Chronic Disease staff from Northern NSW Local Health District (NNSWLHD) recently presented on chronic disease management at 2 Primary Care Nurse Network dinners held in Tweed Heads and Alstonville last month.
The dinners which were hosted by the North Coast Primary Health Network (NCPHN) in partnership with the Australian Practice Nurse Network (APNA) form part of a series of events being coordinated by the Northern Rivers Primary Care Nurse Network which was launched in May 2017.
The Chronic Disease staff presentations centred around Sick Day Action Plans and the ‘café’ style presentations meant that small groups had the ability to ask questions more easily and were more engaged. NNSWLHD staff even gave out their work phone numbers in order to support ‘learning lunches’ at the various practices.
Informal feedback regarding the presentations has been excellent and the difficulty moving groups on to the next table for the next presentation was a good indication that attendees were all very engaged would have liked longer to discuss issues with the Chronic Disease staff.
Who was in the Room?
Of the 37 staff invited to the Tweed dinner, 17 attended. A mix of attendees and presenters included Nurse Practitioners, North Coast Primary Health Network staff, Northern NSW Local Health District staff from both hospital and community health and Residential Aged Care Facility nursing staff.
At the Alstonville dinner 41 representatives and presenters were invited and 25 were present on the night. In addition to the above attendees this workshop also attracted nurses from local Aboriginal Medical Services and the Liver Clinic.
What was Presented?
Diabetes:
Presented by Wendy Livingstone Diabetes CNC, Credentialled Diabetes Educator, NP, | Ballina Diabetes Centre; Ballina Community Health.
The main focus was to ‘walk’ the groups through the layout of the sick day documents as they can appear a little lengthy; and to focus on the main messages of sick day management for the person with diabetes, which are:
- keep hydrated
- test their blood glucose levels 2nd hourly
- should never stop taking their insulin (people with Type 1 diabetes often need to take extra insulin)
- may need to stop their Metformin until well
- that unwell people with Type 1 diabetes can go into ketoacidosis quite quickly if not managed early and properly
- let others know they are unwell
- know when to seek medical attention
Everyone had a query and everyone was keen to know about the management.
General Practitioners and SDAPs
Presented by Allison Eastman, Respiratory Liaison Nurse, Community Nursing, The Tweed Hospital.
The focus was on ‘How do we get GPs to agree with action Plans’, more specifically signing off on prednisolone dosage and antibiotic scripts.
The main variable issues with SDAPs are the agreement with GPs to give scripts in lieu of COPD patients becoming sick. A way to get GPs on board is complete a pathology form for a sputum culture test, where it is discussed with the patient that a ‘spit test’ must be done when the patient fills the antibiotic script. This will notify the GP that the patient is unwell requiring antibiotics and it allows the GP to revisit the patient during this time. It also decreases the use of incorrect antibiotics where the GP can swiftly change antibiotic regime if necessary.
This plan further allows for analysis of a behaviour pattern if the patient is continuously non-infective, steering conversations towards other discussions to understand the individual’s exacerbation issues.
With prednisolone scripts, a weaning chart could be developed and implemented for corrective weaning as per best practice, which gives the patient clear and conscious instructions.
Heart Failure
Presented by Francesca Leaton, Heart Failure Liaison, The Tweed Heads Hospital, Adult Community Health.
The heart failure table was a great success generating lots of interest in symptom management and sick day action plans.
Frequently Asked Questions:
- Difference between dry and wet weights
- Dry weight is taken early morning after emptying the bladder and prior to breakfast. It is the weight all weighs should be compared to too determine accurate fluid retention. The rule is 1kg = 1L in fluid.
- Wet weight is a weight that has been affected by fluid intake and food e.g. breakfast. This is not an accurate measure in weight.
- (Wake, Wee, Weigh and Write)
- What are the typical signs of deterioration in a heart failure patient?
- Generally, the typical signs of deterioration are shortness of breath, dyspnoea, fatigue, reduced exercise tolerance and fluid retention.
- Why do patient’s take a ‘wait and see’ approach?
- Patients usually don’t want to make a fuss or burden their partner or family
- Denial
- Inconvenience
- What is the recommended amount of salt per day?
- The National Australian Heart Foundation recommend 2000mg (2G) per day. However, many Dieticians recommend somewhere between 2,000 – 2500mg (2.5G) per day. Always check with the patient’s GP as renal and hyponatraemic patients are usually on a NO SALT DIET
- What is the recommended intake of fluid per day – are there any further restrictions for example in renal disease or hyponatraemia?
- The National Australian Heart Foundation recommend 1.5 – 2.0L/day.
- However, patients with hyponatraemia are usually directed by their GP/Specialist to remain at somewhere between 800mls – 1L/day. This may be increased if the serum sodium returns to the normal therapeutic level and as directed by the patient’s GP/Specialist.
- Renal disease – usually 1 – 1.2L/day or as directed by the patient’s GP/Specialist.
- How to use ‘The Daily Heart Failure Management Book’
- Instructions are included in this booklet.
- ‘Your Action Plan’ on Page 4 is an instruction by the patient’s GP to increase the dose of a prescribed diuretic e.g. Lasix to corresponding gains in weight of 2kgs over 1-3 days. Sometimes in patients with heart failure and accompanying renal failure the GP/Specialist may increase a prescribed diuretic with smaller gains in weight of around 1 – 2kgs. This will always be at the discretion of the GP/Specialist and will be included in the nominated area on Page 4 of the ‘Daily Heart Failure Management Book’.
- Increases in diuretics are for a few days only or at the discretion of the GP/Specialist.
- Heart failure and co-morbidities and readmissions to hospitals.
- Studies clearly demonstrate that patients with co-morbidities have a higher risk of readmission and a poorer prognosis.
- How to refer to the Heart Failure Education and Exercise Program at The Tweed Hospital.
- Anyone can refer to The Tweed Hospital’s Heart Failure Program. However, patient’s will require exercise clearance from their GP or Cardiologist prior to commencing the exercise component of the Program.
- Contact number is 0755067818.
- Contact: Francesca Leaton.
- Email: Francesca.Leaton@ncahs.health.nsw.gov.au
- Is there a Pathway that we can follow for general heart failure information
- Healthpathways.org.au
- Username:manchealth
- Password:conn3ct3d
- Make sure your GP has a shortcut on his/her desktop
Chronic Kidney Disease
Presented by Graeme Turner Nurse Practitioner Chronic Kidney Disease.
Talk initially focused on consequences of Acute Kidney Injury and discussed acute admissions with Metformin Associated Lactic Acidosis.
We talked about the importance of identifying people with CKD and the fact that these people are at risk of Acute Kidney Injury. Mechanisms of acute kidney injury discussed including pre renal caused by dehydration leading to hypoperfusion of the kidney and also interstitial nephritis caused often by medications.
Discussion then lead to walking through the sick day management plan:
- What do we mean by sick?
- What medications need to be withheld:
- Medications that can cause renal hyporperfusion
- Diuretics.
- ACE inhibitor and ARB antihypertensive medications.
- SGLT2 inhibitors
- NSAID’s
- Medications that may build up and become nephrotoxic
- Metformin
- NSAID’s
The importance of GP follow up and communication between GP’s and sub specialty staff was discussed.
COPD Action Plans
Presented by Lyn Menchin Chronic Care Respiratory CNS2, Pulmonary Rehabilitation Coordinator, Lismore Base Hospital.
Chronic Obstructive Pulmonary Disease (COPD) action plans were presented and below were the most commonly asked questions regarding the use of the these.
Frequently Asked Questions:
- Were who can write out the plan?
- The Practice nurse can write up the plan so long as it is reviewed and signed off by the medical practitioner
- How do we encourage the ownership of the COPD action plan?
- Try to involve the client and the carer in all the education around the action plan. Making sure they have a good understanding of their current puffer’s relievers and preventers and correct puffer technique.
- How do we escalate the plan?
- The plan is escalated if the clients condition changes significantly or deteriorates. Often they notice changes in SOB, Coughing and Sputum production and Exercise Capacity as well as increased use of the reliever medications. Subtler changes are changes in appetite and energy levels.
- What strength of prednisone should patients commence on?
- The medical practitioner needs to prescribe the prednisone dose worked out on weight a good rule of thumb is to commence on 50mg daily for 3 days then start to reduce The Client needs to be reviewed by the medical practitioner if they have escalated their care plan
Integrated Aboriginal Chronic Care (IACC) 
Presented by Ragina Rogers, Integrated Aboriginal Chronic Care Coordinator, Integrated Aboriginal Chronic Care.
The main focus of the Integrated Aboriginal Chronic Care (IACC) talk was to introduce the IACC service now available to ALL Aboriginal clients with chronic care needs.
Breaking down the individual IACC service providers and staff, focussing on their different Chronic Care Service scope. These services include:
- NNSW LHD
- Bulgarr Ngaru Aboriginal Medical Service (Grafton)
- Bulgarr Ngaru Aboriginal Medical Service (Casino)
- Bullinah Aboriginal Health Service
- Primary Health Network
- Rekindling The spirit
- Jullums Aboriginal Medical Service
- University Centre for Rural Health
The introduction was kept brief to allow sufficient time for questions and open discussion, this was beneficial as each participant had their own client scenarios, issues and concerns.
Across the board it was welcoming and reassuring to have an Aboriginal ‘one stop shop’ to help each Practice provide a holistic, transparent and culturally appropriate chronic care plan for their patients.
Frequently Asked Questions:
- How do I refer to IACC?
- Call 1800 93 1144
- What is the Eligibility Criteria?
- Must be of Aboriginal and Torres Strait Islander descent
- Must have a chronic disease such as heart, kidney or lung disease, diabetes or cancer
- Other chronic diseases may be considered by request
- What will my client have access to?
- One contact number for all services
- Case management
- Support to go to appointments
- Support for certain medical aids
- Home visits
- Support to self-manage their condition
- How will I benefit from using the IACC program?
- One point of contact
- Consistent information about the care of client
- Management of your client’s chronic care without the need for more staff
- Coordination of case conferences
- Self-management support
- Medicare benefits from coordinated care (via MBS)
