2. Occupational Therapy in Emergency Medicine
2
Occupational Therapy in
Emergency Medicine
Admission Avoidance
Assessing Potential for
Safe Discharge
Rapid Assessment and Intervention
Community Liaison
Facilitate Independence
Identify Appropriate Patient
Destination Based on Current
Needs
3. Occupational Therapy in Emergency Medicine
National Service Framework for Older People (2001) called for an action plan to improve
discharge process through a more integrated multidisciplinary service
Ability to perform basic activities of daily living often overlooked
(Smith and Rees, 2004)
OTs well placed to provide assessment and intervention at time of initial admission
Addresses the unmet functional and performance needs of older adults
(Cusick, Johnson and Bissett, 2009)
3
4. 4
Occupational Therapy Role in
Emergency Medicine
Patient admitted to ED
If appropriate, patient
assessed by OT
DischargeAdmitted to ward
Patient admitted to
Medical Admissions Unit (MAU)
for further medical observation
DischargeAdmitted to ward If appropriate, patient
assessed by OT
Potential OT follow-up on
outlying ward
5. 5
Overview of Case Study
Referral
Sheila (pseudonym) – 84 years old
Admitted to the Emergency Department (ED) following a mechanical fall at home
Sustained left lower limb injury and decreased mobility
Referred to OT to assess potential for safe and appropriate discharge home from ED
Presenting Situation
No fracture sustained
Sheila currently ‘off legs’ and reportedly has been unable to weight bare since admission to ED
Past Medical History – cerebrovascular event (CVE) 4 years ago resulting in expressive dysarthria and
left sided weakness
6. Falls and Older People
Prevalence
30% of people aged over 65 and 50% of people aged 80 and over fall at least once a year
More than 600,000 people per year aged 65 and over are admitted to A&E following the result of a fall
Cost
Estimated cost to the NHS of £2.3 billion per year
Injury, pain, loss of confidence, emotional distress and loss of independence (Boye et al. 2013)
Often, falls go unreported and unacknowledged, preventing appropriate assessment and onward follow-
up by falls prevention services
6
(Great Britain. Department of Health, 2007; National Institute for Health and
Clinical Excellence (NICE), 2013; College of Occupational Therapists (COT), 2013)
7. 7
Assessment Process
Information Gathering
• Reviewed medical and nursing documentation
• Not awaiting further medical assessment or intervention
• Sheila medically fit for OT to assess the potential for safe
discharge home
Initial Interview
• Consent gained from Sheila for OT assessment
• Lives alone in a bungalow
• Has twice a day long term package of care to assist with personal ADL
• Reportedly mobilises with walking stick on her right side
• Independent with all transfers on and off bed, chair and toilet – has assistive
equipment to aid her
• Reportedly falls ‘often’ at home
Verification
• Contacted son who lives locally to verify information from Sheila
• He assists her with domestic ADL during the week
• Happy with Sheila’s current support from care agency
• Is worried about her frequent falls
• No other concerns about his mother’s well-being apart from her falling
and sustaining more serious injury
Assessment of Occupational Function
• Assessed Sheila’s ability to remain independent in her functional
occupations – transfers from lie to sit to stand and mobility with
front wheeled frame
• Sheila’s confidence reduced since fall and feeling more unsteady
as a result of this
• Identified how Sheila’s current function compares to her pre-
morbid level
9. 9
Occupational
Performance
Adapted from Law et al.
(1996)
Maintains core professional
values
Flexible in its approach to
addressing occupational
performance (Maclean et
al. 2012)
Demonstrates the importance of
‘interdependent interaction’ (Law et
al. 1996)
Provides a meaningful framework to
address the challenges of an acute
setting (Maclean et al. 2012)
Person
EnvironmentOccupation
Occupational
Performance
• Role
• Motivation
• Interests
• Needs
• Cultural
• Socioeconomic
• Institutional
• Physical
• Social
• Self-care
• Productivity
• Leisure
Person-Environment-Occupation Model
10. 10
Occupational
Performance
• Mobilises with support of
walking aid
• Left sided weakness – limits
occupational function
• Able to perform domestic
and personal ADL
• Has support at home from
carers to assist with ADL she
struggles with
• Independent with all
transfers – has some
assistive equipment
• Active in social community
• Motivated to go home
• Wants to remain as independent as
possible in ADL
• Feels she is managing with current levels
of support
• Has family and friends around her
• Lives in a bungalow that is
all on one level
• Has equipment to aid
occupational function
• Lives close to local
amenities
• Able to enjoy gardening
and the view from
bedroom window
• Reports falls have been a
result of left leg weakness
rather than
environmental factors
Result of the transactive
relationship between person,
environment and occupation
Maintaining the desired level
of occupational performance
(Law et al. 1996; Turpin and Iwama, 2011)
12. 12
Strengths and Needs Identified from Assessment
Mobilises independently
with aid of stick
Independent with all
functional transfers – has
assistive equipment at home
Has in place twice daily
package of care to assist
with personal ADL
Good level of support from
son
Motivated to return home
and remain as independent
as possible
Aware of own capabilities
Strengths
To regain pre-morbid levels
of occupational function
Needs
13. 13
Aims and Objectives of Occupational
Therapy Intervention
LTA
STA STA
LTO LTO
STA STA STA STA
To discharge home from ED today
LTA – Long Term Aim
LTO – Long Term Objective
STA – Short Term Aim
STO - Short Term Objective
14. 14
To discharge home
from ED today
To independently
transfer from lie to sit
within 15 minutes
To mobilise
independently up to 10
metres with support of
walking aid within 1 hour
To walk to toilet with
supervision and
complete all personal
care, within 1 hour
To independently stand
with support of walking
aid for 20 seconds
To mobilise 4 steps
from bed to chair with
support of walking aid
within 15 minutes
To mobilise up to 5
metres with supervision,
within 30 minutes
(Social Care Institute for Excellence, 2013)
To increase
confidence in mobility
To be independent with
personal transfers
To independently
transfer from lie to sit
within 15 minutes
To independently stand
with support of walking
aid for 20 seconds
To mobilise 4 steps
from bed to chair with
support of walking aid
within 15 minutes
To mobilise up to 5
metres with supervision,
within 30 minutes
16. 16
• OT to encourage independence in transfers by ensuring
the bed is lowered to appropriate height
• Sheila to transfer from lie to sit with independence. OT
to provide assistance if needed
• OT to ensure Sheila is wearing non-slip footwear
• OT to continue to advise on risk assessment and
prevention to ensure safe transfers
• OT to provide Sheila with information pack containing
information on future support services
• OT to locate front wheeled walking frame and ensure
frame is fixed to an appropriate height for Sheila
• OT to advise on safe transfer method to reduce risk of
injury or fall
• Sheila to stand and gain balance with support of walking
frame. OT to provide assistance if needed
• Sheila to stand with support of walking frame for 20
seconds
• Sheila to mobilise from chair to toilet with support of
front wheeled frame. OT to supervise
• Sheila to complete all personal care and transfer
independently from toilet. OT to assist if needed
• Sheila to mobilise back to the bed with support of front
wheeled frame. OT to supervise
• With Sheila’s consent, OT to refer Sheila to the local falls
prevention service for further support
• OT to issue front wheeled walking frame for Sheila’s
temporary use at home
• OT to contact Sheila’s care agency to inform them to re-
start package of care on discharge
• OT to advise on weight bearing technique to prevent
pain or further injury
• Sheila to mobilise to chair with supervision of OT
• Sheila to mobilise out of the bay with support of front
wheeled frame. OT to supervise
• Sheila to mobilise up to 5 metres with supervision from
OT
• OT to ensure Sheila can change direction safely by
assessing her ability in figure-of-8 walk test. OT to
monitor Sheila’s gait and balance and advise on safety
techniques
Short Term Intervention
(up to 30 minutes)
Long Term Intervention
(up to 1 hour)
Further OT Intervention
to Support Discharge
17. Intervention - Referral to Falls Prevention Service
Falls are leading cause of accident-related mortality (Jones and Whitaker, 2011)
The majority of risk factors that result in falls can be prevented
(COT, 2013; NICE, 2013)
The most effective prevention is a multifactorial falls risk assessment undertaken by a falls specialist
(Great Britain. Department of Health, 2001)
Ensures appropriate follow-up and assessment in order to reduce the risk of further falls
Shown to decrease the rate of older people falling in the community (Logan et al. 2010; Campbell and Robertson,
2013)
Further information, advice and referral is often overlooked by the MDT (Lee et al. 2013)
17
18. Further Considerations for Discharge Planning
18
MDT liaison
Contact Family
Equipment provision
Documentation
Staff nurse, ED coordinator, ED
consultant, care agency
Inform of plan for discharge,
arrange transport home
Ensure patient receives
appropriate
guidance/information
Documentation of all patient /
community contact
Subjective
Objective
Analysis
Plan
(COT, 2010; Health and Care
Professions Council (HCPC),
2012)
19. Ethical Considerations in the
Emergency Department
Intervention carries higher risk due to the emergency nature of patient presentation
Important to respect the patients wishes even if it contradicts your planned intervention
Family dynamics
Duty of care to all people (Mid Staffordshire NHS, 2013)
19
‘The Standards of Conduct, Performance and Ethics’ (HCPC, 2012)
20. 20
Policy and Best Practice Guidelines:
Informing Practice
Relevant National Policy
National Institute for Health and Clinical Excellence Guidelines for the Assessment and Prevention of
Falls in Older People (2013)
National Service Framework for Older People. Standard six: Falls (Great Britain. Department of Health,
2001 - Modified 2008)
Best Practice Guidelines
Urgent Care Pathways for Older People with Complex Needs – Falls Care Pathway (2007)
College of Occupational Therapists Falls Management Guidance (2013)
21. Ongoing Assessment and
Outcome Measurement
No standardised occupational therapy outcome measures used on a regular basis in this setting
Not widely used in ED due to the short period of time spent with patients
(Cusick, Johnson and Bissett, 2009)
This despite evidence that standardised assessments contribute to a more holistic approach to risk
identification in acute hospital settings
(Robertson and Blaga, 2013)
Barthel Index of Activities of Daily Living and Functional Status Assessment of Seniors in the Emergency
Department (FSAS-ED) can more reliably determine the current occupational function of older adults in ED
(Veillette et al. 2009; Bissett, Cusick and Lannin, 2013)
21
22. Ongoing Assessment and
Outcome Measurement
22
• Observational assessment throughout
intervention
• Continuous assessment of occupational
function
Ongoing Assessment
• Achieving identified aims and
objectives
• Completion of Goal Attainment Scale
Outcome
Measurement
Potential Considerations
for Future
Cognitive Assessment
• Neurological Screen
• Abbreviated Mental Test Score
• Montreal Cognitive Assessment
Further functional assessment and
outcome measurement
• Barthel Index of Activities of Daily
Living
• FSAS-ED
Methods Used
(Mahoney and Barthel, 1965; Veillette et al.
2009; Quinn, Langhorne and Stott, 2011)
23. 23
Discharge Summary and Conclusion
OT Process – utilising core
skills
Person-centred in my
approach
Identified strengths and
needs for safe, effective
discharge planning
Achieved the aims and
objectives of intervention
Facilitated independence at
home
26. References
Bissett, M., Cusick, A. and Lannin, N.A. (2013) ‘Functional assessments utilised in emergency
departments: a systematic review’, Age and Ageing, 42(2), pp.163-172.
Boye, N., Van Lieshout, E., Van Beeck, E., Hartholt, K., Van der Cammen, T. and Patka, P. (2013)
‘The impact of falls in the elderly’, Trauma, 15(1), pp.29-35.
Campbell, A.J. and Robertson, M.C. (2013) ‘Fall prevention: single or multiple interventions?
Single interventions for fall prevention’, Journal of the American Geriatrics Society, 61(2), pp.281-
287.
College of Occupational Therapists (2010) Code of ethics and professional conduct [Online].
Available at: http://www.cot.co.uk/sites/default/files/publications/public/Code-of-
Ethics2010.pdf. (Accessed: 15 June 2014).
College of Occupational Therapists (2013) Falls management. London: COT.
26
27. 27
Cusick, A., Johnson, L. and Bissett, M. (2009) ‘Occupational therapy in emergency departments:
Australian practice’, Journal of Evaluation in Clinical Practice, 15(2), pp.257-265.
Great Britain. Department of Health (2001) National Service Framework for older people
[Online]. Available at: http://www.apllg.eu/resources/NSF+for+Older+People.pdf. (Accessed:
12 June 2014).
Great Britain. Department of Health (2007) Urgent care pathways for older people with complex
needs: best practice guidance [Online]. Available at: http://www.em-
online.com/download/medical_article/36261_Older%20People%20Complex%20Needs.pdf.
(Accessed: 12 June 2014).
Health and Care Professions Council (2012) Standards of conduct, performance and ethics
[Online]. Available at: http://www.hpc-
uk.org/assets/documents/10003B6EStandardsofconduct,performanceandethics.pdf.
(Accessed: 15 June 2014).
Jones, D. and Whitaker, T. (2011) ‘Preventing falls in older people: assessment and
interventions’, Nursing Standard, 25(52), pp.50-55.
28. 28
Law, M., Cooper, B,. Strong, S., Stewart, D., Rigby, P. and Letts, L. (1996) ‘The Person-
Environment-Occupation Model: a transactive approach to occupational performance’,
Canadian Journal of Occupational Therapy, 63(1), pp.9-23.
Lee, D., McDermott, F., Hoffman, T. and Haines, T. (2013) ‘They will tell me if there is a problem’:
limited discussion between health professionals, older adults and their caregivers on falls
prevention during and after hospitalization’, Health Education Research, 28(6), pp.1051-1066.
Logan, P., Coupland, C., Gladman, J., Sahoto, O., Stoner-Hobbs, V., Robertson, K., Tomlinson, V.,
Ward, M., Sach, T. and Avery, A. (2010) ‘Community falls prevention for people who call an
emergency ambulance after a fall: randomised controlled trial’, British Medical Journal, 340.
[Online] DOI: http://dx.doi.org/10.1136/bmj.c2102. (Accessed: 13 June 2014).
Maclean, F., Carin-Levy, G., Hunter, H., Malcolmson, L. and Locke, E. (2012) ‘The usefulness of
the Person-Environment-Occupation Model in an acute physical health care setting’, British
Journal of Occupational Therapy, 75(12), pp.555-562.
Mahoney, F.I. and Barthel, D.W. (1965) ‘Functional evaluation: the Barthel Index’, Maryland State
Medical Journal, 14, pp.61-65.
29. 29
Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) Report of the Mid
Staffordshire NHS Foundation Trust public inquiry: Executive summary (House of Commons
Papers 947). London: The Stationary Office.
National Institute for Health and Clinical Excellence (2013) Falls: assessment and prevention
of falls in older people. Manchester: NICE.
Quinn, T.J., Langhorne, P. and Stott, D.J. (2011) ‘Barthel Index for stroke trials: development,
properties, and application’, Stroke, 42, pp.1146-1151.
Robertson, L. and Blaga, L. (2013) ‘Occupational therapy assessments used in acute physical
care settings’, Scandinavian Journal of Occupational Therapy, 20(2), pp.127-135.
Smith, T. and Rees, V. (2004) ‘An audit of referrals to occupational therapy for older adults
attending the accident and emergency department’, British Journal of Occupational
Therapy, 67(4), pp.153-158.
30. 30
Social Care Institute for Excellence (2013) Maximising the potential of reablement:
the importance of goal-setting. Available at:
http://www.scie.org.uk/publications/guides/guide49/goalsetting.asp. (Accessed: 15 June
2014).
Turpin, M. and Iwama, M. (2011) Using occupational therapy models in practice: a field
guide. London: Churchill Livingstone Elsevier.
Veillette, N., Demers, L., Dutil, E. and McCusker, J. (2009) ‘Item analysis of the functional
status assessment of seniors in the emergency department’, Archives of Gerontology and
Geriatrics, 31(7), pp.564-572.
Editor's Notes
Humanistic and Compensatory frames of reference - synthesise
