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- 1. E V E R Y T H I N G I W I S H I K N E W … By Becca Aston A guide for students
- 2. W H E R E T O S TA R T: DON’T PANIC!?!? ! Naumov (n,d)
- 3. C A S E S T U D Y: Hello, I am Winnie* *Name has been changed for this presentation Winnie Wright 26/07/1941 82 y/o female PC – collapse 2 steps and right knee pain PMH – Registered blind, Dementia, RA, Previous fragility #’s. SHx - Patient lives with with husband in a house with stairs but did previously manage these well, usually mobilises with supervision indoors and a walking stick outdoors. Is independent with personal cares. Husband aids in assistance with meals and meds as well as household chores. No formal PoC. Have x2 helpers to come in to do the cleaning twice a week. Currently- Ao1 with wz/f short distances 23 Broadlands, Harrogate, Yorkshire, HG1 1AF Sstocker (n,d)
- 4. S C R E E N I N G T H E N O T E S
- 5. W H AT T O L O O K F O R ? Presenting Complaint: What is it they have been admitted with? Past Medical History: Are there any conditions that could potentially have any contraindications you should be aware of? Social History: Includes elements of patients lives including; smoking, alcohol use, drug use, and employment data (Walsh & Elhadad, 2014) as well as housing, previous PoC etc. Previous PT/OT input:
- 6. P H Y S I C A L A S S E S S M E N T
- 7. 1) CLARIFY THE Social Hx 2) ASSESS the most likely method of transfer 3) ASSESS strength and RoM / Transfer and mobilisation ability 4) SET expectations - Equipment - Access - Support - PMH What equipment will the patient likely need to transfer safely Of areas identified that require rehabilitation and establish baselines - How many sessions there will be /week. - What is likely to be achievable - What input is required from them 5) IDENTIFY goals - Work out what it is your patient wants to achieve - How are you going to achieve this - Are they SMART DOESN’T HAVE TO BE IN THIS ORDER BUT IT IS A STRUCTURE TO FOLLOW.
- 8. C A S E S T U D Y / Sstocker (n,d) So what would we do with Winnie upon meeting for the first time?
- 9. G O A L S E T T I N G
- 10. M A K I N G TA R G E T S S M A R T S M A R T P E C I F I C E A S U R A B L E C C E P T E D E A L I S T I C I M E - B O U N D
- 11. S A F E G U A R D I N G
- 12. W H A T A R E S A F E G U A R D I N G I S S U E S A N D W H A T T Y P E S A R E T H E R E ? Types of Abuse PHYSICAL ABUSE DOMESTIC ABUSE SEXUAL ABUSE PSYCHOLOGICAL / EMOTIONAL ABUSE FINANCIAL ABUSE MODERN SLAVERY DISCRIMINATOR Y ABUSE ORGANISATION AL ABUSE (SCIE, 2015)
- 13. N E G L E C T A N D S E L F N E G L E C T NEGLECT SELF NEGLECT
- 14. G E T T I N G T H E F A M I LY I N V O LV E D Fakhry et Mohammed 2022 found by analysing 225 surverys of patients that the impact of family presence and found it improved healthcare outcomes both psychologically and physically. We can encourage family involvement with the consent of the patient in multiple ways whether this be through being involved in patients goal setting, helping with discharge planning or as simple as bringing in a patients clothes and talking to them. PJ paralysis EndPJparalysis has become a global movement and it aims to improve patient dignity and encourage physical activity by encouraging patients to get out of bed and create a routine. It has been found that 10 days of bed rest can decrease muscle mass by up to a kilo. By involving the family and asking them to simply bring in clothes for the patient to wear can provide routine and motivation which will benefit their rehabilitation as we reduce to the amount of sedentary behaviours in the acute setting. - In winnies case it has been deemed there are no safeguarding issues.
- 15. R E F E R R A L S O N T H E W A R D
- 16. Referrals are important on the ward and allow patients to get the most out of the therapy we can provide. - Orthotics - Dietician - SaLT - GP - Social Worker - Pharmacist - Occupational Therapy AND MANY MORE.
- 17. C A S E S T U D Y / Sstocker (n,d) What Referrals would Winnie benefit from?
- 18. E Q U I P M E N T
- 19. C O M M O N E Q U I P M E N T U S E D T O A I D I N M O B I L I S A T I O N A N D T R A N S F E R S .
- 20. C A S E S T U D Y / Sstocker (n,d) What equipment may be appropriate for Winnie?
- 21. D I S C H A R G E P L A N N I N G :
- 22. D I S C H A R G E PAT H W AY S P A T H W A Y 0: No additional support needed. A patient can return to usual residence (can include a care home) Fully independent – no additional support required OR restarting of existing services P A T H W A Y 1: Additional support at home/ usual residence. Assessment and some additional care and support is needed including; therapy, equipment, care support workers Safe to be at usual residence (with extra support) P A T H W A Y 2: Rehab +/- Reablement om a temporary bedded setting Includes a specialist rehab bed includes short-term bedded rehab. Not safe to be at usual residence Patient is transferred to a non acute bed for rehabilitation and assessment until safe to go home. NHS (2015)
- 23. D I S C H A R G E PAT H W AY S P A T H W A Y 3: Complex Patient has significant health +/or social care needs and requires a longer term placement this may be new or require significant changes to the PoC already in place. Patient is transferred to a new long-term or assessment bed or usual residence to receive complex support D I S C H A R G E T O A S S E S S (D2A): Occurs after pathway 2 or after a stay on an acute ward where a patient is transferred to their usual residence with care staff to assess if they will be able to cope at home and what support they might need. O T H E R: Neighbourhood Teams = community rehab Fast track = for end of life patients with up to 3 months to live Rapid discharge = very limited length of life - Can be to a hospice or home dependent on patients wishes.
- 24. P O C O R R E A B L E M E N T ? ? ? Reablement - Free service - Ao1 - Up to 6 weeks of support visiting up to 4x/day - Specially trained carers - For patients who had not before admission had a previous PoC. - PT/OT referral Package of Care (PoC) - Ao2 / 24hr care / have had previous reablement - Safeguarding and social concerns can influence the type of reablement they get - Up to 4x/day unless specialist medical requirements - Referred or allocated a Social Worker by other members of MDT - Can be organised privately as well
- 25. C A S E S T U D Y / Sstocker (n,d) Should Winnie be offered Reablement or a standard PoC?
- 27. A N Y Q U E S T I O N S ?
- 28. R E F E R E N C E S : • Naumov, E. (n.d.) Scared and Panicked Young Man Sceaming Desperately, Emotional Guy Afraid of Something Vector Illustration on a White [Online image]. Available from: <https://www.dreamstime.com/scared-panicked-young-man-creaming-desperately-emotional-guy-afraid-something-vector-illustration-isolated-white-image129923421> [Accessed 27 May 2023]. • sstocker (n.d.) Old Woman with Cane [Online image]. Available from: <https://stock.adobe.com/images/old-woman-with-cane/98622575?start-checkout=1&content-id=98622575> [Accessed 27 May 2023]. • NHS (2015) QUICK GUIDE: DISCHARGE to ASSESS TRANSFORMING URGENT and EMERGENCY CARE SERVICES in ENGLAND [Online]. NHS, pp. 1–12. Available from: <https://www.nhs.uk/NHSEngland/keogh-review/Documents/quick-guides/Quick-Guide-discharge-to-access.pdf> [Accessed 28 May 2023]. • SCIE (2020) Reablement: A Guide for Carers and Family [Online]. Social Care Institute for Excellence (SCIE). Available from: <https://www.scie.org.uk/reablement/what-is/carers-family#:~:text=The%20reablement%20approach%20supports%20people> [Accessed 28 May 2023]. • Walsh, C. & Elhadad, N. (2014) Modeling Clinical Context: Rediscovering the Social History and Evaluating Language from the Clinic to the Wards. AMIA Joint summits on Translational Sciences [Online], 20 (14) April, pp. 223–231. Available from: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4333691/> [Accessed 30 May 2023]. • SCIE (2015) Safeguarding Adults: Types and Indicators of Abuse [Online]. Social Care Institute for Excellence (SCIE). Available from: <https://www.scie.org.uk/safeguarding/adults/introduction/types-and-indicators-of-abuse> [Accessed 7 June 2023]. • NHS (2022) Community Orthotics - Overview [Online]. Guy’s and St Thomas’ NHS Foundation Trust. Available from: <https://www.guysandstthomas.nhs.uk/our-services/community-orthotics> [Accessed 11 June 2023]. • Giladi.N,Manor.Y,Hilel.A,Gurevich.T(2014)Interdisciplinary Teamwork for the treatment for People with Parkinson’s disease and their families.Current Neurology and Neuroscience Reports.[Online],14(September),Available from:< https://link-springer-com.leedsbeckett.idm.oclc.org/article/10.1007/s11910-014-0493-1> [Accessed 8th November 2022]. • NHS (2015a) General Practitioner [Online]. Health Careers. Available from: <https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/general-practitioner#> [Accessed 11 June 2023]. • NHS (2021) Speech and Language Therapist [Online]. Careers in Learning Disability. Available from: <https://learning-disability.hee.nhs.uk/careers/find-a-role-to-suit-you/allied-health-professions-ahps/speech-and-language-therapist/> [Accessed 11 June 2023]. • NHS (2018) Community Pharmacist - Pharmacy Careers. Pharmacy Careers [Online]. Available from: <https://careersinpharmacy.uk/job-roles/community-pharmacist/> [Accessed 11 June 2023]. • Estrany-Munar, M.-F., Talavera-Valverde, M.-Á., Souto-Gómez, A.-I., Márquez-Álvarez, L.-J. & Moruno-Miralles, P. (2021) The Effectiveness of Community Occupational Therapy Interventions: A Scoping Review. International Journal of Environmental Research and Public Health [Online], 18 (6) March, p. 3142. Available from: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8002958/> [Accessed 11 June 2023]. • Physiopedia (2022) Transfer Aids [Online]. Physiopedia. Available from: <https://www.physio-pedia.com/Transfer_Aids> [Accessed 11 June 2023]. • Tessier, A., Beaulieu, M.-D., Mcginn, C. A. & Latulippe, R. (2016) Effectiveness of Reablement: A Systematic Review. Healthcare policy = Politiques de sante [Online], 11 (4) May, pp. 49–59. Available from: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4872552/> [Accessed 11 June 2023]. • Banovic, S., Zunic, L. & Sinanovic, O. (2018) Communication Difficulties as a Result of Dementia. Materia Socio Medica [Online], 30 (2) October, p. 221. Available from: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6195406/> [Accessed 11 June 2023]. • Fakhry, M. & Mohammed, W. E. (2022) Impact of Family Presence on Healthcare Outcomes and Patients’ Wards Design. Alexandria Engineering Journal [Online], 61 (12) December, pp. 10713–10726. Available from: <https://www.sciencedirect.com/science/article/pii/S1110016822002897> [Accessed 11 June 2023]. • Crabtree, A., Lane, T. J., Mahon, L., Petch, T. & Ekegren, C. L. (2021) The Impact of an End-PJ-Paralysis Quality Improvement Intervention in Post-Acute Care: An Interrupted Time Series Analysis. AIMS Medical Science [Online], 8 (1) February, pp. 23–35. Available from: <https://www.aimspress.com/article/doi/10.3934/medsci.2021003?viewType=HTML> [Accessed 11 June 2023]. • Vermunt, N., Elwyn, G., Westert, G., Harmsen, M., Olde Rikkert, M. & Meinders, M. (2019) Goal Setting Is Insufficiently Recognised as an Essential Part of Shared Decision-Making in the Complex Care of Older Patients: A Framework Analysis. BMC Family Practice, 20 (1) June. • White.N.D,Bautista.V,Lenz.T,Cosimano.A(2020)Using the SMART-EST Goals in Lifestyle Medicine Prescription.American Journal of Lifestyle Medicine[Online]14 3(February),pp.271-273.Available from:< https://journals-sagepub-com.leedsbeckett.idm.oclc.org/doi/10.1177/1559827620905775> [Accessed 16th November 2022]. • •
Editor's Notes
- So its your first day and you have bigged up your skills a little too much to your educator and now they have given you your own patient. OH DEAR First things first don’t panic I will walk you through patient assessment, treatment planning and discharge with help from…
- I would like to introduce Winnie. Winnie is an 82 year old lady who has suffered an unwitnessed fall and collapse down 2 steps and now has R knee pain. She is registered blind, has early onset Dementia, RA and previous fragility fractures. She lives with her husband in a 2 story house with stairs which she previously managed well, usually mobilises with supervision indoors and a walking stick outside of the house. Is independent with personal cares and husband aids in assistance with meals, meds and household chores. No formal PoC but she does have x2 helpers that attend to help with cleaning twice a week. She has been referred to the assessment and rehab team for ongoing treatment. She is currently mobilising with a wz/f and Ao2 over short distances.
- Where to start looking, What is it I need to treat this patient.
- So what is it we are looking for? First things first What is it that they were admitted for? What is their presenting complaint? You can find this in places such as: Community Referral notes, YAS admission form, PT/OT/Dieticians etc. one click on PPM. It is important you look at their PMH: This is because PMH can have effect on their current condition and the treatment options available to you. For example a patient with previous episodes of postural hypotension you will need to take increased precautions in assessment when changing their position. Social History: A patients social history includes: smoking, alcohol use, drug use, and employment data (Walsh & Elhadad, 2014) as well housing and previous PoC. It is important to know this as factors such as smoking can have an effect on a patients performance but similarly housing and any previous help they were receiving has an effect on goals they may have and discharge planning. Previous PT/OT input: Can give you a baseline and an area to begin your assessment.
- NEED A STUDY ABOUT SETTING STANDARDS STUDY ABOUT GOAL SETTING AND SMART TARGETS
- To begin with we would screen Winnies notes and establish the PC, PMH, as much of the SH we can as well as current mobilisation status. As we know Winnie has recently been diagnosed with dementia and Banovic et al 2018 found that patients with dementia scored lower results in areas of understanding and verbal expression, meaning we may need to adapt our language for the physical exam. As well as this having an understanding of her PMH and mobility status will help us plan for the assessment. In the Physical Assement: It would be wise to assess transfer ability, is a patient able to move from lying to sitting, sitting to standing and so forth this is the safest way as we assess as a patient as we slowly increase the level of difficulty. In the PA we are looking for a patients ability to transfer and mobilise and their methods of doing this and assessing their falls risk. Common risk factors for an increased falls risk include Visual impairment (which Winnie has), reduced strength, impaired balance for a variety of reasons, fear etc. We would talk to Winnie about her goals and if she is assessed to have capacity involve her in discharge planning as well as involving her husband Post assessment we would make decisions regarding her mobility on the ward and update the board by the bedside and the nursing staff this is important as Muusse et al 2023 found that the quality of interprofessional communication effected a patients falls risk.
- SMART GOAL: S- They must be specific to the patient you are setting them for. M - These goals will be measurable in order for changes to be monitored A – The patient must accept these goals. Vermunt et al 2019 FOUND Shared Decision Making in the form of goal setting should be used to engage patients. Finding engaged patients had better health related outcomes when actively involved in their rehab. Patient centred goal setting R – They must be attainable to maintain motivation T – Having a set time allows for goals to be achieved as it gives a point to aim for. Allowing for clear understanding between practitioners and patients; whilst ensuring goals are both realistic and attainable (White et al. 2020
- Safeguarding is a major part of the healthcare role to keep our patients safe
- EXAMPLES: Physical Abuse – Signs – unexplained bruises, falls or injuries with no explanation or inconsistencies. Sexual Abuse - Can be psychological, physical, sexual, financial or emotional Psychological or Emotional Abuse- Enforced social isolation, failure to respect privacy, preventing expression of choice Financial Abuse – Taking unlawful control over someone’s finances, property and possessions Signs of this include someone unable to maintain lifestyle, unexplained withdrawel from accounts Modern Slavery – Signs of physical or emotional abuse, appearing malnourished, isolation from the community Discriminatory Abuse- Unequal treatment based on age, gender, race etc. can express anger, frustration, fear or anxiety Organisational Abuse - Inadequate staffing, lack of respect for dignity and privacy, not providing adequate food and drink
- NEGLECT : Failure to provide access to food, shelter, clothing, heating or medical care Refusal of access to visitors Isolation Preventing access to glasses, hearing aids, dentures etc. Failure to administer medicine as required SELF NEGLECT: Very poor personal hygiene Lack of food Malnutrition / Personal hygiene Hoarding NEED TO DESCRIBE WHAR IS BOTH
- SO WE HAVE COMPLETED AN INITIAL ASSESSNEBT AND WE ARE BEGINNING TO CREATE A TREATMENT PLAN AND WERE THINKING WHO ELSE SHOUDL BE INVOLVED IN THIS PATIENTS THERAPY What would this patient benefit from the most?
- These are but a few examples of the MDT members on the team that are work in a joined collaborative way to provide holistic care to patients.
- Role of Orthotics - To treat a variety of conditions of both neurological and musculoskeletal in nature. Aiming to support unstable joints, reduce pain and can come in a range of forms such as footwear or insoles etc. they are specially made for the patient. Role of Dieticians – Working with patients to ensure proper nutrition by assessing calorie needs, healing, energy as well as PMH and PC. They do this by creating meal plans and giving patients supplements as well as advise. TO HELP WINNIE IN THE HEALING PROCESS AND TO REGAIN STRENGTH Role of SaLT – Help identify speech, language, communicational, swallowing needs of a patient and have to balance quality of life and safety of the patient. Working closely with all members of the MDT to improve position and ensure proper nutrition. – DEMENTIA PATIENTS OFTEN STRUGGLE WITH COMMUNICATION AND ALSO FUNCTIONS SUCH AS SWALLOWING IN LATER STAGES Role of GP – Are to treat all common medical conditions and refer patients to other medical services and help establish and diagnose conditions. – CAN OFFER REFERRALS AND SUPPORT TO OTHER MEMBERS OF THE MDT BASED ON THE PRESENTATION OF WINNIE Role of Pharmacist – To dispense medications and advise patients on taking these medications for example the use of a dosit box. - TO HELP THEM AND THEIR CARERS MANAGE MEDICINES AS WELL AS ASSESSING FOR APPROPRIATE MEDICATION THAT CAN HELP THOSE WITH DEMENTIA. Role of SW- A social worker can provide services to benefit everyone involved, reducing the strain on the primary carer and the patient for example providing home help Role of OT - The Community Occupational Therapy interventions to reduce the risk of falls and enhance the performance of activities of daily life in older people by providing equipment and assessing the home to allow QoL to improve.
- We would aim to get Winnie back to her baseline but a functional assessment will allow us to decide what is the safest method of transfer for example using a zimmer frame and then as therapy progresses moving back to the stick if appropriate.
- The difference between reablement and PoC/ REABLEMENT = Is a free service that is provided to patients who are up to Ao1 to mobilise and have not previously had a package of care. It can be provided for up to 6 weeks and specially trained carers that are used to support patients to retrain and relearn skills and confidence to become independent and manage post reablement after a period of illness. It is only available for patients who have not previously had a package of care prior to admission. PACKAGE OF CARE= Is a support plan normally for patients who are AO2 but can be Ao1,are for 24hr care, have had previous reablement or there is safeguarding / social concerns surrounding their discharge. Carers can be recruited suitable for a patients needs and visit generally up to 4x/day unless there is specialist medical requirements. They are generally organised by social workers which they can be referred to by other members of the MDT, however this can also be done privately.
- Winnie has not previously had a PoC before admission so she would be likely accepted by reablement due to this and she is Ao1 so would fall into the criteria. Allowing her receive goal orientated support will aid both herself and her husband to manage and assess needs in the long term particularly as she has dementia and it is likely needs will also increase in relation to the development of the disease. Tessier et al 2016 analysed 10 studies comprising of a total of 14,742 participants and found that reablement had a positive impact on health related quality of life and service utilization. 7/10 considered reablement to be either excellent or good quality. It has found to have a positive effect on functional capacity and allowed patients to require minimal to moderate assistance with their ADL’s something that Winnie will benefit from.