Delegation

In elderly care, medication management is primarily delegated. At the same time, medication discrepancies are a common deviation. Education, knowledge follow-up, and safe routines are significantly important for the risks of deviations.

Delegation means that a person with formal education (such as a nurse or physiotherapist) gives a person without formal education but with real competence (nurse assistant, residential support worker, personal assistant, etc.) the right to perform health and medical care tasks. The most common delegation is about medication management. Delegation can involve tube feeding, wound dressing, injections, support stockings, special training, catheter management, and more.

Delegation of injections such as insulin and blood thinning injection drugs requires special education and instruction. Medication is delegated by a nurse, but it also happens that for example a physiotherapist delegates tasks.

Delegation is a trust assignment and the person delegating should ensure that the one receiving the delegation understands and can perform the task correctly. Control can be done through knowledge tests or the nurse being present when the task is performed. The person receiving a delegation is health and medical personnel when delegated tasks are performed and is then under the supervision of the Health Board. You are obliged to decline delegation if you feel unsure. The responsibility includes reporting any deviations and contacting the nurse if something goes wrong.

Delegation can take place across care provider boundaries, for example from specialist care to a nurse assistant in home care. No one may receive delegation without having the management's approval to perform the task.

In municipally funded care, the medically responsible nurse is responsible for ensuring that delegations meet patient safety requirements. Each care provider should have documented routines for how delegations are handled in the business.

The Dementia Association, Dementia ABC provides a web-based film, an educational material for the delegation of medication to healthcare staff. The staff can get a certificate of completed training by answering questions after watching the film. The training is supplemented with a review and questions by the responsible nurse, which can serve as a sub-element in delegation. There are other actors offering a similar service.

The first time a nurse is to delegate to a person, the person should take a written test in the presence of the nurse to ensure that basic knowledge exists. The delegation training should include education in basic hygiene and how to act in emergencies, for example, to get in touch with a nurse.

If something happens that makes the nurse not fully trust the person who has received delegation, the delegation should be revoked. A nurse must not feel pressured to delegate, for example, for summer temporary staff. It is about planning the business so that it works without newly hired substitutes needing to get delegation.

Prescription Basis

Access to correct prescription documents is sometimes a concern. Telephone prescriptions, temporary prescriptions and as needed medication should be included. Functional cooperation with the resident's doctor is necessary. Errors in medication management are serious deviations that can have severe consequences for the resident.

The prescription basis is an original document. Many serious errors have occurred when nurses have written off a prescription basis or when the basis is unclear. A misplaced comma can mean that the individual gets a dose of the drug ten times too strong.

Normally, it is the doctor who orders and prescribes medication. District nurse with prescription rights can prescribe certain drugs. In addition, there are often "General directives" where the nurse can order based on her own assessment. It could be about giving Paracetamol for headaches and similar prescriptions.

Prescription basis should be current. When initiating or discontinuing medication, the basis should be updated. Many have pre-packaged dose bags. When changes are made, the nurse must replace the old basis. This should then be done both in connection with the staff's signing list and in the journal or in the digital signing system.

If the resident is not admitted to Pascal, the primary care center should provide new prescription basis. Pascal is a digital portal that has information about all dose medications. It is an advantage for the business and contributes to safer care if residents have dose medications and are included in Pascal.
When dose delivery, the dose bags must be checked by the nurse so that what is in the packages matches what is prescribed and that all possible changes are included.

The routines should also work to get in temporary prescriptions that can come via the phone from the doctor.

Natural Medication

For some, natural remedies are a milder alternative that works. There are often active substances in natural remedies that can interact with other drugs that the resident is taking. Therefore, the doctor must be informed and approve the natural remedies.

It happens that residents want to eat various types of natural remedies. For the elderly home, there must be routines for handling. Natural remedies are drugs made from plants or other things in nature. Basically, all drugs come from nature in one way or another. There is a kinship between teas, spices, and drugs. Many teas and spices have some form of medical effect if taken in a sufficient amount.

Everyone must understand what side effects can occur when the natural remedy is eaten together with other drugs. In the worst case, the risk of falls or bleeding tendencies increases. An example is that certain natural remedies lead to an increased risk of bleeding in connection with Waran treatment®.

Natural remedies should be recorded in the journal just like other drugs and the doctor should be informed. It happens that residents wish Valeriana in the evening to calm down. It can be a less risky alternative to stronger sleep medications.

It happens that relatives come with natural remedies and where it is difficult to get the resident's consent. In this situation, care is in a tricky situation by relatives not having the right to decide over a resident in medical matters. On the other hand, it happens that residents have a glass of wine or a whiskey at night which can have significantly more effect. Everyone is recommended to be moderate when it comes to alcohol intake. The resident's self-determination is guiding for what decisions are made.

Complement to medication

Our lifestyle affects what drugs we eat. There are often good complements to drug treatment. Diet, exercise, and activities can significantly improve health in many states if it is adapted to the resident. Diet and exercise are two factors.

In several states, there are complements to drug treatment. Eating right and exercising is good for everyone, not just in connection with diabetes. Here is knowledge that is not always fully conveyed by care. FAR (Physical Activity on Prescription) is often prescribed in primary care.

An active lifestyle can reduce unnecessary drug use. With a thorough drug review, there is usually a better drug treatment as certain drugs are unsuitable for those who get older. In many regions, there is the "wise list" or equivalent that describes which drugs are unsuitable in connection with aging. The resident can often find alternatives together with the team that gives positive health effects.

When it comes to anxiety-reducing and sleeping medicine, activities, conversations, and other things can often reduce the needs. This reduces the risk of side effects and, for example, falls.

Blood thinning drugs

Many elderly people receive treatment with blood thinning drugs such as Waran, Fragmin, and Trombyl. It is important to be aware of treatment with blood thinning as, for example, a fall accident can cause internal bleeding. Blood thinning drugs are used for patients with atrial fibrillation to prevent blood clots in the brain (stroke) and in the arteries, and to prevent heart attacks. It is also used to prevent venous clots such as deep vein thrombosis (DVT) and pulmonary embolism.

Treatment with blood thinning (anticoagulants) carries risks. It increases the risk of bleeding, for example in connection with fall injuries. Especially if the head has hit in. Likewise, if the resident bleeds nosebleeds or has blood in urine or feces. Some who are treated get large bruises in the skin. This must be reported to the nurse so that the treatment can be properly followed up.

The dental hygienist and dentist also need to be informed. The treatment makes the blood not clot, which means that it can take longer before it stops bleeding.
The drugs are often set temporarily after surgeries but can be given temporarily in connection with the healthcare setting needle for a drip. A common reason for long-term treatment is often an increased risk of clot formation. It may be, for example, the heart that pumps unevenly.

The drug that poses the most risks in elderly care is Waran®. It is also very effective for those who really need it. It is vital that those who eat it get exactly the right dose. To ensure that the effect on the blood is correct, the resident must take regular blood tests and the dose is often adjusted for one or a few weeks at a time. The use of Waran® has in recent years largely been replaced with Eloquis® which is not controlled with blood tests.

The bleeding risk can increase even more if the person eating anticoagulants at the same time eats certain natural remedies but also over-the-counter drugs such as Ibuprofen® and Naproxen®. The doctor should always be informed if the resident eats natural remedies.
Monitored drug intake

If the business has taken over the drug responsibility, the person dividing the drugs must monitor that the resident gets their drugs. It is not enough to put them on the breakfast table. Partly because the medication treatment that elderly people have is important for their well-being, but also so that no one else accidentally gets the resident's drugs.
Therefore, the nurse should be contacted if the resident vomits or for other reasons do not get their drugs, get the wrong dose or someone else's drugs. Deviation is written.

Reflection - medication management
Care staff:
• Is the education in connection with delegation good?
• Does it happen that the prescription bases do not match?
• Do you get information about which residents are being treated with blood thinning drugs?

Manager, nurse, occupational therapist, and physiotherapist:
• Do you ever revoke delegations?
• Can there be pressure to delegate to substitutes, for example, before the summer?
• Do you have a uniform education and follow-up of delegated staff?
• Do the routines for "as needed medication" work well?
• Are there alternative treatments that are in demand?

Resident and relative:
• Do you judge that the nurse assistants receive good further education and supervision by nurses, occupational therapists, and physiotherapists?
• Do you get information when medication prescriptions change?
• Does the elderly home use diet, exercise, and other alternatives to drug treatment?

Erland Olsson
Specialist nurse
Sofrosyne - Better care every day