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					GP Residential Aged Care Kit                                                    Section Five


5: Clinical Information Sheets
 List of Clinical Information Sheets and Reference Cards
 Use of Clinical Information Sheets
 Process used to develop Clinical Information Sheets

List of Clinical Information Sheets and Reference Cards
Clinical Information Sheet          Reference Cards
Advance Care Planning to Improve    1. GP Steps to Advance Care Planning
End-of-Life Care                    2. Assessing a Patient’s Legal Capacity
                                    3. ACP Discussion Guide
                                    4. Resident Information and Documentation for ACP
                                       including Refusal of Treatment for Competent Person
                                    5. Resident Information and Documentation for ACP for a
                                       resident who cannot consent including Refusal of
                                       Treatment for Incompetent Person
                                    6. Victorian Public Advocate Fact Sheets:
                                       - Enduring Power of Attorney (Medical Treatment)
                                       - Medical/Dental Treatment for Patients Who Cannot
                                           Consent
                                       - Refusal of Medical Treatment
Cardiac Chest Pain                  1. Initial Management of Cardiac Chest Pain
                                    2. Basic Life Support
Cardiac Failure
Cellulitis                          1. Cellulitis Assessment
Delirium                            1.   Confusion Assessment Method (CAM) Tool
                                    2.   NEECHAM Confusion Scale
Dementia: Behavioural and           1.   Neuropsychiatric Inventory Questionnaire
Psychological Symptoms              2.   Cohen-Mansfield Agitation Inventory (CMAI)
                                    3.   Behaviour Observation Chart
                                    4.   Sleep Assessment
Diabetes                            1.   Hypoglycaemia Management
                                    2.   Hyperglycaemia Management
                                    3.   Diabetes Sick Day Management – IDDM (Type 1)
                                    4.   Diabetes Sick Day Management – NIDDM (Type 2)
Elder Abuse                         1.   Elder Abuse Suspicion Index
                                    2.   Elder Abuse Action Flow Chart
End-of-Life Care                    1.   Liverpool Care Pathway for the Dying Patient
                                    2.   Memorial Symptom Assessment Scale
                                    3.   Edmonton Symptom Assessment Scale
                                    4.   Palliative Care Visual Analog Scale
                                    5.   Spiritual Involvement and Beliefs Scale
Epilepsy and Seizures               1.   Seizure Observation Chart


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GP Residential Aged Care Kit                                                        Section Five

Clinical Information Sheet           Reference Cards
                                     2. Seizures Record Chart
Falls Management and Prevention      1. Management After a Resident Fall
                                     2. Neurological Observation Chart
                                     3. Incident Report for Reporting a Resident’s Fall
Gastrostomy Tube Management          1. Gastrostomy Tube Blockage or Dislodgement
Medication Management                1. RACF Medication Management Policy
                                     2. RACF List of Nurse Initiated Medicines
                                     3. Anaphylaxis Management
                                     4. Medications That Should Not be Crushed
                                     5. Assessment of a Resident’s Ability to Self-administer
                                        Medication
                                     6. Compact Tools:
                                        - Doctors Fax Medication Order – Label
                                        - Confirmation of Telephone Medication Order - Label
                                        - Medication Labels for Compact Medication Charts –
                                            Handwritten Option
Osteoarthritis                       1. Clinical Pathway Model of Care for Osteoarthritis
Pain Assessment and Management       1.   Breakthrough Pain Management
                                     2.   Pain Assessment and Management
                                     3.   Resident’s Verbal Brief Pain Inventory
                                     4.   Abbey Pain Scale for people with dementia or who cannot
                                          verbalise
                                     5.   Example of Pain Care Plan
                                     6.   Sedation Scale
Respiratory: Asthma                  1.   Asthma Management
                                     2.   Acute Asthma Management Plan
Respiratory: Chronic Obstructive     1.   Modified Medical Research Council Dyspnoea Scale
Pulmonary Disease                    2.   Modified Borg Dyspnoea Scale
                                     3.   Visual Analog Dyspnoea Scale
Respiratory: Influenza
Respiratory: Inhalation medication
delivery devices
Respiratory: Pneumonia               1. Pneumonia Management
                                     2. Pneumonia Severity Index
Subcutaneous Hydration               1. Subcutaneous Hydration
Urinary Indwelling Catheter          1.   Urinary Catheterising a Female
Management                           2.   Urinary Catheterising a Male
Urinary Tract Infections             1.   Management of Kidney Infection
                                     2.   Hospital in the Home IV Antibiotic Therapy – Kidney
                                          Infection




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GP Residential Aged Care Kit                                                                                                                        Section Five

Use of Clinical Information Sheets

Purpose
The purpose of the Clinical Information Sheets (CIS) is to assist RACF staff, GPs and other service
providers to prevent and manage clinical conditions occurring within the facility in hours or after
hours. Each CIS includes a focus on the aspects of care relevant to the residents’ age, frailty and co-
morbidities.

Clinical Information Sheets can be used as an adjunct to knowledge and experience of health
professionals to 1:
    - Inform clinical care of RACF residents;
    - Provide residents and their families with health information; and
    - Be an educational tool for health professionals.

The Clinical Information Sheets should be used with consideration to the:
   - Resident’s preferences, existing medical care plans, and advance care plan;
   - Health professional’s role, knowledge, preferences and professional experience;
   - Policies and resources available within the RACF;
   - Requirements of local professional registration and regulatory bodies; and
   - Relevant local legislation.

Use of Clinical Information Sheets by RACF staff and medical practitioners
Implementing clinical information provided in the sheets within the RACF offers the following
benefits 2:
   - Improved health outcomes of residents through systematic prevention and management of
        chronic conditions and acute events ‘round the clock’;
   - Increased autonomy of residents through improved information, education and involvement
        in care decisions;
   - Enhanced clinical decision-making by RACF staff;
   - Increased confidence of RACF staff in ability to implement clinical interventions;
   - Opportunity for RACF staff to learn about emerging treatment options; and
   - Reduced variability in care practices that may lead to more cost effective care.

Introducing a Clinical Information Sheet into a RACF can be done using the facility’s usual
processes or following the steps outlined below.
   1. Designate responsibilities:
         i. Identify a RACF clinical care co-ordinator or committee to facilitate the introduction of
             new clinical information and processes into your facility.
   2. Asses/Audit:

1
  National Health And Medical Research Council, (NHMRC) (1998). A guide to the development, implementation and
evaluation of clinical practice guidelines. Canberra, NHMRC; Kingston, M, J Krumberger, et al. (2000). "Enhancing
outcomes: guidelines, standards and protocols." AACN Clinical
Issues: Advanced Practice in Acute and Critical Care 11(3): 363-374; Hewitt-Taylor, J (2003). "Developing and using
clinical guidelines." Nursing Standard 18(5): 41-44.
2
  National Health And Medical Research Council, (NHMRC) (1998). A guide to the development, implementation and
evaluation of clinical practice guidelines. Canberra, NHMRC; Kingston, M, J Krumberger, et al. (2000). "Enhancing
outcomes: guidelines, standards and protocols." AACN Clinical
Issues: Advanced Practice in Acute and Critical Care 11(3): 363-374; Conn, V, K Burks, et al. (2002). "Evidence-based Practice for Gerontological
Nursing." Journal of Gerontological Nursing Feb: 45-52




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GP Residential Aged Care Kit                                                           Section Five

         i. Review your current processes for routine medical care and after hours care;

         ii. Review the medical profile of your residential care population and identify specific
              residents with complex needs (e.g. advanced COPD, epilepsy) whose medical care
              could be improved by a systematic approach;
         iii. Review existing clinical protocols; and
         iv. Review and adapt the ‘After hours and acute referral Reference Card’ to suit the
              facility.
  3.   Develop an Implementation Plan:
         i. Select priority areas that require improvement;
         ii. Decide which Clinical Information Sheets would improve care of residents if
              implemented in your facility;
         iii. Identify who needs to be involved, e.g. RN, PCW, GP, pharmacist; and
         iv. Identify any changes that need to be made, e.g. equipment, systems, in your RACF to
              support the new clinical information and recommendations.
  4.   Implement:
         i. Develop and agree on revised protocols;
         ii. Provide an opportunity for stakeholders to ask questions or provide feedback on the
              Clinical Information Sheets and the impact they will have within the RACF, e.g. staff
              meetings, education session;
         iii. Provide staff members and residents to whom the clinical information applies a copy
              of, or access to, the Clinical Information Sheets.
         iv. Adapt the clinical information into your own policies or procedures, or adopt the
              Clinical Information Sheets as part of your management system; and
         v. Incorporate clinical information into resident care plans as appropriate.
  5.   Maintain/sustain use of Clinical Information Sheets:
         i. Education sessions with staff; and
         ii. Review outcomes for residents.
  6.   Evaluate:
         i. Monitor RACF system changes to help achieve, sustain and demonstrate better
              outcomes for residents; and
         ii. Review and update Clinical Information Sheets regularly.

Implementation of the clinical information sheets could be used as evidence in relation to several of
the Accreditation Standards; these include:
    - Expected Outcome 2.3 Education and staff development: Management and staff have
       appropriate knowledge and skills to perform their roles effectively;
    - Expected Outcome 2.4 Clinical Care: Residents receive appropriate clinical care;
    - The Medication Management Clinical Information Sheet could be used as evidence in
       relation to Expected Outcome 2.7 Medication Management: Residents’ medication is
       managed safely and correctly;
    - The Advance Care Planning to improve End of Life Care Clinical Information Sheet and
       End-of-Life Care Clinical Information Sheet could be used as evidence in relation to
       Expected Outcome 2.9 Palliative Care: The comfort and dignity of terminally ill residents is
       maintained; and
    - The Elder Abuse Clinical Information Sheet could be used as evidence in relation to
       Expected Outcome 3.2 Regulatory Compliance: The organisation’s management has



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GP Residential Aged Care Kit                                                                      Section Five

          systems in place to identify and ensure compliance with all relevant legislation, regulatory
          requirements, professional standards, and guidelines, about resident lifestyle.

Process used to develop Clinical Information Sheets
The Clinical Information Sheets have been developed through a process of selecting topics relevant
to the prevention and management of chronic conditions and acute events ‘round the clock’;
incorporating the best available evidence on the topics that they address; and taking into account
relevant legislative and professional codes in the aged care industry in Victoria, Australia. The
information provides a general guide to assist RACF staff to manage specific health problems
and/or to provide residents, relatives and RACF staff with appropriate health information 3.

In each Clinical Information Sheet, the writers address the clinical issues that may occur in
residential aged care, particularly related to:
    - Residents’ age, comorbidities, medication effects and interactions;
    - Levels of dependency and capacity to make decisions;
    - Stage of illness: stable chronic condition, acute event, end-of-life care; and
    - The roles of residents, relatives, GPs, RACF staff, pharmacists and other professionals.

A Reference Group was established to oversee the production of the Clinical Information Sheets.
The purpose of this group was to advise and assist the core developers with the identification of
reference material and with the development, review, implementation and evaluation of
information. The reference group contained experts and representatives from many stakeholders in
the Victorian aged care industry, including multidisciplinary health care staff from hospitals and
RACFs. See Acknowledgements in Section One.

Selection of topics
The writers together with the reference group identified areas of clinical practice for which
information sheets would be developed. Topics were selected for the first and second editions of
the Kit based on:
    - Analysis of common reasons for after-hours medical care and hospital presentation
        identified in an initial needs assessment in 2002 for the first edition of the Kit. Common
        reasons for medical deputising service visits were resident falls, urinary, chest and other
        infections, and indwelling catheter problems, as well as to rewrite resident medication
        charts. Common reasons for presentation to emergency departments included, falls or
        injury, shortness of breath, altered conscious state / delirium, pain, cardiac chest pain and
        PEG tube or indwelling catheter problems.
    - Chronic conditions that have high prevalence among residential aged care patients, and may
        require acute medical care after hours, such as asthma, cardiac failure, chronic obstructive
        pulmonary disease, dementia (behavioural and psychological symptoms), diabetes, epilepsy,
        osteoarthritis.
    - Issues recognised as important for health care and quality of life of residents, such as
        Advance Care Planning, end-of-life care, and protection from elder abuse.

Literature search and evaluation
The strength of evidence on which clinical information is based influences both the uptake of
recommendations in clinical practice settings and the effectiveness of the clinical information in
contributing to a positive health outcome for the resident. Where possible the Clinical Information

3
    National Health And Medical Research Council, (NHMRC) (1998). A guide to the development, implementation and
     evaluation of clinical practice guidelines. Canberra, NHMRC

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GP Residential Aged Care Kit                                                                                   Section Five

Sheets have been developed from systematic research reviews or meta-analyses, as these currently
provide the highest level of evidence 4. If these forms of evidence were unavailable, the information
sheets were developed through a review of individual research studies, clinical guidelines produced
by national or international health organisations, or from consensus opinion5.

Literature was identified through:
    - Search of publications by major national and international health organisations involved in
        the publication of systematic reviews or clinical guidelines, e.g. WHO, NHMRC, Cochrane
        Library; and/or
    - Search of 2 major health databases, CINAHL and MEDLINE, using the search terms
        “clinical guideline” and “practice guideline” in combined searches with terms related to
        each information sheet topic; and/or
    - Internet search using HONcode (a health industry search engine that searches sites which
        meet strict principles of website publication, including transparency) using the search terms
        “clinical guideline” and “practice guideline” in combined searches with terms related to
        each guideline topic; and/or
    - Sources recommended by members of the Reference Group, including Australian guidelines
        published or in final draft form, produced by the relevant specialist organisation.

When possible, existing systematic reviews or clinical guidelines were used for the development of
the Clinical Information Sheets. Literature was evaluated according to its relevance to the RACF
setting and the strength of evidence. All references used in the development of each Clinical
Information Sheet were evaluated and graded according to a scale of evidence adapted with
consideration to the literature available in the aged care sector from the scale published by NHMRC
in 1995 6. The scale was adapted by adding a level of evidence: Level V for non-referenced material
such as that developed in local RACFs. This scale was used as it allows description of lower levels
of evidence when randomised control data is not available (see Table 1). Prescribing information is
consistent with the Australian Therapeutic Guidelines, at the time of writing.

Table 1: Scale of evidence used in development of Clinical Information Sheets (adapted from
NHMRC, 1995)
    Level             Type of Evidence
    Level I           Evidence, including reports and guidelines, obtained from a sound systematic
                      review of all relevant randomised controlled trials

    Level II          Evidence obtained from at least one properly designed randomised trial

    Level III         Evidence obtained from well designed, non-randomised controlled trials or from
                      well designed cohort or case-control analytic studies or from multiple time series
                      with or without the intervention

    Level IV A Descriptive studies
             B Reports or guidelines from expert committees not based on a systematic review of
               best available evidence, or where the method of development is not stated

4
  National Health And Medical Research Council, (NHMRC) (1998). A guide to the development, implementation and
   evaluation of clinical practiceguidelines. Canberra, NHMRC; Michie, S and M Johnston (2004). "Changing clinical
   behaviour by making guidelines specific." BMJ 328: 343-345.
5
  National Health And Medical Research Council, (NHMRC) (1998). A guide to the development, implementation and
   evaluation of clinical practice guidelines. Canberra, NHMRC
6
    National Health And Medical Research Council, (NHMRC) (1995). Guidelines for the development and implementation of clinical
            practice guidelines.Canberra, AGPS; National Health And Medical Research Council, (NHMRC) (1998)


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GP Residential Aged Care Kit                                                                          Section Five


              C Opinions of respected authorities or expert health practitioners based on clinical
                experience

    Level V        Any other evidence (e.g. un-referenced policies/procedures from facilities)

Identification of roles and responsibilities
To assist RACF staff to implement the Clinical Information Sheets, the roles of various health
practitioners were identified with consideration to recommendations in references specific to each
information sheet, for example where national clinical guidelines made recommendations on the
experience required by health professionals performing specific procedures. Consideration was
given to current practice in the aged care industry as well as published guidelines on roles of
specific health practitioners working in the aged care industry in Australia such as:
    - ANCI – National Competency Standards for the Registered Nurse 7;
    - ANCI – National Competency Standards for the Enrolled Nurse8;
    - ANF – Role boundaries in the provision of personal care9; and
    - APAC - Guidelines for medication management in residential aged care facilities 10.

Published guidelines on roles of registered nurses will vary between states. The Clinical
Information Sheets were developed with consideration to the role of nurses in Victoria, Australia:
    - NBV - Role of nurses registered in Division 1, Division 3 or Division 4 11.

Readers outside Victoria, Australia are advised to review the material in the context of their local
legislation and health system regulations.

CIS content and format
The Clinical Information Sheets include:
     - Purpose statement describing the clinical problem and particular issues for RACF;
     - How to assess the clinical problem;
     - Management including goals, maintenance and acute care, medication and non-
         pharmacological strategies;
     - Related literature and research that provides evidence for the techniques recommended;
     - Acknowledgement of the primary sources, including a statement outlining the strength of
         primary sources;
     - Grading of the level of evidence of references used in development of the CIS; and
     - Date the information sheet was developed and updated or revised 12.

7
  Australian Nursing Council Inc., (ANCI) (2003). National competency standards for the registered nurse. Canberra,
          ANCI.
8
  Australian Nursing Council Inc, (ANCI) (2002). National competency standards for the enrolled nurse. Canberra,
          ANCI.
9
  Australian Nursing Federation, (ANF) (2003). Role boundaries in the provision of personal care. Policy statement.
          ANF.
10
   Australian Pharmaceutical Advisory Council, (APAC) (2002). Guidelines for medication management in residential
aged care facilities (3rd edition).
Canberra, Commonwealth Department of Health and Ageing.
11
   Nursing Board Victoria, (NBV) (2001). Role of nurses registered in division 1, division 3 or division 4. Melbourne,
          NBV.
12
   National Health And Medical Research Council, (NHMRC) (1998). A guide to the development, implementation and
evaluation of clinical practice guidelines. Canberra, NHMRC.; Mead, P (2000). "Clinical guidelines: promoting clinical
effectiveness or a professional minefield." Journal of Advanced Nursing 31(1): 110-116.



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GP Residential Aged Care Kit                                                         Section Five


The information sheets are presented in an easy-to-use format and consideration given to wording,
layout and presentation of information to maximise uptake of the information in RACFs.

We strongly recommend that the Clinical Information Sheets be regularly reviewed and
revised as the evidence base and availability of national guidelines for clinical care and
multidisciplinary service delivery is rapidly changing. For more detailed or up to date
information please refer to cited sources and current literature.




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