The Purple Book A reference source for Care Home staff in ...

The Purple Book version 1 – Section 3 Produced by IESCCG and WSCCG May 2018

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The Purple Book

A reference source for Care Home staff in Suffolk

Section 3 - Protocols


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Contents Page

Care Home MUST Local Policy …………….. 3 ONS in Care Homes Policy …………………… 4 Dietary advice …………………………………….. 6 Recipes ………..……………………………………… 7 Managing Swallowing Difficulties ………… 8 Care provider letter …………………………….. 9 Gluten free formularies ……………………… 12 COPD Symptoms & Action to take ……….14 Good Sleep Guide ………………………………. 15 Diagnosis & Management of UTIs .……… 16 UTI Information Leaflet ………………………. 20 Cases of Diarrhoea and/or Vomiting …… 21 Hand Hygiene …..…………………………………. 24 Recognising Cellulitis ..…………………………. 25 IStumble Falls Protocol ………………………… 26 MAR Chart Reconciliation Form ..…………. 28 Clinical Frailty Scale ..……………………………. 30 Support Tool EOL care ………………………….. 31 Contracture Early Warning Trigger Tool .. 32 Guidance on outbreaks of influenza ……… 34 Safer eating & drinking framework ……….. 35


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Date: October 2018

Dear Care Provider, This year, our recommendations regarding thickening of fluids and diet descriptors will be changing in line with new international guidelines. Ipswich and East Suffolk CCG and West Suffolk CCG in conjunction with Speech & Language Therapy Services will therefore be using the International Dysphagia Diets Standardisation Initiative (IDDSI) Framework descriptor on all dysphagia care plans for fluids & foods from mid October 2018. Our aim is to ensure that these changes happen as smoothly as possible.

The IDDSI framework consists of a continuum of 8 levels (0-7). Levels are identified by text labels,

numbers, and colour codes to improve safety and identification.

Previous Drink Stages

New IDDSI Drink Levels

Previous Food Descriptors

New Food Descriptors

UK National Descriptors

IDDSI Framework

N/A Level 1 Slightly thick

Texture B Thin purée

Level 3 Liquidised

Stage 1 Level 2 Mildly thick

Texture C Thick purée

Level 4 Puréed

Stage 2 Level 3 Moderately thick

Texture D Pre-mashed

Level 5 Minced & Moist

Stage 3 Level 4 Extremely thick

Texture E Fork mashable

Level 6 Soft & Bite-sized

Normal Level 7 Regular

IDDSI Level 6 Soft & Bite-sized is NOT THE SAME as Texture E Fork mashable. The maximum piece size in Level 6 is 1.5cm x 1.5cm to reduce the risk of choking on food


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We will no longer be recommending “stages” for drinks and fluids. Instead we will be

recommending an “IDDSI level” of thickness. We are using this change opportunity to enhance quality care and have decided to move to a new thickener called Nutilis Clear.

What is Nutilis Clear® and why is it the thickener of choice?

Nutilis Clear is a new generation gum based thickener by Nutricia.

Other gum based thickeners on the market are mixed slightly differently to Nutilis Clear and

traditional starch based thickeners in that they require the powder to be placed in a clean,

dry cup before adding the fluid. Some patients and providers, as well as our partners in

acute services have found this to be a barrier as it adds additional mess, time and risk of

being the wrong consistency if not mixed correctly. Nutilis Clear can be added to the fluid

either before or after it is poured which is considered simpler to mix safely and correctly.

The choice to adopt Nutilis Clear as the first line formulary inclusion across Suffolk and

North East Essex has been made following a thorough evaluation process facilitated by

clinical procurement with full engagement from the Speech and Language Therapy

(SLT), Dietetics and Medicines Management teams.

How do I order Nutilis Clear?

The new Nutilis Clear tins are available from all pharmacies using either:

1. Product code 60794

2. PIP Code 373-1908

The tin will contain a green scoop and display the IDDSI dosing guidelines printed on the

back of the tin. (See a copy of the tin label guidance below)

*The quantity of Nutilis Clear used may vary slightly depending on temperature or thickness of the liquid and viscosity required. For more information, please visit mynutilis.co.uk

What you need to do

We have advised GPs that the formulary has changed and that patients will be moved onto Nutilis Clear over the coming weeks. Once staff have received IDDSI and Nutilis Clear training you will be asked to utilise the attached letter template and populate the chart for all patients currently receiving a thickener prescription residing within the care home. This should then be sent directly to the GP surgery where the patients are registered so that the prescription change can be processed.


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If you notice any symptoms of aspiration when patients are drinking after the changeover e.g. coughing, choking, throat clearing, wet “gurgly” voice or breath quality, then please seek a re-referral to SLT via the usual route or contact the relevant SLT service for advice on the service numbers listed below.

Training

Your Nutricia representative will be in touch soon to arrange Nutilis Clear staff training, they will be happy to answer any questions you may have regarding this correspondence and moving patients from current stages to the new levels on that day.

For further information regarding IDDSI please go to www.IDDSI.org

For more general queries regarding Nutilis Clear, including queries regarding mixing of drinks please call the Nutricia Patient and Carer Helpline.

UK – 08457 623653 or [email protected]

Yours sincerely,

Speech & Language Therapy Services ESNEFT Tel: 01473 275285

Speech & Language Therapy Services WSFT Tel: 01284 748847

http://www.iddsi.org/

mailto:[email protected]


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Gluten Free Formulary from December 2018

For adults aged 19 years and over no gluten free food is to be prescribed, this should be purchased by the patient.

For children and adolescents up to 18 years a maximum of 8 units per month can be prescribed, and the following items must be adhered to:

Long-life bread/rolls

Fresh bread/rolls

Mixes

Quantities

Age Number of units per month

Children 18 years and under 8

Adults 19 years and over 0

Product Pack size Units per pack Long-life bread Glutafin gluten free white sliced loaf 300g 1 x 300g 1 Glutafin gluten free fibre sliced loaf 300g 1 x 300g 1 Glutafin gluten free high fibre sliced loaf 350g 1 x 350g 1 Glutafin gluten free Select white sliced loaf 400g 1 x 400g 1 Glutafin gluten free Select fibre sliced loaf 400g 1 x 400g 1 Glutafin gluten free Select seeded sliced loaf 400g 1 x 400g 1 Juvela gluten free white sliced loaf 400g 1 x 400g 1 Juvela gluten free white unsliced loaf 400g 1 x 400g 1 Juvela gluten free fibre sliced loaf 400g 1 x 400g 1 Juvela gluten free fibre unsliced loaf 400g 1 x 400g 1 Juvela gluten free part-baked white loaf 400g 1 x 400g 1 Juvela gluten free part-baked fibre loaf 400g 1 x 400g 1 Long-life rolls Glutafin gluten free white rolls 200g (50g x 4) 4 x 50g 0.5 Glutafin gluten free part-baked fibre rolls 200g (50g x 4) 4 x 50g 0.5 Juvela gluten free white rolls 425g (85g x 5) 5 x 85g 1 Juvela gluten free fibre rolls 425g (85g x 5) 5 x 85g 1 Fresh bread Genius white sandwich bread sliced 535g 6 x 535g 6 Genius brown sandwich bread sliced 535g 6 x 535g 6 Glutafin gluten free Select fresh white sliced loaf 400g 8 x 400g 8 Glutafin gluten free Select fresh brown sliced loaf 400g 8 x 400g 8 Juvela gluten free fresh white sliced loaf 400g 8 x 400g 8 Juvela gluten free fresh fibre sliced loaf 400g 8 x 400g 8


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Fresh rolls

Juvela gluten free fresh white rolls 425g (85g x 5) 8 x 5 x 85g 8 Juvela gluten free fresh fibre rolls 425g (85g x 5) 8 x 5 x 85g 8 Mixed cases of fresh bread and / or rolls Juvela fresh white loaves 4 x 400g + fresh fibre loaves 4 x 400g 8 x 400g 8 Juvela fresh white loaves 4 x 400g + fresh white rolls 4 x 425g 4 x 400g + 4 x 425g 8 Juvela fresh white loaves 4 x 400g + fresh fibre rolls 4 x 425g 4 x 400g + 4 x 425g 8 Juvela fresh fibre loaves 4 x 400g + fresh fibre rolls 4 x 425g 4 x 400g + 4 x 425g 8 Juvela fresh fibre loaves 4 x 400g + fresh white rolls 4 x 425g 4 x 400g + 4 x 425g 8 Juvela fresh white rolls 4 x 425g + fresh fibre rolls 425g 8 x 425g 8 Mixes

Barkat gluten free all purpose flour mix 500g 1 x 500g 2 Glutafin gluten free multipurpose white mix 500g 1 x 500g 2 Glutafin gluten free wheat free multipurpose fibre mix 500g 1 x 500g 2 Glutafin gluten free Select multipurpose white mix 500g 1 x 500g 2 Glutafin gluten free Select multipurpose fibre mix 500g 1 x 500g 2 Juvela gluten free white mix 500g 1 x 500g 2 Juvela gluten free fibre mix 500g 1 x 500g 2 Juvela gluten free harvest mix 500g 1 x 500g 2 Barkat gluten free hi-fibre bread mix 500g 1 x 500g 2 Glutafin gluten free bread mix 500g 1 x 500g 2 Glutafin gluten free fibre bread mix 500g 1 x 500g 2 Glutafin gluten free Select bread mix 500g 1 x 500g 2 Glutafin gluten free Select fibre bread mix 500g 1 x 500g 2


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COPD Symptoms & Action to take

Good days Bad days Need to call for help

SYMPTOMS Client is able to do what they

usually do

Energy levels good

Sleeping at night time

Coughing and clearing normal amounts of sputum

Normal levels of breathlessness

Rarely needing reliever inhaler

No more tired than usual

Needing to use reliever inhaler more frequently

More breathless and /or wheezy than normal

Difficulty with usual activities (washing/dressing/eating) due to shortness of breath

More chest tightness

More coughing

More sputum than normal

Feeling unwell and less energy

Not sleeping or sleeping too much

Severe breathlessness with no relief from inhalers

Feverish / temperature

More fatigued / sleeping more/drowsy

Coughing more

More sputum / secretions than usual

Sputum/ secretions changed in colour compared with normal

Sounding wheezy or noisy breathing despite use of inhalers

Client looks blue or pale

Client agitated or confused

Client is more breathless and /or wheezy and the reliever inhaler has not been effective.

ACTION Encourage to keep doing

normal daily activities where possible

Exercise daily e.g. walking for about 30 minutes a day or seated exercises

Keep drinking plenty to stay hydrated

Maintain healthy weight by eating a balanced diet

Take medication as prescribed

Make sure client uses a spacer where indicated to take inhalers and uses correct technique.

Make sure client has flu vaccine and pneumovax injections

Smoking cessation advice if smoker

Check inhalers have not run out.

Encourage breathing/relaxation exercises (as per advice sheet)

Use a handheld fan to control breathlessness (as per advice sheet)

Increase use of ‘reliever’ inhalers as instructed by GP or nurse.

If signs of aspiration or choking due to breathlessness when eating or drinking provide with soft diet, and plenty of rest between small mouthfuls to enable client to ‘catch’ breath

Encourage regular fluids to stay hydrated

Encourage combination of gentle rest and activity

Encourage regular small amounts of high fat/calorie foods

Consider starting steroid/antibiotic pack IF worsening breathlessness/discoloured sputum persists over 2 days. (See flare ups leaflet)

Call GP for advice. They may start steroids/antibiotics (if no emergency packs held)

GP may refer to COPD team for Admission Avoidance support if required.

If GP unavailable, call out of hours service/111

Call ambulance 999 if very short

of breath/unable to wake patient


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Local Health Protection Team: Regional Health Protection Unit at Croxton Way, Thetford on 0344

225 3546 for Care Home related outbreaks.


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More information is available at http://sepsistrust.org/

Don’t forget your wrists!

Alcohol gel does not kill Clostridium Difficile spores or Norovirus

Hand Hygiene

http://sepsistrust.org/


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NO

YES

YES

CELLULITIS UNLIKELY

Does the Resident have a

swollen limb?

(Usually the leg, but upper

arm may be affected)

The swelling seems

localised.

There is a distinct

red, tender area.

The whole limb is

not NEWLY swollen.

There may be signs

of fever.

POSSIBLE DVT

A SCAN IS NEEDED

NOTIFY THE GP

PROBABLE

CELLULITIS

Using a pen or permanent marker, draw on the

limb around the outside of the inflamed area.

Record temperature, pulse and respiration.

Give pain relief.

Provide adequate fluids to drink.

Elevate the limb where appropriate.

ANTIBIOTICS ARE REQUIRED

NOTIFY THE GP

Recognising Cellulitis

The leg and ankle have

become more swollen

QUICKLY.

There is no distinct area

of inflammation.

The leg is generally

tender.


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MAR chart reconciliation form

It is important that every Care Home Resident has an accurate and up-to-date medication

administration record (MAR) chart.

This form should be used to inform your community pharmacy if any items currently listed on a

Resident’s MAR chart are no longer in use. The pharmacy should remove these medications from

future MAR charts for that Resident.

Remembering to use this chart keeps the Resident’s medication record as accurate as possible. It also

alerts the pharmacy to any changes in the medication.

If you are unsure whether the Resident is, or should be, still using any of the items on their list, please

contact the GP surgery to confirm.

The following blank MAR chart can be copied and used for Residents in your Care Home if needed.


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MAR chart reconciliation form

Please use this form to inform the community pharmacy of items that are still listed on the patients

MAR chart, but are not actively being used. This will apply to all items which are no longer listed on

the patient’s repeat, and items which are not being given as a current acute course, including

dressings, inhalers, creams and sprays, as well as drugs which may no longer be needed.

If you are unsure of whether the patient is still using one of the items listed, then please contact the

GP surgery to confirm.

Please use one form per patient

Dear Pharmacist, Please remove the following items from the printed MAR charts for the listed

patients, as they are no longer of clinical need.

Patient name: __________________________

NHS number: __________________________

DOB: ________________

MAR charts should only contain items in current use by the patient in order to reduce errors in

reconciliation and administration of medicines.

Name of drug Strength Directions Additional comments


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