Case Study: Community Urgent Care

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

Written following intervention in 2019

'Dorothy'

Follow-up home visit, by Occupational Therapist, Urgent Care Team.

For ongoing clinical and functional assessment, focusing on general mobility and transfers, toileting and personal care.

OVERVIEW

Dorothy (not her real name) is a retired midwife, with a past degree in philosophy. She lives with a live-in carer, in a two storey semi-detached house, on the city outskirts.

Dorothy was referred by a hospital emergency department discharge team, following a fall and sustained right fractured scapula. Conservative management in broad sling. A recent fracture clinic appointment also identified an old fractured clavicle. She is taking analgesia for pain. Her GP has held some medications for one week, due to low blood pressure and her falls risk. Bloods taken showed reduced EGFR, ferritin and folate levels. GP has referred to the district nurses, for repeat bloods. A falls assessment has been completed. Cognitive assessment is not indicated.

Equipment in situ Quad stick, perching stool, bed lever, static commode, cantilever table, slide-sheets, two-wheeled walking frame (out of use, due to non-functioning right arm).

Factors affecting engagement and participation

Dorothy has had high levels of acute anxiety regarding falling, with subsequently reduced functional mobility and difficulty with her daily transfers. Since referral to the urgent care team, she has required close supervision of two, by her OT and live-in carer. Alongside historic and new fractures and anxiety, Dorothy has significant kyphosis of the spine.

Dorothy has mental capacity to give consent. Given today for assistance with toileting transfers, mobility and personal care assessment. Access to property gained via live-in carer. On arrival, Dorothy was sat up in bed. In a settled mood and in company of her carer.

ASSESSMENTS

CLINICAL OBSERVATIONS

[Heart rate, blood pressure, respiration rate, oxygen saturation, temperature]

Not indicated today; clinically stable on recent visits.

CARDIAC

• Patient has no chest pain

• Patient has no oedema

• Dizziness not present

• Waterlow pressure sore risk: 16

RESPIRATORY

• Breathless on mild exertion; likely due to anxiety before and during completing mobility and transfers

• No cyanosis

• No cough

ABDOMINAL

• No abdominal pain

• No nausea or vomiting

• Diarrhoea not present

• Not constipated

• Bowels last open: Yesterday

• No genitourinary pain

• New urine incontinence: Raised during intervention. Message left with GP for callback, regarding medication changes related to this

• Incontinent of faeces severity: Mild. Perceived cause is inability to easily and independently reach commode

NEUROLOGICAL

• Alert, no confusion

• No FAST symptoms

• No memory concerns identified on this visit

• Anxiety: Longstanding generalised anxiety, with recent acute anxiety, related to falls risk and lack of confidence with functional mobility and transfers

• Loss of confidence

EXPOSURE

• Amber Protocol: No current pressure damage, but largely bed-bound until now

• Implement full skin inspection weekly

• Increasingly mobile and finding transfers less anxiety-provoking

• Sitting for short periods in chair during the day

• Live-in carer monitoring skin. No pressure areas identified, other than mild redness of skin at ankles; feet elevated in bed

MUSCULOSKELETAL

• Pain: Continues to complain of pain in right humerus and scapula areas. Increases on mobility and during transfers, plus during personal care and when assisted with dressing

• Number of falls in last year: 3

• Falls risk assessment: Completed

• Canadian Study of Health and Ageing clinical frailty scale: 7

Mobility Assessment

Mobile with quad stick. Once transfer from commode was complete, Dorothy's mobility was largely independent. She required regular reassurance and light-touch support at waist, assisted by OT. Using quad stick, Dorothy was able to mobilise from the commode at bedside to the perching stool in her bathroom. Suggested by OT, her live-in carer followed behind with the static commode, should patient want to sit to rest mid journey. However, this was not required. Normal gait, adequate power and balance. On completion of her personal care (as below), Dorothy was able to return to her bedroom via the same method, unaided beyond close supervision.

Dorothy has a significant lack of confidence with stepping/walking backwards. On return to her bedroom, she needed to step backwards to sit on the chair at the end of her bed. She was unable to complete this and required the commode to be placed right behind her. She fell back heavily onto the commode, before completing a transfer from the commode to a chair, where she would be given lunch by her carer.

Transfer Assessment

In contrast to recent visits this week, Dorothy was very able with her transfers out of bed, onto the left side, via use of bed lever. She remains very nervous, but was vocally less anxious than on the last visit. Close supervision of OT was required for her turn clockwise on the spot, to stand in front of the commode. She was not confident with stand-to-sit transfers, with a (controlled) fall back onto the commode seat. On arriving in her bathroom later, she safely and independently completed transfers on and off her perching stool.

Personal Care Assessment

Dorothy was able to reach her bathroom, having requested support to brush her teeth. Sat on the perching stool, she explained her routine prior to her fall and fracture. At baseline, she perches her toothbrush head on the plug hole, to allow her to apply toothpaste. Dorothy completed brushing independently. She required support to hold a towel under her chin, to prevent paste dripping. A towel was brought to her mouth for drying.

Dorothy was able to flannel wash and dry some areas of her upper body, using her left (unaffected) arm. She required assistance from her carer to complete a strip wash at the sink, covering areas not reachable to her (including her back). Kyphosis and pain from her scapula fracture acted as barriers to her engaging fully in independent self-care.

ACTIONS

• Support, with live-in carer, to mobilise and transfer to commode for toileting

• Close supervision and regular reassurance to complete mobility to bathroom

• Assessment of and assistance with personal care: upper body and brushing teeth

• Reablement referral passed onto urgent care admin for processing

• Discussion with manager of care provider, who was visiting to reassess support needs. Informed and demonstrated current level of function

• Call to GP surgery; to request a discussion regarding potential return to ceased medications; for review of incontinence

• Out-of-hours team referral complete, for night-time routine and assistance with toileting

• Referral made to reablement and community rehabilitation teams, for support following discharge from urgent care team

ANALYSIS

Dorothy continues to be highly anxious before, during and after engaging in all mobility and transfers. This was highlighted during commode access and whilst engaging in her personal care. Dorothy has long-standing generalised anxiety and reports that she "worries if there is nothing to worry about." A lack of confidence and trust in her own abilities is not supported by having a temporary live-in carer. Her regular, familiar carer is on a two-week holiday.

New urinary incontinence has been identified. This is likely due to her inability to easily reach her commode independently and in haste, rather than other physiological causes. Her GP has held some medication for one week, ending tomorrow, which will need a review.

A huge improvement in functional ability has been observed in recent days, with Dorothy able to walk independently to the bathroom and back, using her quad stick and with close supervision of one. Notably, ongoing encouragement and patience - from the urgent care team staff - has contributed to her now being able to complete some personal care tasks in her bathroom. This progress and goal achievement has been aided by the occupational therapist's therapeutic use of self and by building rapport, via discussions around her past vocation.

RECOMMENDATIONS

• Teatime visit today, to continue to assist live-in carer with toileting

• Out-of-hours team referral for night-time routine and toileting

• Follow up GP call requested, regarding medication changes

• Telephone care agency on Monday, for outcome of future care provision

• Await start date of reablement (support workers) and community rehabilitation team (occupational therapists and physiotherapists). To continue progress engaging in personal/instrumental activities of daily living and to develop self confidence around independent living, thus reducing falls risk