Background We are a 140 bed long term care residential care facility for older people. We strive to achieve a ‘Restraint Free Environment’ in accordance with Article 40.4 of the Irish Constitution and Articles 14 (liberty and security) and 15 (freedom from torture or cruel, inhuman or degrading treatment) of the UN Convention on Rights of Persons with Disabilities(1). Health Act 2007, Regulations 2013 defines restrictive practice as ‘the intentional restriction of a person’s voluntary movement or behaviour’. Use of restrictive practices is warranted when there is a real and substantial risk to a person and this risk cannot be addressed by non-restrictive means’ (HIQA, 2019) (2). Methods An extensive review of non pharmacological restrictive practices in the Organisation was undertaken. This included One to One supervision, use of bedrails, Exit Alarm mats and Electronic Monitoring bracelets. Bedrails were replaced for some residents with Safety Wedges and Ultra Low beds. Results Review of restraint interventions showed no clear link to prevention of falls or injuries as a result of restraint. Contrary there was evidence of breach of dignity and privacy for the residents. Based on the review, bedrail use was reduced radically between 2016 and 2021 by 79% (42–9). Falls rate remained consistent approximately 3.6–3.2 per 1,000 Occupied Bed Days. Exit Alarm mats, Electronic Monitoring bracelets and One to One supervision was discontinued. These were replaced with direct observation and two hourly anticipation of needs. Cost saving on One to One estimated to have been €25,000 in 2016 alone. Clear care planning of the resident’s needs are core. Conclusion We have demonstrated that we could successfully reduce restrictive practices, thus respecting Human Rights, with no compromise to resident safety. References 1. United Nations Convention on Rights for Persons with Disabilities (2007) 2. H.I.Q.A 2019 Guidance on promoting a Care Environment that is Free of Restrictive Practice.
Background For consent to be valid the resident must be able understand the information and communicate their choice. People with dementia can have a number of communication deficits; difficulty word finding, tendency to digress and repeat themselves, understanding the spoken word, maintaining a conversation topic without losing track, using semantically empty words (e.g. ‘thing’, ‘stuff’) in place of content words. This can limit their ability to express wishes and preferences. Out of 100 residents in our Older Person Residential Care facility 48% require some supports with communication; 25 diagnosed with dementia, 8 suspected (33%) and 15 with cognitive impairment. As per the HSE National Consent policy 2022 we have a duty to maximise capacity for our residents to consent to treatment and interventions. Insight into the factors involved in the communication process between nursing staff and people with dementia is limited. Speech and Language Therapists (SALT) identify the specific nature of communication deficits for a person with dementia. Methods Our SALT reviewed our residents and advised on actions required to reduce the impact of communication deficits. We implemented a Communication care plan for our residents to include all identified communication abilities and disabilities for both speech and language across all modalities (reading, writing, gesture, symbols). To evidence understanding of consent, all staff interacting with residents were requested to undertake the HSELand National Consent policy module. All staff attended training which involved enhancing communication abilities. Results In February 2022, 95% of care plans audited had actions to address communication deficits in place. Ad hoc discussion with staff evidenced improved understanding of each resident’s communication deficits and necessity to use SALT reviews to enhance capacity to consent. Conclusion We have demonstrated that the use of SALT to enhance ability to communicate has enhanced capacity to consent for our residents. Staff also demonstrated improved communication practices.
Background We are a 140-bed Care of the Older Person facility. Approximately 50% of Sepsis cases occur in this demographic. The Irish National Early Warning System (INEWS) is an early warning system to assist staff recognise and respond appropriately to clinical deterioration. Currently there is no INEWS for Older Person Residential Services. Challenges for treatment relating to deterioration in our service are; detecting ‘new confusion’, access to doctors, treatment options available and the necessity to transfer a resident to the Acute Care sector if intravenous antibiotics were required. We used the National Clinical Guideline INEWS Version 2 (2020) to develop a clinical monitoring and escalation protocol. This was rolled out December 2021. Methods A Nurses Opinion survey was carried out to determine Nurses experience with using the locally modified Early Warning System. Results There was a 63% (n=35) response rate. 100% reported improvement in identifying clinical deterioration in a timely manner and effective monitoring for deteriorating residents. 96% reported improvement in confidence with monitoring unwell residents, confidence with transfer out decisions and referring the resident to the doctor for review. 91% noted improvement in communicating residents’ condition to doctors. 87% improvement in clinical practice when monitoring vital signs. 82% improved communication using the ISBAR. On reviewing clinical documentation for all residents who had deteriorated post implementation there was a significant improvement in monitoring and documentation. 23% stated increased time and staffing levels were required for monitoring of residents. 9% stated doctors didn’t always understand the INEWS. Conclusion Implementation of the modified INEWS has resulted in considerably improved clinical monitoring, documentation, & Nurses confidence. Significant challenges remain including ethical issues with decision to transfer out a resident for treatment. Recommendations are upskilling of Health Care Assistants to carry out vital signs monitoring, robust advanced healthcare decision making and implementation of an INEWS for Older Person Services.
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