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)

Frailty

  • Treatment Escalation Level
    Poor oral intake (often with aspiration risk)
    Management Plan and Wishes :
    ITU
    Trial 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 nutrition
    Hospital
    Trial 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 nutrition
    Home
    Declining oral intake is a common symptom of end stage frailty & other 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.
    Comfort
    ​Consider 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.
  • NOTE: Consider whether you need specific seperate TEPs for particular types or sites of infection or whether a "catch all" is sufficient. E.g. for COPD exacerbations or cellulitis, more specific management instructions and/or team contact details may be helpful. 
    Infection    TEP Level: ITU  Mx Plan: In
    Infection    TEP Level: Hospital  Mx Plan: In
    Infection    TEP Level: Home  Mx Plan: In
    Infection    TEP Level: Comfort  Mx Plan: In
    Treatment Escalation
    ​Level
    INFECTION (Chest/Urine/Unknown Source)​​
    Management Plan and Wishes :
    ITU
     ​​​Consider source of infection & starting appropriate oral antibiotics.
    If deteriorating on oral antibiotics or not feasible, then admit to hospital for possible IV antibiotics. ITU admission will be decided in hospital as appropriate.
    Hospital
    Consider source of infection & starting appropriate oral antibiotics.
    If deteriorating on oral antibiotics or not feasible, then admit to hospital for possible IV antibiotics. Does not wish to be admitted to ITU.
    Home
    Consider source of infection & starting appropriate oral antibiotics.
    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. Move to comfort measures
    Comfort
    Consider source of infection & starting appropriate oral antibiotics, if feasible and wanted.
    Anticipatory meds. in place, use as required.
    Ensure Community Team supporting and Package of Care is sufficient for patient & family needs.
  • Delirium    TEP Level: ITU  Mx Plan: Investigate possible causes. Manage at home as appropriate. If deteriorating on oral treatment, then admit to hospital for further investigation. ITU admission will be decided in hospital as appropriate.
    NOTE: Consider whether appropriate if past history of dementia, a progressive neurological or palliative condition. Does patient have rehabilitation potential after active treatment.
    Delirium    TEP Level: Hospital   Mx Plan: Investigate possible causes. Manage at home as appropriate. If deteriorating on oral treatment, then admit to hospital for further investigation. Does not wish to be admitted to ITU.
    NOTE: See above. Patient, or family if LPoA for H&W is in place, may also wish to limit other treatments.
    Delirium    TEP Level: Home   Mx Plan: Investigate possible causes. Manage at home as appropriate. Ensure "Just in Case" meds and Admin orders are available. If deteriorates despite oral treatment, consider whether this is an end of life situation. D/W Palliative care, other involved Specialist Team or GP if not clear.
    NOTE: This option is only likely to be appropriate on a background of a palliative diagnosis or recurrent delirium & frailty. Seek specialist advice as appropriate.
    Delirium    TEP Level: Comfort   Mx Plan: Anticipatory meds. in place, use as required.
    Ensure Community Team supporting and Package of Care is sufficient for patient & family needs.

Fall with . . . 

  • Fall with Suspected Fracture   TEP Level: ITU    Mx Plan:  Offer analgesia for any pain. Assess post fall and convey to hospital if concerns about a fracture. ITU admission will be decided in hospital as appropriate.
    Fall with Suspected Fracture   TEP Level: Hospital    Mx Plan:  Offer analgesia for any pain. Assess post fall and convey to hospital if concerns about a fracture. Does not wish to be admitted to ITU.
    NOTE: In most cases palliative care and other teams having advance care planning conversations will be guiding patients towards hospital admission in the face of a possible femoral fracture. This is driven by experience. Trying to provide pain control for a patient with an unstable femoral fracture with anything oral, SC or IV, other than a spinal or intra-thecal infusion, is nearly always a high road to failure. Internal orthopaedic fixation is a much speedier, more resilient and effective route to pain relief, despite the anaesthetic risk in a poorly or frail patient.    
    Fall with Suspected Fracture   TEP Level: Home    Mx Plan:  Offer analgesia for any pain. 
    Assess post fall and only convey to hospital if concerns about a long bone fracture as these are very difficult to pain control without fixation.
    If fracture unlikely, stable or comfortable and patient wishes to remain at home. THEN consider reversible causes of a fall (such as infection, constipation, urinary retention) that could be treated with measures at home. ALSO consider involving local community urgent response service/virtual ward/frailty team for further monitoring and support. AND prescribe a supply of pain relief.
    NOTE: 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.
    Fall with Suspected Fracture   TEP Level: Comfort    Mx Plan:  Only 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 Level
    Management Plan and Wishes :
    ITU
     ITU admission will be decided in hospital as appropriate.
    Hospital
    Does not wish to be admitted to ITU.
    Home
    Is aware of the risk of an intra-cranial haemorrhage and would not want active neurosurgical treatment. Please do not convey to hospital for brain imaging. Manage conservatively. If deteriorates, consider whether this is an end of life situation. Move to comfort measures
    Comfort
    Anticipatory meds. in place, use as required.
    Ensure Community Team supporting and Package of Care is sufficient for patient & family needs.
  • Treatment Escalation Level
    Management Plan and Wishes :
    Hospital
    Home
    Comfort
  • Treatment Escalation Level
    Management Plan and Wishes :
    Hospital
    Home
    Comfort