Vulnerable patient policy

vulnerable patient policy based on NABH guidelines.

1. By A.DEEPARANI.,RNRM. DEPUTY NURSING SUPERINTENDENT VULNERABLE POLICY

2. objectives At the end of the session staff nurses shall, define vulnerable patients. list identified vulnerable patients in prashanth hospitals. knows fall risk assessment tools. explains policy on vulnerable patients. enemurate and practice patient education and implement. interventions based on fall risk assessment.

3. DEFINITION OF VULNERABLE PATIENT A patient who is or may be for any reason unable to protect and take care of him or herself, against significant harm or exploitation.

4. Assessment of Vulnerable Elderly: Neurological status Psychological and mental status Ability to meet Activities of Daily Living General physical assessment Assessment for suspected nutritional and functional risks Assessment for the risk of fall injury Skin integrity assessment Assessment of Vulnerable Young Children: General conditions Medical or surgical conditions Assessment for a suspected abuse or maltreatment

5. Following type of patients can be identified as vulnerable patients    Below 12 years. Above 65 years. Terminally ill patients. Patient with intense and chronic pain(Pain more than 6). Women experiencing terminations and pregnancy. Patients with emotional psychiatric disorders. Patients receiving Chemotherapy. Patient whose immune systems are compromised. Patient Suspected of Drug and alcohol dependency. All dialysis patients.

6. Fall risk assessment tools Morse fall risk assessment Humpty dumpty scale for paediatrics Obestetric fall risk assessment

7. Policy on Vulnerable patients Staff nurse shall assess Fall risk assessment for all patients, twice a day(Morning and Night) initiate appropriate interventions and ensure these are documented. Fall risk assessment need to be reassessed on internal transfer of patient from one unit to another& in case of patients’ clinical condition alters(e.g.Surgical intervention, clinical deterioration). Assess the patient condition and provide care according to their condition Provide education on safety first programme and same need to be documented.

8. Vulnerable patients are prone to face following problems during their stay in the hospital 1.       Fall from bed or in washroom or while transporting from one place to another. The physical and mental limitation makes it difficult for these patients to avoid falls 2.       Harms due to  medical errors  such as wrong medication, wrong diet etc., as they are unable to be watchful about the care being given to them 3.       Neglect, abuse (verbal or physical) and similar other behaviours by some staff 4.       Infringement of their rights, such as privacy, informed consent, confidentiality, respect etc. 5.       Acquiring of healthcare-associated infections, as these patients may not be observant about infection prevention practices

9. How to take appropriate care of vulnerable patients It is evident that vulnerable patients require special care and attention to prevent them from likely harms. Following things can be done in this regard               1.         Identifying vulnerable patients  – The first step is to identify the vulnerable patient who may require special attention. The list of conditions under which a patient should be considered ‘Vulnerable’ (as the one, given above) can be used for quick identification of such patients..

10. Contd…. Vulnerable patients so identified can be given a patient ID band of a Orange colour, or a safety first labelled on their medical file for the information of healthcare staff. Fall leaf is displayed on patient cot.     2.        Fall risk assessment  -  One of the prevalent risk, all vulnerable patients face is the risk of fall. Hence, as a prevention measure, all patients identified as vulnerable must be assessed for risk of fall. ‘ Morse fall scale ’ can be used for this purpose, which gives a risk score. Necessary measures can be taken for a patient with high score to prevent fall.

11. 3.        Safety of vulnerable patient  – As vulnerable patients are susceptible to certain harms, following safety practices must be followed for each vulnerable patient. While this list is generic and can apply to all types of vulnerable patients, inclusion, exclusion and modifications can be done in the list depending upon the type and level of vulnerability assessed.     Hospitals must have  disabled friendly  environment as many patients categorized as vulnerable will be disabled.      Such patients should be monitored more frequently for ensuring that they are safe.

12.       They shall be accompanied by an attendant while going to washroom or any other area.       The washroom that they use must have grab bars, anti-skid mats and call alarm system     While they are on bed safety railings should be put up in place to prevent fall from bed        While being transported on wheelchairs or stretchers, safety belt shall be put up

13. Within the hospital the all vulnerable elderly and children will be given all-necessary care needed with consideration. If the patient’s condition demands further care which is not available in our hospital , patient will be transferred to the other hospitals/facilities. W hi l e t r ansfer r ing the patients a s ta f f nu r se will be a c co m pa n y the patient along with the caregiver. If the patient’s condition is critical , will be escorted by a doctor and a nurse while transferring them form hospital to hospital. Staff taking care of high risk patients must have adequate training and skills. The identified vulnerable patients will be under close monitoring at all times during their hospitalization to minimize risks of health care services.

14. All healthcare providers will maintain a safe environment, related but not limited to: equipment, wheelchairs, bed rails, mobility needs, fall precautions . All healthcare providers will encourage family involvement and support in care delivery, education and decisions as appropriate. Special consent considerations will be taken when needed for each individual case following the hospital approved consenting policies Once the patient is stabilized with the disease process, they will be fit for the discharge. The di sch a r ge pa t i e nt wi ll be di s cha r ged wi th foll o w -up advise. All documentation required for the team to work and communicate effectively in the care of high risk patients must be maintained as per hospital documentation policy.

15. Maintaining a safe environment for all patients Patients are nursed in an appropriate bed Orientate all patients, parents/carers to room and ward Keep beds in low position with brakes on and bed ends in place Side rails and cot sides are raised for appropriate age and patient groups Appropriate  non slip footwear for ambulating patients Nurse call within reach; educate patients and families on its functionality Maintain adequate lighting in patient’s room; low level lighting at night.

16. Conti….., Keep floors clear of clutter including equipment and toys incase of paediatrics. Secure and supervise all patient with a safety belt or harness in wheelchairs,stretchers Hourly rounding will support the provision of proactive care such as the need for assistance to the bathroom Assist unsteady patients with ambulation; refer to physiotherapy notes where available Place necessary items a patient may need within reach (drinking water, phone, etc) Patients who have received sedation or general anaesthetic may be unsteady and require supervision Ensure equipment is well maintained and serviced appropriately (such as wheelchairs and commodes)

17. Documentation of a fall event Record the incident including: description of event (location, activity occurring, time, who was present), assessment findings, interventions and patient outcomes, notification of the incident to the relatives. Report the incident through the hospital incident reporting system, All falls, including near misses should be reported. The information from reported falls is used to gain insight of the causes of falls for patients at the prashanth hospitals and continuously improve the local falls prevention program.    A fall has occurred What factors contributed to the fall. Outcome of post-fall assessment. What additional protective measures have been put in place.

18. Who can give consent? The consent shall be taken from the patient in all cases when the patient is capable of giving consent and above the legal age for giving consent. In case the patient is independent of decision making , this would include the next of kin. The order of preference for next of kin/legal guardian is Spouse Son/daughter/Parents Brothers/Sisters For life threatening situations , when a patient is incapable and next of kin is unavailable, in the interest of time, the treating doctor and another clinician can take a decision to safeguard the patient’s life. For Adult patients: His/her signature or thumb impression is obtained in the consent form along with the witness signature, name and contact details. For Paediatric cases: The signature is obtained from the parents.

19. For unknown patients: Consent shall be given by the Medical Director along with witness signature and are marked as MLC in the patient case sheet and the police is intimated about the same. For unconscious patients: consent shall be given by the attendant with the reason for why the patient could not give the consent has to be documented by the consultant. On life saving conditions: treating Doctor shall be authorized for decision making. Consent for surgery and other related procedure shall be obtained by the surgeon prior to surgery explaining about the procedure, outcome and expected duration of recovery and the consent is obtained from patient / attending relative. Consent for anaesthesia is obtained from patients after explaining the risks, benefits and alternatives, person performing the procedure by the anaesthetist. All patients those who undergo plastic surgery at Prashanth hospital, consent will be obtained from the patient for taking photographs(before and after surgery) by the surgeon. For blood transfusion consent shall be obtained from patient by staff nurse and the same will be verified and counter signed by the ordering consultant/ Doctor on duty. For all invasive procedures consent will be obtained from the patients / attending relative.

20. EXCLUSIONS OF INFORMED CONSENT A. Medical Emergency: A procedure which may otherwise require informed consent may be performed without obtaining prior informed consent in an emergency when the patient is incapable and cannot make an informed decision, and the patient has a life-threatening situation requiring immediate treatment such that any delay in treatment would likely result in death, deterioration, or serious permanent impairment. In such circumstances treating doctor shall consent the patient, with proper reasoning and the same shall be documented in the patient case sheet. If the patient is unconscious or not in a state to give consent, the treating physician shall seek the consent from attending relative or next of kin.

21. B.Minor: If the patient is under 18 years of age, consent should be obtained from legal guardian with the specific facts and reasons the exception applies must be documented in detail in the medical record.

22. C.Emergencies in unconscious patients: If an emergency arises in an unconscious patient the practitioner should, if time permits, endeavor to obtain the consent of the next of kin, but if urgent treatment or investigation is essential the doctor should have no hesitation in proceeding to do what is necessary. A written opinion of a professional colleague that an emergency operation is absolutely necessary can be obtained.

23. Patient and family education Educational activities will be part of the fall prevention program and will be as follows Staff training to increase awareness of high risk patients and prevention strategies All nurses will be familiarized with the fall prevention program and evaluated Educating the patient and family about the risk of falls, safety issues and their mobility limitations. The same will be documented in patient records. Teaching patients to make position changes slowly. Orienting all patients to their bed area, ward facilities and how to get assistance. Explaining the use of grab bars in toilets to all patients Reinforcing education to all high risk patients on a regular basis (every shift) and on transfer between two wards Side rails to be kept raised at all times for all high risk patients. Place call bell & other necessary items like spectacles, drinking water etc. within patients reach Hourly visit to all patients to ensure all basic needs are met & all necessary items & call bell is kept with the patients reach.  

24. ENVIRONMENTAL ISSUES Activities that aim to reduce environmental risks include:   Decreasing obstacles and clutter Night lights at bedside and toilet Stabilizing beds and bed side furniture Having grab bar inside toilets All repairs to be attended without delay. If an equipment or furniture requires repair, patientis admitted to the room only after the issue is fixed. Caution board stating “wet floor” must be placed in case of wet floor or during routine mopping.

25. ELIMINATION NEEDS: Interventions to support the patient’s elimination needs include: Placing patients with urgency near toilets Checking patients who are receiving laxatives and diuretics Toileting at risk patients routinely (offering bed pan and urinal at regular intervals) Instructing male patients prone to dizziness to sit while urinatingIf need to stand, ensure someone is there with the patient Emergency call bell must be placed inside toilets  

26. MEDICATIONS & MOBILITY MEDICATIONS Activities related to medication include: Assessing patients receiving laxatives, diuretics, anti-hypertensives etc. MOBILITY Interventions related to mobility: Non-skid footwear Providing physiotherapy Instructing patients to rise slowly Assistance while walking for “PTF” patients Repeating activity limitation instruction to patient and family Assisting “PTF” patients during transfer Assisting “PTF” patients to increase mobility by walking patients in corridor if there is no medical contraindication.

27. MENTAL STATE, BED REST MENTAL STATE Altered mental status is one of the common identified risk factor for falling and the intervention include:   Reorienting confused patients regularly Orienting patients to the hospital environment Keeping confused patients near nurse’s station Using family members to be with confused patients at all times BED REST Interventions that aim to reduce the risk of falling while patient is on the bed include: Ensure bed is in “Low” position Ensure bed is locked. Ensure bed side-rails are in “UP” position Ensure patients can reach necessary items

28. WHEEL CHAIRS & CHAIRS To prevent fall involving wheel chairs include: Use safety straps or seat belts in chairs Ensure support to prevent slipping from chairs Selecting suitable chairs for sitting.

29. Orange colour ID Band to identify vulnerable patients

30. call bell

31. Foot stool Call in bath room

32. Side rails and fall leaf

33. Grap bar Safety belt in wheel chair

34. Thank you…