The Silver Book.

Is there any argument that one of the areas of quality improvement activities that requires great attention in our emergency departments is around the care of the aged?
I attended a presentation at the recent CENA conference about this very topic which mentioned something called The Silver Book.

The Silver Book was produced in the UK and involved the engagement of 13 major health organisations. It gives evidence based, integrated, best practice guidelines for care of the aged in the first 24 hrs of an urgent care episode.

Although based on UK models, the silver book contains some excellent information (and links) for all nurses involved in acute care of the aged.

Some of the key messages from the silver book include:

• Respect for the autonomy and dignity of the older person must underpin our approach and practice at all times. They have the right to a health and social care assessment, and should have access to treatments and care based on need, without an age-defined restriction to services.
• There must be better communication between in and out-of-hours services.
• There must be greater teamwork, both between professions (eg, social care, physiotherapy and occupational therapy) and within professions (eg, geriatricians working closely with emergency physicians).
• The ambulance service has a key role and can contribute to doing things differently, for example, referring non-conveyed individuals directly to urgent care, community and primary care services, including falls services.
• There must be an initial primary care response to an urgent request for help from an older person within 30?min.
• Ambulatory emergency pathways with access to multidisciplinary teams should be available within <4?h for older people who do not need admission but need ongoing treatment (eg, in a Clinical Decisions Unit).
• Staff must improve their knowledge and confidence in managing common frailty syndromes, such as confusion, falls and polypharmacy. They are markers of poor outcomes and are commonly overlooked, but focusing on them greatly improves outcomes.
• One or more frailty syndrome must trigger a detailed comprehensive geriatric assessment in 2?h (14?h overnight) in the community, person’s own home or in hospital.
• For falls, differentiate between syncopal (eg, cardiac, polypharmacy), or non-syncopal causes (strength, balance, vision, proprioception, vestibular and environmental hazards), and exclude immediately reversible causes.
• Immobility or ‘off legs’ hides many diagnoses from cord compression to end-stage dementia. A comprehensive assessment is needed.
• Delirium and dementia are interrelated, but each needs distinct management; it is common for delirium to be superimposed on pre-existing dementia.
• Adverse drug events lead to increased hospital stay, morbidity and mortality. Consider a drug review focusing on identifying inappropriate prescribing, as well as drug omissions. An acute crisis in a frail older person should prompt a structured drug review.
• Incontinence is a marker of frailty and a risk factor for adverse outcomes. More common is abuse of urine dipstick testing leading to erroneous diagnosis of infection, inappropriate antibiotics and increased risk of complications, such as clostridial diarrhoea.
• When suspecting lower urinary tract infections (UTIs) in people unable to express themselves, dipstick testing should only be for those with unexplained systemic sepsis (which may manifest as delirium). A urine dip is not to be used to diagnose a UTI in coherent individuals without lower urinary tract symptoms. Older people should not be routinely catheterised unless there is evidence of urinary retention.
• Mental health services should be commissioned so that they can contribute to specialist mental health assessments within 30?min if appropriate.
• Older people who present with intentional self-harm should be considered as a failed suicide; along with older people with unintentional self-harm they should be assessed for ongoing risk of further self-harm in any setting.
• GPs should monitor hospitalisation and avoidable ED attendances and see if alternative care pathways are more appropriate.
• There must be an area in EDs which is visually and audibly distinct, that can facilitate multidisciplinary assessments.
• There must be quick access to time-critical drugs used by the elderly, for example, l Dopa.
• A procedure on a confused patient needs two health professionals, one to monitor, comfort and distract and the other to perform the procedure; carers and/or family members must be involved if possible; topical anaesthetic gel should be used before cannulation, particularly if the person is confused.
• Urgent and emergency care units must have accessible information about local social services, falls services, healthy eating, staying warm and benefits.
• Intra- and inter-hospital transfers of older people at night should be minimised as it increases the risk of delirium.
• Major incident plans need to include explicit contingencies for the management of multiple casualties of frail older people.

The silver book can be downloaded as a pdf file here: The Silver Book.
Make sure you check out the appendix, as there is plenty of useful information there also.