Comprehensive Care Standard

Background to this standard

Safety and quality gaps are often reported as failures to provide adequate care for specific conditions, or in specific situations or settings, or to achieve expected outcomes in certain populations. The purpose of this standard is to address the cross-cutting issues underlying many adverse events. These issues often include failures to:

• Provide continuous and collaborative care
• Work in partnership with patients, carers and families to adequately identify, assess and manage patients’ clinical risks, and find out their preferences for care
• Communicate and work as a team (that is, between members of the healthcare team).

Processes for delivering comprehensive care will vary, even within a health service organisation. Take a flexible approach to standardisation so that safety and quality systems support local implementation and innovation. Target screening, assessment, comprehensive care planning and delivery processes to improve the safety and quality of care delivered to the population that the organisation serves.

Although this standard refers to actions needed within a single episode of patient care, it is essential that each single episode or period of care is considered as part of the continuum of care for a patient. Meaningful implementation of this standard requires attention to the processes for partnering with patients in their own care and for safely managing transitions between episodes of care. This requires that the systems and processes necessary to meet the requirements of this standard also meet the requirements of the Partnering with Consumers Standard and the Communicating for Safety Standard.

This standard is informed by research and developed collaboratively with clinical experts, states and territories and includes information to support implementing the Comprehensive Care Standard; a conceptual model for comprehensive care; Essential elements for delivering comprehensive care; End-of-life care and multiple supporting resources.

Minimising patient harm

Implement targeted, best-practice strategies to prevent and minimise the risk of specific harms identified in this standard.

Pressure injuries

Pressure injuries can occur in patients of any age who have one or more of the following risk factors: immobility, older age, lack of sensory perception, poor nutrition or hydration, excess moisture or dryness, poor skin integrity, reduced blood flow, limited alertness or muscle spasms.¹ Evidence-based strategies to prevent pressure injuries should be used if screening identifies that a patient is at risk.

Falls

Falls also occur in all age groups. However, the risk of falls and the harm from falls vary between individuals as a result of differences in factors such as eyesight, balance, cognitive impairment, muscle strength, bone density and medicine use. The Australian Commission on Safety and Quality in Health Care (the Commission) has developed evidence-based guidelines for older people.^2-4 Policies and procedures for other age groups need to be based on available evidence and best practice.

Poor nutrition

Patients with poor nutrition, including malnutrition, are at greater risk of pressure injuries, and their pressure injuries are more severe.^5,6 They are also at greater risk of healthcare-associated infections and mortality in hospital, and for up to three years following discharge.^7-11 Malnutrition substantially increases length of hospital stay and unplanned readmissions.^9,10,12 Ensure that patients at risk of poor nutrition are identified and that strategies are put in place to reduce these risks.

Cognitive impairment

People with cognitive impairment who are admitted to hospital are at a significantly increased risk of preventable complications such as falls, pressure injuries, delirium and failure to return to premorbid function, as well as adverse outcomes such as unexpected death, or early and unplanned entry into residential care.¹³ People with cognitive impairment may also experience distress in unfamiliar and busy environments. Although cognitive impairment is a common condition experienced by people in health service organisations, it is often not detected, or is dismissed or misdiagnosed. Delirium can be prevented with the right care¹⁴, and harm can be minimised if systems are in place to identify cognitive impairment and the risk of delirium, so that strategies can be incorporated in the comprehensive care plan and implemented.

Unpredictable behaviour

People in healthcare settings can exhibit unpredictable behaviours that may lead to harm. Health service organisations need systems to identify situations that have higher risk of harm, and strategies to mitigate or prevent these risks. They also need systems to manage situations in which harm relating to unpredictable behaviour occurs. In this standard, unpredictable behaviours include self-harm, suicide, aggression and violence. It is important that systems designed to respond to the risks of unpredictable behaviour minimise further trauma to patients and others. This relates to both the material practices and the attitude with which care is delivered.

Processes to manage people who have thoughts of harming themselves, with or without suicidal intent, or who have harmed themselves are needed. These processes need to provide physical safety, and support to manage psychological and other issues contributing to self-harm. The health service organisation is responsible for ensuring that follow-up services are arranged before the person leaves the health service because of the known risks of self-harm after discharge.¹⁵

Some people are at higher risk of aggressive behaviour as a result of impaired coping skills relating to intoxication, acute physical deterioration or mental illness. Healthcare-related situations, such as waiting times, crowded or high-stimulus environments and conflicts about treatment decisions, can precipitate aggression. Members of the workforce need skills to identify the risk of aggression, and strategies to safely manage aggression and violence when they do occur.

Restrictive practices

Minimising or, if possible, eliminating the use of restrictive practices (including restraint and seclusion) is a key part of national mental health policy.^16,17 Minimising the use of restraint in other healthcare settings besides mental health has also been identified as a clinical priority. Identifying risks relating to unpredictable behaviour early and using tailored response strategies can reduce the use of restrictive practices. Restrictive practices must only be implemented by members of the workforce who have been trained in their safe use. The health service organisation needs processes to benchmark and review the use of restrictive practices.

Key links with other standards

To implement systems that meet the requirements of the Comprehensive Care Standard, identify areas of synergy with the other NSQHS Standards. This will help to ensure that the organisation’s safety and quality systems, policies and processes are integrated, and will reduce duplication of effort.

References

1. National Pressure Ulcer Advisory Panel, Panel EPUA, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: clinical practice guideline. 2nd ed. Perth: Cambridge Media; 2014.
2. Australian Commission on Safety and Quality in Health Care. Preventing falls and harm from falls in older people: best practice guidelines for Australian residential aged care facilities. Sydney: ACSQHC; 2009.
3. Australian Commission on Safety and Quality in Health Care. Preventing falls and harm from falls in older people: best practice guidelines for Australian community care. Sydney: ACSQHC; 2009.
4. Australian Commission on Safety and Quality in Health Care. Preventing falls and harm from falls in older people: best practice guidelines for Australian hospitals. Sydney: ACSQHC; 2009.
5. Banks M, Bauer J, Graves N, Ash S. Malnutrition and pressure ulcer risk in adults in Australian health care facilities. Nutrition 2010;26(9):896–901.
6. Fry DE, Pine M, Jones BL, Meimban RJ. Patient characteristics and the occurrence of never events. Arch Surg 2010;145(2):148–51.
7. Correia MI, Hegazi RA, Higashiguchi T, Michel JP, Reddy BR, Tappenden KA, et al. Evidence-based recommendations for addressing malnutrition in health care: an updated strategy from the feedM.E. Global Study Group. J Am Med Dir Assoc 2014;15(8):544–50.
8. Tappenden KA, Quatrara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. JPEN 2013;37(4):482–97.
9. Lim SL, Ong KC, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr 2012;31(3):345–50.
10. Agarwal E, Ferguson M, Banks M, Batterham M, Bauer J, Capra S, et al. Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: results from the Nutrition Care Day Survey 2010. Clin Nutr 2013;32(5):737–45.
11. Charlton KE, Batterham MJ, Bowden S, Ghosh A, Caldwell K, Barone L, et al. A high prevalence of malnutrition in acute geriatric patients predicts adverse clinical outcomes and mortality within 12 months. e-SPEN Journal 2013;8(3):e120–5.
12. Charlton K, Nichols C, Bowden S, Milosavljevic M, Lambert K, Barone L, et al. Poor nutritional status of older subacute patients predicts clinical outcomes and mortality at 18 months of follow-up. Eur J Clin Nutr 2012;66(11):1224–8.
13. National Health Service. Compassion in practice: two years on. Leeds (UK): Nursing Directorate, NHS England; 2014.
14. Hshieh TT, Yue J, Oh E, Puelle M, Dowal S, Travison T, et al. Effectiveness of multi-component non-pharmacologic delirium interventions: a meta-analysis. JAMA Intern Med 2015;175(4):512–20.
15. National Health and Medical Research Council Centre of Research Excellence in Suicide Prevention. Care after a suicide attempt. Sydney: National Mental Health Commission; 2015.
16. National Mental Health Working Group. National safety priorities in mental health: a national plan for reducing harm. Canberra: Australian Government Department of Health and Ageing; 2005.
17. Australian Government Department of Health. National standards for mental health services 2010. Canberra: DoH; 2010.