The most frail elderly are often affected by acute events

The residents are often frail. Events occur that require the resident to be sent to the hospital. These can be fall injuries, stroke, difficulty breathing, or other more unclear reasons for deterioration, often during on-call hours. There must then be routines for what to prepare. The individual should have an ID band with their name and social security number or identification, so that the hospital can identify the person. Written information about health history and medication should be sent along. The hospital should have information about why the resident has been sent to the hospital.

The routines for sending to the hospital can vary between regions. Often, those who prioritize ambulance transports want information in order to assess how urgent it is to get an ambulance transport. It is therefore good if the nurse or the person calling has information about vital parameters (see below). Check if there is a position on whether end-of-life care should take place at the residence. The decision is usually made in consultation with the resident, relatives, and the responsible doctor. This is to prevent anyone from being subjected to medical interventions against their will.

Many operations have routines for acute events with a prepared message sheet, prescription basis for drug treatment, and a name band. Here, in this, decisions about end-of-life care are usually stored, as well as doctor's decisions to delegate the examination of the deceased in connection with death to a nurse.
During on-call hours, the responsible nurse often has responsibility for several residential units. In an emergency situation, this can mean that the nurse assistant must know the routines.

Vital parameters that are often asked for are

• Free airway? Is the resident breathing or talking?
• Respiratory rate between 8-25/minute
• Heart rate, pulse between 50 - 100 beats/minute
• Level of consciousness, i.e. if the resident is alert and awake, responds to speech, responds to pain or does not respond at all when attempting contact. Possible follow-up questions about pupil size and blood sugar.
• Temperature 36 - 38.5 - it is often possible to feel if the resident is warm, sweaty, or has other symptoms of changed body temperature.
• The highest systolic blood pressure should be over or equal to 100 mmHg and the lowest diastolic should be between 70 - 90. If the diastolic pressure drops down to 35, the kidneys can be damaged (requires measurement with a blood pressure cuff)
• Saturation (blood oxygenation) should be above 92% (over 88% in COPD). Requires saturation meter (pulse oximeter).
Feel free to read more about vital parameters in the nursing handbook.

To get a clear message, it is good to report according to SBAR.

• S - Situation Presentation of yourself with name, title, area, and the resident with name, age, and social security number, address. What is the reason for the contact?
• B - Background Short relevant medical history, ongoing health problems, ongoing care and care plan, current medication list, ADL, possible allergies, risk of infection
• A - Current assessment Assess and report facts about the current situation regarding the general condition: temp, pulse, blood pressure, respiratory rate, saturation, level of consciousness, and possibly p-glucose. In case of abdominal pain: exclude urinary retention and or constipation. In case of fall/skeletal injury: malposition, pain when moving. Give a reasonable interpretation of the problem.
• R - Recommendation I recommend that the outcome of the decision support be followed/not followed I want help with assessment/treatment/order/home visit. Conclude by confirming the action. Are there more questions? Are we in agreement?
SBAR can be used in all contact with the nurse.

It is best if relatives are informed by the nurse, otherwise by the care staff. If there is time and opportunity, it is good if they can be a support for the resident during the visit to the emergency room. People with dementia should not be left alone in the emergency room. If relatives cannot accompany, the operation must ensure that staff go along instead.

Acute events

That the staff knows how to act in acute situations can be life-saving for the resident. One day I came into the dining room. I see that one of our residents is sitting completely silent. He is bluish-gray in the face and his eyes are wide open with fear. My coworkers were busy with other things and no one seemed to notice the resident's situation. I stood behind the man and performed the Heimlich maneuver as I learned it in the nurse assistant training. The man coughed and up came a sausage shaped like the throat of hard-packed hash browns.

There are times when someone chokes. Most often it is not a complete blockage as in this case. Fall injuries can be nasty, especially when someone has hit their head. Often we as employees have not seen the whole process. We may just hear someone whining or calling for help. Determining how serious it is can be difficult and wrong actions can cause more damage or even death. An example is if the person who has fallen has broken their neck.

Cut injuries are uncommon, but stopping bleeding before the ambulance arrives can save lives. When someone suffers a stroke, decisions must be made quickly. The right treatment and actions improve the ability to rehabilitate from the long-term damage a stroke risks giving the resident.

It is important to know what the resident wants in the event of, for example, an acute cardiac arrest. Does the person want to die in peace and quiet or should staff start cardiopulmonary resuscitation. Not all staff have training in cardiopulmonary resuscitation.

Substitutes, nurse assistants, and nurse aids are not licensed staff. This means that they do not have obligations to, for example, start cardiopulmonary resuscitation in an acute condition. The Social Services Act describes that there should be staff with suitable education and experience based on the fact that care should be given with respect and of good quality.

This means that in acute events, the care staff should be aware of the routines that exist for different events. It is fundamental that employees should know how to contact licensed staff or 112 in acute conditions at the resident. Care staff should have continuing education with a focus on, for example, handling acute situations, giving the resident support for activity in daily life, knowledge of anatomy, and being able to work preventively regarding falls and pressure sores.

The responsible persons must see what advantages there can be from a patient safety perspective to provide employed staff with training, and a plan for competence development. There are employees who are weak in the Swedish language. For those who are unsure, it can certainly get worse in an acute situation. Everyone who works must be able to call the on-duty nurse or and describe what happened.

In order for those who work in healthcare to be able to handle different situations, they must train together. Those who are nurse assistants hopefully have been taught how to act in different acute situations. Many nursing homes have substitutes who lack vocational training. If there are few in service, each one must know the routines for different events.
The business should have run-throughs on how employees call the nurse or 112 and what should be prepared.

Fall injuries

Many fall injuries can be prevented. Every day, people die from fall injuries and even more suffer from fractures that cause suffering and reduced quality of life. Fall accidents are often preceded by acute states of confusion. These should always be investigated to prevent fall injuries.

Medication reviews are the single most important factor. More about that in the book's chapter on medication, activity, and risk prevention work.
Examination and management of fall injuries

If there has been a hard blow to the head, the resident may have a head injury. Skull trauma should always be handled urgently 112.
In assessing the injury, it is good to know if anyone in the staff has seen how the fall has happened. It is a big difference to fall helplessly or to slide out of a chair. In uncertain situations, it is good if the resident can lie down in wait for the nurse's assessment. The nurse must find out if the resident is taking blood thinners or has previous fractures. The physiotherapist can also contribute to examining fall injuries.

Examination of fall injuries

In examining someone who has fallen, it is good if this person tries to move body parts themselves while you assess. The examination is almost always done by a nurse. In rural areas or at high workloads, the nurse may need help with the assessment.
• Can feet and legs be moved without pain?
• Are the legs the same length or does any leg seem shorter - hip fracture?
• Are the knees swollen?
• Can hands and arms be moved without pain?
• Are there bruises or injuries on the body?
• Is the head undamaged or are there bruises, bumps on the head?
• Does the resident have a headache, double vision, or other signs of a head injury?
• Is there suspicion of a stroke? Does the resident have strength in their hands and are they evenly strong?
• Can the resident stand and walk?
If you cannot rule out a fracture - consult a doctor or send to the emergency room for examination. Document the entire examination process carefully. Make sure the fall is followed up. Ask staff to observe headache, nausea, double vision, or signs of pain.
Use a lift to pick up a person who is lying on the floor.

Plan for acute events - they will occur

For nursing homes, it is crucial to have a well-developed emergency plan to handle acute events. Here are some measures that nursing homes can take to ensure preparedness:

Education and training: Staff should receive education and regular training in handling acute situations. This includes training exercises for fire, first aid, and evacuation.
Develop an emergency plan: A written document that clearly describes how to handle different types of acute situations should be developed and available to all staff. The plan should contain contact persons, routines for alerting and evacuating, and descriptions of different scenarios.
Fire safety: Fire drills should be conducted regularly to ensure that staff know how to handle fire and how to use fire alarms and extinguishing equipment.
First aid: Staff should be trained in first aid and have access to necessary medical equipment.
Other events: What happens if there is a power outage, water leak, food deliveries do not work, the internet or telephony is down for an extended period, etc.
Communication: An effective communication system should be in place to warn and inform both staff and residents in the event of an acute situation.
Storage: The nursing home should have the necessary supplies of food, water, medicine, and other necessities that may be needed in an emergency. There should also be equipment to help with evacuation and rescue operations.
Cooperation with authorities: The nursing home should have an established cooperation with local rescue services and authorities to ensure that contacts work in acute situations.
Evacuation plans: If evacuation becomes necessary, there should be clear plans for how this should be carried out, including opportunities for temporary accommodation for the elderly.
Follow-up and evaluation: After each exercise or real event, the nursing home should evaluate its emergency plan and identify areas where improvements can be made.
Communication with relatives: Inform the elderly's relatives about the nursing home's emergency plan and how they will be informed in the event of an emergency.

By having a well thought out and regularly updated emergency plan, nursing homes can ensure that they are ready to handle different types of acute events and that they can protect the safety and well-being of their residents. It is important that this is a living process to keep preparedness at its peak.

Threats and violence

Threats and violence situations can also cause acute events. Read more here

Reflection - preparedness for acute events
Care staff:
• Do you know what routines apply when someone is sent to the hospital?
• Is each resident's emergency folder up to date?
• Is there a functioning routine for when and how you should contact the nurse?
• Do you have good routines for handling fall injuries and writing deviations?

Manager, nurse, occupational therapist, and physiotherapist:
• Do you use SBAR as a reporting method?
• Can all employees take and report vital parameters?
• Do you have training in handling acute situations, for example in connection with the extension of delegation?
• Do you have a good routine for examining and preventing fall injuries?
• Does team cooperation work in connection with fall injuries?
• Does cooperation with the nurse during on-call hours work well?
• Do you have employees who have difficulty expressing themselves in Swedish who work alone?

Residents and relatives:
• Do you want to be contacted if something happens?
• Can the residence contact you at night?
• Do they have access to all current phone numbers?

https://www.sofrosyne.com/etisk-handlingsberedskap/

Erland Olsson
Specialist nurse
Sofrosyne - Better care every day