This page does not aim to be comprehensive.
It seeks to guide you to think about predictable clinical problems that commonly arise in the following situations.
Common things happen commonly. Frail patients commonly fall over, develop infections and become delirious (confused or muddled simply from being unwell).
People know about this stuff but like to think it will happen to someone else. Grasp the opportunity when it occurs. If a patient has been admitted following a fall, infection or delirium then now is the time to discuss and ask how they would like it managing next time.
It's more difficult to deny the risk if it has just happened.
And, the final thing to remember is that we are not thinking about how to manage a problem in hospital (Consultants and Registrars can worry about that), but in the patients home in the wee small hours.
Failure of Care (Carer crisis, equipment, accommodation)
It seeks to guide you to think about predictable clinical problems that commonly arise in the following situations.
Common things happen commonly. Frail patients commonly fall over, develop infections and become delirious (confused or muddled simply from being unwell).
People know about this stuff but like to think it will happen to someone else. Grasp the opportunity when it occurs. If a patient has been admitted following a fall, infection or delirium then now is the time to discuss and ask how they would like it managing next time.
It's more difficult to deny the risk if it has just happened.
And, the final thing to remember is that we are not thinking about how to manage a problem in hospital (Consultants and Registrars can worry about that), but in the patients home in the wee small hours.
Failure of Care (Carer crisis, equipment, accommodation)
Frailty
- Treatment Escalation LevelPoor oral intake (often with aspiration risk)
Management Plan and Wishes :ITUTrial of community management where feasible and safe
If poor diet and fluid intake cannot be managed in the community, admit to hospital for further investigation and intravenous fluids +/- supportive nutritionHospitalTrial of community management where feasible and safe.
If poor diet and fluid intake cannot be managed in the community, admit to hospital for further investigation and intravenous fluids +/- supportive nutritionHomeAccept that declining oral intake is a common symptom of the end stages of frailty and many illnesses. Artificial nutrition is not indicated, and so hospital admission would not be beneficial.
Follow any specific SaLT or dietetics plan (if one is in place).
Manage at home with supportive measures by encouraging diet and fluids. Offer food and drink the person enjoys
Offer regular mouthcare
Trial oral nutritional supplements if appropriate
Consider reversible causes (such as infection, constipation, poor dentition, oral thrush) that could be treated with oral medications.
Consider involving local community urgent response service/virtual ward/frailty team for further monitoring and support.
If oral intake continues to decline despite above measures, then consider whether this an end of life situation. If so, arrange anticipatory/palliative medications and move to comfort measures.ComfortConsider whether this is an end of life situation.
Anticipatory medications in place, use as required.
Food/flavour, if requested and able.
Administer mouth care including oral cleaning, ice chips, occasionally artificial saliva to alleviate symptoms of dry mouth. Thirst is rarely a feature.
Moisten the lips/lip moisturizers
Ensure Community Team supporting and Package of Care sufficient to support patient and family needs. - Treatment Escalation
LevelINFECTION (Chest/Urine/Unknown Source)
Management Plan and Wishes :ITUITU admission will be decided if clinically appropriate in hospital.
Aim to treat initially with oral antibiotics where feasible and safe
If oral antibiotics not possible, or if deteriorating on oral antibiotics, then for admission to hospital for consideration of IV antibioticsHospitalAim to treat initially with oral antibiotics where feasible and safe
If oral antibiotics not possible, or if deteriorating on oral antibiotics, then for admission to hospital for consideration of IV antibioticsHomeConsider and identify likely source of infection
Treat with oral antibiotics if feasible.
Consider involving local community urgent response service/virtual ward/frailty team for further monitoring and support.
If deteriorates despite oral antibiotics, consider whether this is an end of life situation.
Ensure SC anticipatory medication supply in place and move to comfort measuresComfortConsider and identify likely source of infection
Treat with oral antibiotics if feasible and wanted.
Anticipatory medications in place, use as required.
Ensure Community Team supporting and Package of Care sufficient to support patient and family needs.
Fall with . . .
- Treatment Escalation LevelFall with suspected fracture
Management Plan and Wishes :HospitalOffer analgesia for any pain.
Assess post fall and convey to hospital if concerns about a fracture. HomeOffer analgesia for any pain and prescribe a supply.
Assess post fall and only convey to hospital if concerns about a long bone fracture are very difficult to pain control without fixation).
If fracture unlikely, stable or comfortable, wishes to remain at home.
Consider reversible causes of a fall (such as infection, constipation, urinary retention) that could be treated with measures at home.
Consider involving local community urgent response service/virtual ward/frailty team for further monitoring and support.
If concerns about a significant fracture, consider referral to hospital for XR assessment, but discuss with patient and/or family first. Plan to be discharged back home as soon as possible after assessment, unless operative management is indicated. Not to remain in hospital for investigation or management of unrelated issues unless agreed with the patient and/or family.ComfortOnly convey to hospital if concerns about significant painful fracture (e.g. neck of femur) where operative management would be considered and after discussion with patient and/or family. Consider any operative management only as a palliative procedure to relieve pain and with discharge home as soon as practicable.
If no concerns about significant fracture, treat any pain with analgesia. Consider whether this is an end of life situation. Anticipatory/palliative medications in place, use PRN.
Move to comfort measures. - Treatment Escalation LevelManagement Plan and Wishes :ITUHospitalHomeComfort
- Treatment Escalation LevelManagement Plan and Wishes :HospitalHomeComfort
- Treatment Escalation LevelManagement Plan and Wishes :HospitalHomeComfort