Barbara Chandler, managing risk workshop 2017 oct 30th 2017(1)
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Barbara Chandler, managing risk workshop 2017 oct 30th 2017(1)
- 1. Managing Risk in Advanced MS Dr Barbara Chandler NHS Highland 13th November 2017
- 2. Assessing Risk • Travel to conference • What are the risks • How did you manage those risks • What would increase or decrease those risks • Who else is affected by the risks you take • Can you separate internal and external factors
- 4. Plan Building Blocks and Ideas • Definitions • Risk Assessment • Principles • Tools • Practical risk management • Context • Legal • Practical • Managing Outcome • Case studies Learning Outcomes • Understand concept of risk in the context of advanced MS • Understand how to assess risk and enable PwMS and/or relatives and professionals to assess risk • Understand how to manage risk to facilitate a positive outcome
- 5. Advanced MS • Spastic Tetraparesis • Neurogenic bladder • Neurogenic bowel • Dysphagia • Dysarthria • Fatigue • Cognitive deficit • Pressure area risk/pressure sore • Epilepsy • Frequent UTI • Aspiration pneumonia • PEG • Family stress • Care package • Multiple professionals • Coordination of care
- 6. Risk definition • a situation involving exposure to danger. • someone or something that creates or suggests a hazard • the possibility of something bad happening • the potential of gaining or losing something of value
- 7. Risk Assessment “A risk assessment can only identify the probability of harm, assess the impact of it on key individuals, and pose intervention strategies which may diminish the risk or reduce the harm. Assessments cannot prevent risk” Hope and Sparks, 2000
- 8. Risk management: probability and impact • Large potential loss • Low probability • Low potential loss • High probability
- 9. Risk • Identify • Assess • Manage
- 10. What are the risks How do you go about the risk assessment CASE EXAMPLE
- 12. Risk Mental Capacity Legal Framework Quality of Life Goal engagement Goal dis-engagement Managing risk Accountability Documentation Independence Hope Conflict Choice Safety Freedom Multi-agency Cost Availability of resources Concept vs reality Realistic Medicine
- 13. Principles of risk assessment • Identify context • Identify risks • Perceived by individual • Perceived by professional • Analyse risks • High probability; low impact • Low probability; high impact Compromise Uncertainty
- 14. Principles of risk assessment • Evaluate risk • Potential benefits of managing risk • Potential adverse outcome of managing risk • Potential risk of not intervening • Management/Action taken or recommended DOCUMENTATION
- 15. Activity or Context Risk or Hazard Contributing Factors Impact and Probability Action Impact and Probability REVIEW DATE
- 16. Resources • Mental capacity Act / Adults with Incapacity Act Adults with Incapacity (Scotland) Act 2000 Incapacity means incapable of Acting on decisions; or Making decisions; or Communicating decisions; or Understanding decisions; or Retaining memory of decisions In relation to any particular matter due to mental disorder or physical inability to communicate because of physical disability
- 17. Adult Support and Protection (Scotland) Act 2007 An adult at risk is Unable to safeguard his/her own wellbeing, property, interests At risk of harm Because s/he is affected by disability, mental disorder, illness, mental or physical infirmity is more vulnerable to being harmed than an adult not so affected • Recognise • Respond, ensure safety • Report • Record • Reflect
- 18. Risk of medication • BNF • Specific risks of disease modifying drugs • Experienced colleagues
- 19. Driving Assessing fitness to drive: a guide for medical professionals Published:11 March 2016 • https://www.gov.uk/guidance/assessing-fitness-to- drive-a-guide-for-medical-professionals
- 20. Falls If you have had a fall in the last 12 months or answered Yes to two or more questions in the test then you are advised to discuss your risk of falls with your GP. If they feel that you are at risk of falling they may refer you to specialist falls services. FALL RISK TEST • Have you had a fall in the last 12 months? Yes / No • Are you on four or more medications a day? Yes / No • Do you have Parkinson's disease or have you had a stroke? Yes / No • Do you feel unsteady or have problems with balance? Yes / No • Can you walk while talking? • Do you sway significantly while standing? • The 'Timed Up and Go' test: • Do you struggle to get up from a chair? Yes / No For more fall prevention tips download Get Up and Go: A Guide to Staying Steady (PDF, 2.65MB).
- 22. Marriage breakdown Reduced strength in hands Urinary tract infection Personality Genetic Psychiatric Male Cognitive flexibility Mental health treatment Meaningful relationships Plan next 2 days Liaise with other hcp Note informal support Specialist support – crisis teams Build protective factors Ensure access to help Risk Short term + long term factors – protective factors = risk
- 23. Risks for patient Risks for carer Risk for family Goals for patient Goals for family Goals for professionals Goal engagement and disengagement Hope and hopelessness CASE EXAMPLE
- 24. Risk Documentation Communication and consultation with Individual +/- family and professionals
- 25. Risk Mental Capacity Legal Framework Quality of Life Goal engagement Goal dis-engagement Managing risk Accountability Managing conflictDocumentation Independence Hope Conflict Choice Safety Freedom Multi-agency
- 26. Activity or Context Risk or Hazard Contributing Factors Impact and Probability Action Impact and Prob Living in own home Choking MS Fatigue Saliva Impact – high Prob - medium PEG Swallow Saliva reduction Care package Independent Decision Making Unsafe, poorly understood decision Mental capacity Other influence same Mental capacity Adult support and protection Independent Decision Making Inappropriate restriction of decision making Mental capacity Other influence same REVIEW DATE
- 27. Activity or Context Risk or Hazard Contributing Factors Impact and Probability Action Impact and Prob Living in own home, time alone Night time Calling for help REVIEW DATE
- 28. Risk Documentation Communication and consultation with Individual +/- family and professionals Implementation of agreed plan Review
- 29. Cases
- 30. Resources • Training, professionalism and experience • Risk assessment tools • DMD’s, falls assessment, suicide risk, fire risk, social, financial sexual exploitation risk • Professional standards • GMC good medical practice • Legal framework • Adults with incapacity (Scotland) Act 2000: a short guide • ASP (Scotland) Act 2007 • Experienced colleagues in health and social care; local ethics committee
Notes de l'éditeur
- Hope T, Sparks R 2000 Crime Risk and Insecurity London Routledge P137 Risk management is about minimising not removing risk Risk involves exposure to danger
- Different approach to managing these situations
- Mental capacity What are the factors influencing the decisions made by others cost availability of resources concept vs reality realistic medicine RIGHTS OF CARERS
- Balance these issues around risk management; Ensure documentation at all stages Aim to demonstrate and ask for examples of documentation in case studies The consequences of managing risk must outweigh the consequences of not managing the risk To be managed, the risk must be controllable in a way acceptable to those involved Example using a hoist at home Hoist too time consuming and if incontinence occurs too much work not offset by the longer term risk of back problems, but is there an issue of safety for vulnerable individual as well as for carer?
- Take this simple test to work out if you need to discuss your risk of falls with your GP. This self-assessment is based on the Falls Risk Assessment Tool (FRAT) used by healthcare professionals to help identify at risk patients aged 65 and over. The test can help uncover any health issues that might make you more likely to fall, which you can discuss with your GP. Your fall test score If you have had a fall in the last 12 months or answered Yes to two or more questions in the test then you are advised to discuss your risk of falls with your GP. If they feel that you are at risk of falling they may refer you to specialist falls services. Fall risk test Have you had a fall in the last 12 months? Yes / No You are more likely to have another fall if you have fallen in the last year. A previous fall can also make you overly cautious and lead you to restrict your activities and even avoid leaving your home. A fear of falling can start to become a serious worry and can be quite difficult to deal with, if not addressed quickly. Are you on four or more medications a day? Yes / No Taking four or more medications significantly increases the risk for falling because of the side effects associated with multiple medication use. You should see your GP if you haven't had your medicines reviewed for more than a year. Your GP may recommend alternative medications or lower doses if appropriate. Do you have Parkinson's disease or have you had a stroke? Yes / No Falls are common after a stroke mainly because of leg weakness, sensory loss, and foot, eyesight and balance problems. Up to 73% of stroke survivors experience a fall in the first six months after leaving hospital. If you have Parkinson's, the reasons you fall may include poor balance, taking steps that are too small or that vary in size, or because your arms don't swing when you walk. Involuntary movements, which are a side effect of some Parkinson's medication, can also be a reason. Do you feel unsteady or have problems with balance? Yes / No To help you answer, try these simple tests: Can you walk while talking? Try answering random questions while walking with someone. If you stop walking either immediately or as soon as you start to answer a question, you should answer 'Yes' to the question. Do you sway significantly while standing? Get someone to observe you standing upright. If you raise your arms or adjust your foot placement for balance, you should answer 'Yes' to the question. Take your weight on to one leg and try to lift the other foot off the floor by about an inch (allow a few practice attempts). If you struggle to balance on one leg, you should answer 'Yes' to the question. The 'Timed Up and Go' test: Stand up from the chair - Walk three metres (10 feet) at your normal pace - Turn - Walk back to the chair at your normal pace -If you take more than 12 seconds to complete the Timed Up and Go test, you should answer 'Yes' to the question. Do you struggle to get up from a chair? Yes / No You should be able to stand up from a chair of knee height without using your arms. If you feel unsteady, lightheaded, dizzy or even feel faint after getting up, it could be a sign of low blood pressure. Postural hypotension (or orthostatic hypotension) is when your blood pressure drops when you go from lying down to sitting up, or from sitting to standing. When your blood pressure drops, less blood may reach your organs and muscles. Lowered blood pressure can make you more likely to fall. For more fall prevention tips download Get Up and Go: A Guide to Staying Steady (PDF, 2.65MB).
- Mental capacity What are the factors influencing the decisions made by others cost availability of resources concept vs reality realistic medicine RIGHTS OF CARERS