By Jamie Grant - Occupational Therapist; Director, The Occupational Therapy Hub
Miss B was referred to the rapid response team following acute back, hip and groin pain, akin to symptoms experienced after past fall. I was able to support the patient on four visits, despite the short-term nature of the rapid response service. This was due to her reported increased pain levels, requiring longer input. Assessment and interventions were carried out by occupational therapists, a physiotherapist and a support worker.
History of presenting condition
Referral to our team, following acute pain in hip, left groin and lower back, which began a fortnight ago. Decreased mobility as a result. Prior to pain onset, Miss B stated she was very independent and would regularly walk her dog. A recent X-ray ruled out a fracture, indicating an osteophyte* and a sub-chondral cyst** on her acetabulum.
*osteophyte (bone spur) = small bone prominence, developing in joints damaged by arthritis
**sub-chondral cyst = sac filled with fluid, protruding from joints, that causes pain
Past medical history + current medication
Fell 4 years ago, resulting in pain from thigh to pelvis
Arthritis in hand
On morphine, tramadol, paracetamol, omeprazole
Flushed skin; reduced appetite, with little fluid or food eaten today
Pain score = 10/10. On tramadol, as prescribed
Blood glucose level = 6.3 mmol/l
Clinical Frailty Scale (Canadian Study on Health and Ageing, 2008) = 6/9
Falls assessment: Not required (no falls in the last 12 months)
Mobility and transfers
Use of walking stick for mobility from bed to toilet and with stairs.
Furniture walking observed downstairs, from stairs to kitchen.
National Early Warning Score (NEWS)
BP = 150/70 (left arm, sitting), 142/90 (left arm, standing); no postural drop
HR = 84 regular
Not symptomatic – no chest pains, palpitations or dizziness reported
Respiratory rate = 18/min
Oxygen saturation = 97% (at rest, on air)
No shortness of breath or cough observed
Some wind with abdominal pain
Patient vomited yesterday
Bowels last opened 1 hour prior to visit, previously 4 days ago
Continence: Not previously incontinent; recent urges to urinate; no other symptoms
Patient alert and oriented to time, place and rapid response staff visiting
No FAST symptoms observed
Patient reported reduced muscle strength; no sensory alteration
Mood: Settled, patient reported to feeling OK in herself
FAIRI (cognitive) assessment: Not required, no signs of dementia observed during visit
No injuries, cuts, wounds or bruising observed
SSKIN assessment: Heels, elbows and buttock skin all healthy
Waterlow Pressure Ulcer Risk Assessment and Intervention Tool: Score = 19 (Amber)
Temperature = 37.4 degrees Celsius
NEWS SCORE = 0
Occupational therapy initial assessment
Physical Slight in stature; able to mobilise using stick, although frequently furniture walks; patient has macular degeneration, although this is not currently severe enough to limit daily activities; arthritis in hand.
Cognitive No cognitive deficit observed.
Stable mood. However, frustration displayed, due to reduced occupational performance and unclear cause of current pain.
Western societal upbringing, values independence.
Patient condition not impacting on her ability to communicate verbally/physically.
2-storey house; 1 step up to property; 1 flight of stairs, rail on right side (ascending); upstairs bath, no shower fixings; upstairs toilet only; kitchen with dining table; double bed; adequate lighting and ventilation.
Lives alone. No current family support or package of care. Previously independent with ADLs/IADLs/mobility. Currently supported in meal preparation by two neighbours. Appears to have a close relationship with them, who look out for her. Owns a dog.
Patient has private health insurance, which may allow for more rapid access to hip replacement treatment. However, this would not include occupational therapy provision.
Currently independent in eating, dressing, strip washing and accessing the toilet. However, pain is limiting patient speed and ease with ADL occupations. Meal provision is supported by neighbours. Previously independent with all self-care and IADLs.
Retired. Currently reliant on neighbours to assist with house chores. Usually does her own clothes washing, house cleaning.
Currently limited, as restricted to her house and bed. Usually enjoys an active and independent lifestyle, including walking her pet dog.
Mobility and transfers preparing breakfast - coffee and yoghurt/chopped fruit
Independent with: Set up of environment; Reaching (all meal preparation items within easy reach); Bending; Side stepping; Transporting (released grip from WZF, to place fruit in pockets); Coordination; Manipulation.
Verbal prompts with: Standing (reminder to use WZF provided for stability, instead of furniture); Mobilising (reminder to return to WZF after accessing fridge).
Assistance with: Lifting. I was asked to lift a bag blocking her fridge, due to load/bending effort required.
Independent with: Planning; Initiation; Sequencing; Concentration; Noticing/responding (engaged well in conversation with RRT staff during meal prep); Orientation; Memory; Using items appropriately.
Verbal prompts with: Safety awareness (reminded of importance of using WZF during recovery, as deemed potentially unstable at times, using stick; suggestion to have rug removed, as WZF caught when mobilising to kitchen).
In summary, Miss B was deemed competent and safe whilst preparing a hot drink and cold breakfast. Her gross and fine motor strength and dexterity met the demands of the task. She displayed sufficient strength and stability in both upper and lower limbs, to complete the activity. Miss B is adjusting to using her new downstairs WZF and caddy; she sometimes chooses to furniture walk instead, transferring her weight onto nearby kitchen surfaces and door handle. This could put her at risk if her frailty/stability increase.
Personal Care Plan - goals
The following were established in collaboration with Miss B:
To return to her normal routines
To improve confidence and ability in stair mobility
To return to walking outdoors
The rapid response service remit is short-term input for acute conditions, to maintain independence at home and prevent hospital admission. Therefore, short-term personal goals are set with patients, that may be followed up after referral to ongoing service provision. In this way, goals often focus on ADLs, rather than leisure occupations. Whilst it could be argued that this potentially overlooks more meaningful activity, the aim is to address high priority needs. Maslow’s hierarchy of needs comes to mind here! Once these have been achieved, the patient is likely to participate more actively in wider occupation.
Assistive technology and equipment provision
Walking Zimmer Frames (x2, ground and first floor), for increased stability and confidence. Patient showed safe mobility using stick on stairs, but unsteady walking and furniture walks.
Caddy for ground floor WZF, to allow safer transportation of food and drink during meal preparation.
Bath board, for washing with greater safety and ease. Patient has found rising from her bath difficult and has no shower fitting to stand and wash in her bath. This was fitted at the opposite end to the bath taps, in consultation with Miss B. Patient was observed getting on and off the board with ease and safety. She said she was happy with how much easier this transfer was than she had expected.
A second stair rail fitting was suggested on one visit, due to initial concern regarding Miss B's safety and mobility speed. I recommended a physiotherapy visit, to assess fluctuating ability and confidence with stair mobility. Repeat visits demonstrated safe and competent mobility, using her stick and the one existing stair rail. Patient stated that she would continue to manage in this way.
Complications preventing earlier discharge
Discharge of Miss B from the team's caseload was planned for the last visit I made to the patient. However, on arrival, Miss B complained of an arthritic flare-up, with increased "stabbing pain" in her lower back and down her legs. She continued to rate her pain at 10/10 severity. The multidisciplinary rapid response team felt that Miss B's repeated maximum pain rating did not always match her occupational performance. This included her safe stair mobility and competent ADLs, such as washing her top half in the bathroom.
However, on evaluation, Miss B could not be discharged on the originally planned date. Whilst she was medically stable and could safely engage in toileting, she now lacked confidence and perceived she was unable to descend her stairs. This meant she could not safely access food or fluids, given that she lives alone, with no package of care in place.
Miss B was keen to either be visited by her GP or to be admitted to hospital for tests. An Occupational Therapist telephoned her GP, who visited the patient's home. Morphine was raised to a 15mg dose, including use of a butrans patch.
Ongoing support, following home visits
The patient had contacted a charity for a package of care and was asked to get in touch with other agencies. She stated that she would like assistance with shopping and laundry. She was reported to have eaten twice, having safely mobilised the stairs with her stick and made her own soup. She had a good range of movement in her hip and back, as she was observed to pick up items off her floor.
Therefore, Miss B was not deemed to have acute enough needs to require further rapid response input. She was considered for a community rehabilitation team referral. However, the patient was discharged from rapid response, due to a GP visit that resulted in hospital admission. Her bloods indicated a possible acute kidney injury (AKI), a complication not previously evident to our team or her GP.
Reflection and evaluation of practice
In terms of social and cultural influences on occupational therapy practice, Miss B’s social environment was most influential. Whilst no strong cultural factors were evident, it could be argued her neighbours were both supportive and a hindrance. On one hand, they were a vital lifeline for meal provision and were able to provide a second viewpoint in understanding the patient’s baseline. On the other hand, the team found them to verge on interfering at times. Concern was well-placed, although they could be distracting. Whilst carrying out a lengthy initial assessment, the presence of 3 staff and 2 neighbours was deemed too much for Miss B.
Furthermore, the lack of a package of care or family support meant that discharge took longer than it could have. Had there been more reliable and regular help accessing food and fluids, the rapid response team may have not felt the need to retain Miss B on the caseload for so long.
I also came to understand the importance of the patient taking control of their health in this acute setting. A fine line exists between being wholly supportive with critical care and encouraging the patient to remain motivated and empowered to help themselves. As therapists, we sometimes went beyond our remit, including making Miss B breakfast and contacting her GP, at a stage where she could have done this herself.
On reflection – in terms of personal goals – Miss B was unable to return to walking outdoors during our brief time with her. She was able to continue routines related to ADLs, although these were sometimes restricted to her upstairs. I believe the patient achieved her goal of improving confidence and ability in stair mobility, as best as possible. The nature of an acute and changing condition was often a barrier to this. Additionally, her wavering confidence and tendency to rate maximum pain levels proved challenging.
I am pleased with the interventions myself and the rapid response team recommended and provided for Miss B. I gained greater confidence as visits progressed. Having developed an understanding of her situation and built rapport, I was able to articulate progress to members of the MDT going on subsequent visits. I had reached a stage on my placement that I felt confident in my clinical reasoning behind provision of assistive technology, walking and bath aids. I identified a potential need for the fitting of a stair rail, although this was later deemed unnecessary, given Miss B’s safe demonstration of stair mobility.
Originally written in 2017.
Townsend, E.A. and Polatajko, H.J. (2007) Enabling Occupation II: Advancing an Occupational Therapy Vision for Health, Well-being & Justice through Occupation. Ottawa: CAOT Publications.
Turpin, M. and Iwama, M.K. (2011) Using Occupational Therapy Models in Practice: A Field Guide. Edinburgh: Churchill Livingstone Elsevier.