Person Resident Information and Documentation for ACP for a resident who cannot consent including Refusal of Treatment for Incompetent Person Victorian Public Advocate Fact Sheets:
Enduring Power of Attorney (Medical Treatment) Medical/Dental Treatment for Patients Who Cannot Consent Refusal of Medical Treatment
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Cardiac Chest Pain
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Initial Management of Cardiac Chest Pain Basic Life Support
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Cardiac Failure
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Cellulitis
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Cellulitis Assessment
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Delirium
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Confusion Assessment Method (CAM) Tool NEECHAM Confusion Scale
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Dementia: Behavioural and Psychological Symptoms
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Neuropsychiatric Inventory Questionnaire Cohen-Mansfield Agitation Inventory (CMAI) Behaviour Observation Chart Sleep Assessment
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Diabetes: Blood Glucose Monitoring
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Hypoglycaemia Management Hyperglycaemia Management Diabetes Sick Day Management – IDDM (Type 1) Diabetes Sick Day Management – NIDDM (Type 2)
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Elder Abuse
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Elder Abuse Suspicion Index Elder Abuse Action Flow Chart
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End-of-Life Care
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Liverpool Care Pathway for the Dying Patient Memorial Symptom Assessment Scale Edmonton Symptom Assessment Scale Palliative Care Visual Analog Scale Spiritual Involvement and Beliefs Scale
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Epilepsy and Seizures
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Seizure Observation Chart Seizures Record Chart
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Falls Management and Prevention
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Management After a Resident Fall Neurological Observation Chart Incident Form for Reporting a Resident’s Fall
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Gastrostomy Tube Management
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Gastrostomy Tube Blockage or Dislodgement |
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Medication Management
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RACF Medication Management Policy Anaphylaxis Management RACF List of Nurse Initiated Medications Medications that should not be crushed Assessment of Resident’s Ability to Self Administer Medication Compact Tool:
Confirmation of Telephone Order – Label Doctors Fax Medication Order – Label Medication Labels for Compact Medication Charts - Handwritten Option
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Osteoarthritis
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Clinical Pathway Model of Care for Osteoarthritis
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Pain Assessment and Management
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Breakthrough Pain Management Pain Assessment and Management Resident’s Verbal Brief Pain Inventory Abbey Pain Scale for people with dementia or who cannot verbalise Example of Pain Care Plan Sedation Scale
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Respiratory: Asthma
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Asthma Management Acute Asthma Management Plan
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Respiratory: Chronic Obstructive Pulmonary Disease
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Modified Medical Research Council Dyspnoea Scale Modified Borg Dyspnoea Scale Visual Analog Dyspnoea Scale
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Respiratory: Influenza
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Respiratory: Inhalation medication delivery devices
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Respiratory: Pneumonia
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Pneumonia Management Pneumonia Severity Index
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Subcutaneous Hydration
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Subcutaneous Hydration
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Urinary Indwelling Catheter Management
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Urinary Catheterisation of a Female Urinary Catheterisation of a Male
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Urinary Tract Infections
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Management of Kidney Infection Hospital in the Home IV Antibiotic Therapy – Kidney Infection
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Use of Clinical Information Sheets
Purpose
The purpose of the Clinical Information Sheets (CIS) is to assist RACF staff, GPs and other service providers to prevent and manage clinical conditions occurring within the facility in hours or after hours. Each CIS includes a focus on the aspects of care relevant to the residents’ age, frailty and co-morbidities.
Clinical Information Sheets can be used as an adjunct to knowledge and experience of health professionals to :1
Inform clinical care of RACF residents; Provide residents and their families with health information; and Be an educational tool for health professionals.
The Clinical Information Sheets should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
Use of Clinical Information Sheets by RACF staff and medical practitioners
Implementing clinical information provided in the information sheets within the RACF offers the following benefits:2
Improved health outcomes of residents through systematic prevention and management of chronic conditions and acute events ‘round the clock’; Increased autonomy of residents through improved information, education and involvement in care decisions; Enhanced clinical decision-making by RACF staff; Increased confidence of RACF staff in ability to implement clinical interventions; Opportunity for RACF staff to learn about emerging treatment options; and Reduced variability in care practices that may lead to more cost effective care.
Introducing a CIS into a RACF can be done using the facility’s usual processes or following the steps outlined below.
Designate responsibilities
Identify a RACF clinical care co-ordinator or committee to facilitate the introduction of new clinical information and processes into your facility.
Assess/Audit
Review your processes for routine medical care and after hours care; Review the medical profile of your residential care population and identify specific residents with complex needs (e.g. advanced COPD, epilepsy) whose medical care could be improved by a systematic approach; Review existing clinical protocols; and Review and adapt the ‘After hours and acute referral reference card’ to suit the facility.
Develop an Action Plan
Select priority areas that require improvement; Decide which Clinical Information Sheets would improve care of residents if implemented in your facility; Identify who needs to be involved – eg RN, PCW, GP, pharmacist . Identify any changes that need to be made (eg equipment, systems) in your RACF to support the new clinical information and recommendations.
Implement
Develop and agree on revised protocols. Provide an opportunity for stakeholders to ask questions or provide feedback on the Clinical Information Sheets and the impact they will have within the RACF (eg staff meetings, education session). Provide staff members and residents to whom the clinical information applies a copy of,or access to, the Clinical Information Sheets. Adapt the clinical information into your own policies or procedures, or adopt the Clinical Information Sheets as part of your management system; and Incorporate clinical information into resident care plans as appropriate.
Maintain/sustain use of Clinical Information Sheets:
Education sessions with staff; and Review outcomes for residents.
Evaluate
Monitor RACF system changes to help achieve, sustain and demonstrate better outcomes for residents; and Review and update Clinical Information Sheets regularly.
Implementation of the clinical information sheets could be used as evidence in relation to several of the Accreditation Standards; these include:
Expected Outcome 2.3 Education and staff development: Management and staff have appropriate knowledge and skills to perform their roles effectively; Expected Outcome 2.4 Clinical Care: Residents receive appropriate clinical care; The Medication Management Clinical Information Sheet could be used as evidence in relation to Expected Outcome 2.7 Medication Management: Residents’ medication is managed safely and correctly; The Advance Care Planning to Improve End-of-Life Care Clinical Information Sheet and End-of-Life Care Clinical Information Sheet could be used as evidence in relation to Expected Outcome 2.9 Palliative Care: The comfort and dignity of terminally ill residents is maintained; and The Elder Abuse Clinical Information Sheet could be used as evidence in relation to Expected Outcome 3.2 Regulatory Compliance: The organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards, and guidelines, about resident lifestyle.
Process used to develop clinical information sheets
The Clinical Information Sheets have been developed through a process of selecting topics relevant to the prevention and management of chronic conditions and acute events ‘round the clock’; incorporating the best available evidence on the topics that they address; and taking into account relevant legislative and professional codes in the aged care industry in Victoria, Australia. The information provides a general guide to assist RACF staff to manage specific health problems and/or to provide residents, relatives and RACF staff with appropriate health information.3
In each Clinical Information Sheet, the writers address the clinical issues that may occur in residential aged care, particularly related to:
Residents’ age, comorbidities, medication effects and interactions; Levels of dependency and capacity to make decisions; Stage of illness: stable chronic condition, acute event, end-of-life care; and The roles of residents, relatives, GPs, RACF staff, pharmacists and other professionals.
A Reference Group was established to oversee the production of the Clinical Information Sheets. The purpose of this group was to advise and assist the core developers with the identification of reference material and with the development, review, implementation and evaluation of information. The reference group contained experts and representatives from many stakeholders in the Victorian aged care industry, including multidisciplinary health care staff from hospitals and RACFs. See Acknowledgements in Section One.
Selection of topics
The writers together with the reference group identified areas of clinical practice for which information sheets would be developed. Topics were selected for the first and second editions of the Kit based on:
Analysis of common reasons for after-hours medical care and hospital presentation identified in an initial needs assessment in 2002 for the first edition of the Kit. Common reasons for medical deputising service visits were resident falls, urinary, chest and other infections, and indwelling catheter problems, as well as to rewrite resident medication charts. Common reasons for presentation to emergency departments included, falls or injury, shortness of breath, altered conscious state / delirium, pain, cardiac chest pain and PEG tube or indwelling catheter problems. Chronic conditions that have high prevalence among residential aged care patients, and may require acute medical care after hours, such as asthma, cardiac failure, chronic obstructive pulmonary disease, dementia (behavioural and psychological symptoms), diabetes, epilepsy, osteoarthritis. Issues recognised as important for health care and quality of life of residents, such as Advance Care Planning, end-of-life care, and protection from elder abuse.
Literature search and evaluation
The strength of evidence on which clinical information is based influences both the uptake of recommendations in clinical practice settings and the effectiveness of the clinical information in contributing to a positive health outcome for the resident. Where possible the Clinical Information Sheets have been developed from systematic research reviews or meta-analyses, as these currently provide the highest level of evidence.4 If these forms of evidence were unavailable, the information sheets were developed through a review of individual research studies, clinical guidelines produced by national or international health organisations, or from consensus opinion.5
Literature was identified through:
Search of publications by major national and international health organisations involved in the publication of systematic reviews or clinical guidelines, e.g. WHO, NHMRC, Cochrane Library; and/or Search of 2 major health databases, CINAHL and MEDLINE, using the search terms "clinical guideline" and "practice guideline" in combined searches with terms related to each information sheet topic; and/or Internet search using HONcode (a health industry search engine that searches sites which meet strict principles of website publication, including transparency) using the search terms "clinical guideline" and "practice guideline" in combined searches with terms related to each guideline topic; and/or Sources recommended by members of the Guideline Reference Group, including Australian guidelines published or in final draft form, produced by the relevant specialist organisation.
When possible, existing systematic reviews or clinical guidelines were used for the development of the Clinical Information Sheets. Literature was evaluated according to its relevance to the RACF setting and the strength of evidence. All references used in the development of each Clinical Information Sheet were evaluated and graded according to a scale of evidence adapted with consideration to the literature available in the aged care sector from the scale published by NHMRC in 1995.6 This scale was used as it allows description of lower levels of evidence when randomised control data is not available (see Table 1). Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Table 1: Scale of evidence used in development of Clinical Information Sheets (adapted from NHMRC, 1995)
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Level
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Type of Evidence
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Level I |
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Evidence (including reports and guidelines) obtained from a sound systematic review of all relevant randomised controlled trials. |
Level II |
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Evidence obtained from at least one properly designed randomised trial. |
Level III |
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Evidence obtained from well designed, non-randomised controlled trials or from well designed cohort or case-control analytic studies or from multiple time series with or without the intervention. |
Level IV |
A |
Descriptive studies. |
Level IV |
B |
Reports or guidelines from expert committees not based on a systematic review of best available evidence, or where the method of development is not stated. |
Level IV |
C |
Opinions of respected authorities or expert health practitioners based on clinical experience. |
Level V |
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Any other evidence (e.g. un-referenced policies/procedures from facilities). |
Identification of roles and responsibilities
To assist RACF staff to implement the Clinical Information Sheets, the roles of various health practitioners were identified with consideration to recommendations in references specific to each information sheet, for example where national clinical guidelines made recommendations on the experience required by health professionals performing specific procedures. Consideration was given to current practice in the aged care industry as well as published guidelines on roles of specific health practitioners working in the aged care industry in Australia such as:
ANCI – National Competency Standards for the Registered Nurse7; ANCI – National Competency Standards for the Enrolled Nurse8; ANF – Role boundaries in the provision of personal care9; APAC - Guidelines for medication management in residential aged care facilities.10
Published guidelines on roles of registered nurses will vary between states. The Clinical Information Sheets were developed with consideration to the role of nurses in Victoria, Australia:
Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
CIS content and format
The Clinical Information Sheets include:
Purpose statement describing the clinical problem and particular issues for RACF; How to assess the clinical problem; Management including goals, maintenance and acute care, medication and non-pharmacological strategies; Related literature and research that provides support for the techniques recommended, Acknowledgement of the primary sources, including a statement outlining the strength of primary sources, Grading of the level of evidence of all the references used in development of the cis, and Date the information sheet was developed and updated or revised.12
The information sheets are presented in an easy-to-use format and consideration given to wording, layout and presentation of information to maximise uptake of the information in RACFs.
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We strongly recommend that the Clinical Information Sheets be regularly reviewed and revised as the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing. For more detailed or up to date information please refer to cited sources and current literature.
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References
National Health And Medical Research Council, (NHMRC) (1998). A guide to the development, implementation and evaluation of clinical practice
guidelines. Canberra, NHMRC; Kingston, M, J Krumberger, et al. (2000). "Enhancing outcomes: guidelines, standards and protocols." AACN Clinical
Issues: Advanced Practice in Acute and Critical Care 11(3): 363-374; Hewitt-Taylor, J (2003). "Developing and using clinical guidelines." Nursing
Standard 18(5): 41-44.
National Health And Medical Research Council, (NHMRC) (1998). A guide to the development, implementation and evaluation of clinical practice
guidelines. Canberra, NHMRC; Kingston, M, J Krumberger, et al. (2000). "Enhancing outcomes: guidelines, standards and protocols." AACN Clinical
Issues: Advanced Practice in Acute and Critical Care 11(3): 363-374; Conn, V, K Burks, et al. (2002). "Evidence-based Practice for Gerontological
Nursing." Journal of Gerontological Nursing Feb: 45-52
National Health And Medical Research Council, (NHMRC) (1998). A guide to the development, implementation and evaluation of clinical practice
guidelines. Canberra, NHMRC
National Health And Medical Research Council, (NHMRC) (1998). A guide to the development, implementation and evaluation of clinical practice
guidelines. Canberra, NHMRC; Michie, S and M Johnston (2004). "Changing clinical behaviour by making guidelines specific." BMJ 328: 343-345.
National Health And Medical Research Council, (NHMRC) (1998). A guide to the development, implementation and evaluation of clinical practice
guidelines. Canberra, NHMRC National Health And Medical Research Council, (NHMRC) (1995). Guidelines for the development and implementation of clinical practice guidelines.
Canberra, AGPS; National Health And Medical Research Council, (NHMRC) (1998). A guide to the development, implementation and evaluation of
clinical practice guidelines. Canberra, NHMRC; Canadian Diabetes Association, (CDA) (2003). 2003 Clinical Practice Guidelines.
http://www.diabetes.ca/cpg2003/chapters.aspx (accessed March 2004). CDA Australian Nursing Council Inc., (ANCI) (2003). National competency standards for the registered nurse. Canberra, ANCI. Australian Nursing Council Inc, (ANCI) (2002). National competency standards for the enrolled nurse. Canberra, ANCI. Australian Nursing Federation, (ANF) (2003). Role boundaries in the provision of personal care. Policy statement. ANF. Australian Pharmaceutical Advisory Council, (APAC) (2002). Guidelines for medication management in residential aged care facilities (3rd edition). Canberra, Commonwealth Department of Health and Ageing.
Nursing Board Victoria, (NBV) (2001). Role of nurses registered in division 1, division 3 or division 4. Melbourne, NBV. National Health And Medical Research Council, (NHMRC) (1998). A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra, NHMRC.; Mead, P (2000). "Clinical guidelines: promoting clinical effectiveness or a professional minefield." Journal of Advanced Nursing 31(1): 110-116.
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