Case Study | Clinical Reasoning: Home or Hospital?

By Jamie Grant, Occupational Therapist; Director, The Occupational Therapy Hub



Service type/setting: Acute care rapid response service; community home visit.

Assessment type: Initial, completed by an Occupational Therapist and Nurse.



History

  • 'Claire' (name changed for confidentiality) was referred by paramedics and district nurses (DN), due to a non-injury fall, with a long lie of approximately 12 hours. DN was visiting for routine wound care - dressing of right lower limb stump (Claire is an amputee)

  • Referred for clinical monitoring, venepuncture (blood sampling), falls assessment, mobility and transfers assessment, safety and welfare check

  • Past medical history (PMH): Below knee amputee (right leg); fracture of thoracic vertebrae; chronic osteomyelitis; previous cellulitis; hypothyroidism, chronic kidney disease (CKD) stage 3; past right frozen shoulder

  • Medications: Levothyroxine, paracetamol, tramadol, alendronic acid

  • Falls assessment: Required

  • Cognitive screening: Required

  • Has mental capacity to give consent for assessment and intervention




Social and Environmental Background


Claire lives alone in a two-storey house. She has no package of care or piper alarm. A local friend comes in to support her with house tasks, on an ad-hoc basis.


Claire has a prosthesis for her lower right limb. She normally uses a collapsible zimmer frame to mobilise around the ground floor and there is a two-wheeled walking frame (2WW) upstairs. Stair lift and key safe in situ. There is no bathroom downstairs. No central heating in property.



Other equipment/aids in place: Walking stick, outdoor four-wheeled walker (4WW), outdoor scooter, 1/2 step into kitchen, helping hand aid, bathroom perching stool, female urinal bottles upstairs, chair raisers on sofa, grab rail by stepped entrance to kitchen and by toilet.



Initial Acute Examination


Access to property via keysafe. On arrival, Claire was sat on her sofa. She was alert, but appearing muddled; unsure if she went to bed last night. Her medication was reconciled against the GP summary. She stated she only takes paracetamol. She has not been taking tramadol, as this makes her sleepy; feels she does not need to take levothyroxine.





Cardiac
  • Sitting blood pressure reading: 102/80

  • Pulse rate: 83 beats/min (regular)

  • Capillary refill time: 2 seconds

  • No chest pain, no heart palpitations, no dizziness

  • Mild oedema up to knee, not pitting; prosthesis on right leg

Respiratory
  • Rate of respiration: 20/minute

  • Peripheral blood oxygen saturation (on room air, at rest): 96 %

  • No breathlessness, no cyanosis

  • Dry cough


Abdominal
  • Acute Kidney Injury (AKI) risk score: 3 - medium

  • Prompted 200mls of water and 100mls of tea. To increase frequency of visits to three times daily (TDS), for fluid and food prompt, plus welfare check.

  • No abdominal pain, no nausea, no vomiting, no diarrhoea, not constipated

  • No genitourinary pain

  • Bowels last open: This morning, during visit

  • Continence: Bladder and bowels fully continent

  • Dietary and fluid intake: Claire had not eaten today, due to inability to rise from chair. She was encouraged to have cup of tea, 200mls of water and and two biscuits during visit. Bi-weekly cleaner entered property as rapid response team left, providing porridge, toast and tea.


Neurological
  • Consciousness level: Alert

  • Known confusion; unsure of the year, next of kin (NOK) states this isn't a new problem for her

  • No FAST symptoms (stroke: Face, Arms, Speech, Time)

  • Neurological pain: Long-term chronic pain over right stump; taking paracetamol for this

  • No obvious head injury from fall; no numbness or obvious weakness

  • Pupils equal and responsive to light (PEARL)

  • Memory concerns identified on this visit; will require a cognitive screen

  • Loss of confidence? With mobility and transfers; worried about falling and about prospect of potential hospital admission

  • Declining hospital admission; anxious about hospital

Exposure
  • Tympanic temperature: 36.8 degrees Celsius

  • Blood glucose level: 5.6 mmol/L

  • Evidence of injury/wounds: Right leg stump wound; known to DNs



National Early Warning Score (Royal College of Physicians): 1



Musculo-skeletal
  • Musculoskeletal pain score: No pain on sitting, but raised to 4/10 on weight-bearing and walking with zimmer frame

  • Current falls history: Has had a fall within the last week; family had to pick her up from the floor. Also fell on floor yesterday, with a long lie of 12 hours

  • Falls in last year: 2 - Multi Factorial Risk Assessment (MFRA) required

  • Pain comments: Complaining of pain, predominantly in right lower limb, in contact with prosthesis. Claire also reports pain in right shoulder, from an historical fall


Skin and Waterlow pressure scale
  • Waterlow pressure sore risk score: 14

  • Examination of skin: No pressure injuries identified

  • Positioning: Claire needs assistance to move (details below). She sits out during the day and repositions every four hours. Rapid response team unsure if Claire has been to bed in the last few days.

  • Incontinence: No issues identified

  • Nutrition: No concerns

  • Malnutrition universal screening tool (MUST) score: 0/6; repeat in 4-6 months



Mobility / Functional Mobility / Transfers


Mobility Assessment

Claire was mobile with aid of a collapsible walking zimmer frame (WZF). She walked slowly, using her prosthesis. Very slow pace and shuffling gait. Trailing left leg as she was unable to put full weight on right (prosthetic) leg with ease. Nonetheless, steady and able to navigate around doorways, from living room to stair lift and top of stair lift to toilet. Claire returned very slowly along first floor landing, with increased speed on return to her living room.



Transfer Assessment

On initial assessment of standing and mobility, it was difficult for Claire to transfer from her sofa. Multiple attempts, requiring much time. Reassurance given, verbal and light physical support of one to stand. Sofa has only one arm support that does not extend to front of sofa; ease of weight bearing in right arm compromised. Sit-to-stand transfer from top of stair lift was completed with greater ease and in reduced time, compared to sofa transfer; arm rests helping here. Final transfer assessment in armchair; multiple attempts and physical assistance of one to stand.


Stairs Assessment


Claire has a stair lift in her two-storey house. It doesn't swing round when downstairs, staying sideways, meaning she has to step onto stairs to sit down. Staircase has a banister on right hand side; Claire uses this to help get onto her stair lift.









Personal Care Assessment

Claire stated that she normally has a strip wash at the sink in her kitchen, sat on an existing low stool. She has a perching stool with back support; this could be brought downstairs for washing. She was able to sit down on first floor toilet; opened her bowels and passed urine. Claire initially needed to readjust her buttocks, due to high toilet seat. She may benefit from a toilet frame. Use of existing right-sided grab rail was used to stand, but she relied on pushing off her seat and the nearby sink.



Kitchen Assessment

Claire has a friend who does her food shopping for her. There were microwave meals in situ during this visit. She stated she can make her own meals. She may benefit from a kitchen assessment on the next home visit.


Falls Assessment
  • Claire has refused hospital admission. CURB: She can communicate, understand, retain and balance information about this decision.

  • No continence issues, no frail skin/pressure area issues, no weight loss or appetite issues

  • History of falls/recent fall: 2 falls in last year

  • Mobility issues: Struggling with ADLs due to pain and reduced mobility

  • Medication issues: Taking more than 4 medications (increased falls risk)

  • Cognitive concerns: Gradual reduced cognition/memory

  • Environmental/social concerns: Isolation/lack of social support; temperature (cold house)

  • Risk Factors: Cognitive concerns; pain that affects function

  • Management Plan: Advise adequate and regular paracetamol; gain consent to a cognitive/memory screening


Clinical frailty scale (Canadian Study of Health and Aging): 7




Shared decision making

The rapid response team's Occupational Therapist and Nurse have raised concerns about Claire being at home alone. This is due to her inability to complete safe transfers without support - and therefore current inability to access food and fluids with ease. The team discussed options of hospital admission (to provide short-term support, therapy and clinical review) and getting more social support at home. The risks of not going into hospital were clearly explained to Claire. She was able to talk these back with the team and has mental capacity to refuse hospital.

Claire declined hospital admission, despite the Nurse's recommendation to be admitted. Therefore a decision was made to take bloods (as below), bring out a commode for downstairs and return for a clinical and mobility review.



Venepuncture

Blood taken by registered nurse, on visit with the Occupational Therapist.


  • Bloods taken from Right Antecubital fossa; two attempts required to take blood; hand hygiene guidelines followed when undertaking this procedure

  • Blood tests requested: Full Blood Count, Serum C reactive protein level, Calcium Group, Liver Function Tests, Serum folate, Urea and electrolytes, Vitamin B12, Thyroid Function Test

  • Results: eGFR = 23 (previously 60, 2 months ago); White Cell Count = no abnormality discovered; Urea = 13.2 (previously 9.0); Creatinine = 169 (previously 77, 2 months ago)

  • Flagged as AKI stage 1

Blood results discussed with senior nurse and physiotherapist (PT), who is due to see Claire next at teatime. Due to having a stage 1 AKI, the PT will take a fluid chart out and prompt further fluid intake. Rapid response team to continue oral fluid protocol with four-times-daily (QDS) visits to support this.



Initial Assessment Actions (Summary)

  • Clinical observations and blood glucose monitoring

  • Medication reconciliation

  • Mobility and transfer assessments

  • Skin pressure areas checked

  • Assistance with toileting on first floor

  • Discussion of commode provision; Clair not keen, but consented

  • Discussion of potential hospital admission; Claire refused and could repeat back the consequences of not going in

  • Discussion of requiring further support; she would accept more support

  • Food and fluids provided - pushed 200ml of water and 150ml of tea; porridge and toast prepared

  • Discussion with NOK (sister): Claire's sister was concerned about her home status, but unable to provide support or stay with her, due to her own Parkinson's-related challenges



Analysis


Claire has poor physical ability to complete functional transfers. This prevents independent engagement in her ADLs - particularly toileting, food preparation and washing. Barriers to her engagement in safe mobility and transfers:- Prosthetic lower limb; long lie following fall; weakness in right upper limb; lack of food or fluids; gradual but raised acute cognitive confusion; no local and reliable local support.


Claire is not able to get out of her armchair independently and declines Nurse's request for hospital admission. She has mental capacity to make this decision. The Occupational Therapist feels that - with repeat visits in the short-term - Claire may be able to resume engagement in her ADLs and other occupations at home. She will require QDS visits by the rapid response service, until her mobility and transfers improve and ongoing care arrangements are organised.




Recommendations


  • QDS double-up visits: For welfare checks, personal care support, skin checks, food and fluid provision and medication administration support - until mobility and transfers improve

  • Repeat visit today: For provision of (and assessment transferring onto) a commode, plus to repeat clinical review

  • Provision of medium 2-wheeled walking frame, for downstairs mobility

  • Provision of and assessment using toilet frame in upstairs bathroom

  • Lying to standing blood pressure monitoring, to complete falls assessment

  • Advise regular paracetamol, to help with pain when mobilising

  • Monitor and encourage fluids, due to long lie and medium AKI risk; provide food and fluids on visit, if Claire is unable to these herself

  • Assist with personal care as required

  • Mini cognitive screening

  • Kitchen assessment

  • Initiate a social care referral for reablement team or package of care support

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