Home is Where the Heart is…..by Joan Waugh

Rapid Response

I am a community based Advanced Nurse Practitioner, specializing in the care of elderly. I work for Nithsdale in Partnership, within which my colleagues and I deliver a Rapid Response (RR) service to mainly elderly patients, in crisis; collectively we provide home based comprehensive geriatric assessment (CGA).

(bgs.org.uk)

RR does what it says on the tin; we rapidly intervene, deploying the right person at the right time in the right place to prevent further deterioration and avoidable hospitalization, promote recovery where possible and to maximize the individuals independence and well being; often this will involve referral on to other NHS services and those provided by our colleagues in the third and private sectors.

My role in RR is both fulfilling and rewarding; in the six month period from July to December 2019, with the addition of the ANP role we were able to demonstrate a 67% reduction in our already low admission rates.

Amy’s Story

I wanted to share my personal experience of caring for a frail elderly family member in crisis; this is a story of realistic medicine, positivity and inspiration which I feel is worth sharing, especially when we’re all still caught up in the torment of COVID 19.

Importantly, for me this story captures the holistic essence of our work in Rapid Response.

My elderly mother of 86 years was admitted to a local care home for emergency respite care in December of 2019. Initially Mum was severely frail and in really bad shape both cognitively and physically, however slowly and steadily she improved over time, due to excellent care delivered by the care home team. Mum did eventually become a permanent resident; we had all accepted returning home was not an option, given her level of dependency and frailty.

We were wrong; six months down the line she returned home with a package of care and is doing well;  this was during a time when COVID 19 restrictions were slowly being lifted I might add, our only contact was at a distance through her window . From speaking to colleagues and care home staff I understand care home discharge is a fairly unusual situation; admission of the frail elderly tends to be a one way ticket.

It was difficult to decide what the focus of this blog should be

Why identifying understanding the effects of frailty is so important?

Realistic medicine?

The excellent care Mum received by the care home team?

So I decided to touch on all of it:

Effects of frailty

I see frail elderly patients every day, many of whom have been declining steadily for some time. There are instances when family/carers appear somewhat surprised when crisis lands on their doorstep; I have found myself wondering how did the family\carers not appreciate the decline, why are they surprised this crisis has happened and could it have been prevented. So I asked myself how my mum ended up in such a bad way. Should I not have intervened and prevented her from reaching crisis?

As a family we were aware mums health was in decline both physically and cognitively. Despite her daily struggles on a background of dementia and multiple co morbidities, mum was consistent in her view that she did not want “strangers” coming into her house to deliver care; she appeared to be “just” managing, so I as power of attorney reluctantly went along with her wishes, providing whatever support I could whilst working full time. Before I knew it crisis had arrived full on; Mum displayed all the non specific symptoms of frailty, incontinence, increased confusion (delirium), falls and immobility (often referred to as off legs). Frail individuals are also susceptible to side effects and changes in medication; Turned out Mum had not been taking her prescribed medications for some time, she presented her “stash” to me one day stating she had been “saving them up”.

Progressing dementia was the main culprit for her insidious decline and non adherence to her medication regime; her acute on chronic presentation was multifactorial and complex in nature as is often the case.

Frail patients have reduced ability to cope with minor insults or stressors due to age related decline in physiological and functional reserve; their response to insults such as a minor infection is disproportionately negative.  Mum did have a confirmed infection, which was treated with oral antibiotics. In my experience infection such as UTI or LRTI is often presumed when elderly patients present with non specific frailty syndromes, antibiotics are prescribed empirically and this remains the focus of their management; the non specific presentation of frailty syndromes may mask serious underlying issues; collateral history is crucial a  CGA approach is required to uncover any veiled underlying issues, identify baseline function and measure frailty. CGA takes time and often a fair amount of effort, but it provides focus and enables us to set realistic patient centred goals.

Realistic Medicine

In answer to my soul searching, no I don’t think crisis Mums could have been prevented, it’s just not that simple and  I almost feel it needed to happen;  a case of déjà vu here, when I think back to previous conversations with families of dare I say it “stubborn” elderly relatives in decline.

Most importantly, mums situation was dealt with effectively: at the right time, by the right person and she was conveyed to right place:

The GP did not admit mum to hospital in the first instance; primarily she required good old TLC; support with personal care, nutrition, hydration and relief from pain. She required support with administration of medications, monitoring of blood results  and bowel management, all of which was provided in the comfort of the care home; away from a chaotic and alien hospital environment where she would be exposed to hospital acquired infection, multiple tests and investigations, multiple bed moves, prolonged hospital stay, enforced bed rest,  and social isolation.

That said, mum did require acute hospital admission at one point for medical management, this was carefully considered and deemed necessary by all concerned in her care; however, she had previously narrowly escaped admission after a fall (which staff have an obligation to report) in the care home out of hours; admission was advised not because of prodrome or injury but to “find out why she had fallen”; the definitive answer to which would not be revealed by any amount of tests and investigations and short of pinning someone down we can never completely eradicate the risk of falls.

I have to acknowledge, there is an element of luck to mums story; a respite bed was available when she needed it, in my experience this is often not the case and there are no community beds available. Additionally, the circumstances were right for acute admission avoidance; mums condition could be safely managed out with hospital, there was   a shared understanding of the benefits of hospital avoidance unless absolutely necessary. Crucially, the care home team were confident and competent to deal with mums issues; they had the support of a designated ANP. Additionally there was family, and we were all in agreement with the plan.

An example of excellence

The care mum received in the care home was excellent; she was monitored closely, her care was managed with a common sense approach and above all she treated with warmth, kindness and empathy. Mum had an anticipatory care plan, she wished to avoid hospital unless there was a clear need for beneficial treatment which could not be delivered in the care home; the care home staff  were aware, and respected her wishes.

Every effort was made to make the place feel like home, they even allowed her beloved cat Buster to stay with her. Mum and all the other residents were kept safe from COVID 19 thanks to effective management and the hard work and resilience of the care home team

That said, home is where the heart is and that’s where mum wanted to be. If you’d asked me if that were possible a few months ago, I would have said never.

This is a great example of the care we can provide for those patients who are medically unwell and with complex issues which can be effectively managed out with hospital. It also demonstrates frailty is not a fixed state, once identified and measured we can intervene and monitor the effectiveness of our efforts; mum has moved from being severely frail to moderately so. We are ever mindful the smallest insult has the potential to illicit a dramatic decline in her physical and cognitive function.

Of course, as is often the case when dealing with frail elderly complex individuals things may not work out as we hope.  If they don’t, we as a family will not view this as a failure, rather a calculated risk taken in accordance with Mums wishes, with quality of life in mind and the right thing to do.

Mum gave her wholehearted permission for her story to be shared.

The Rapid Response element of Nithsdale in Partnership is available to Nithsdale patients in postcodes DG1-4, via a Single Point of Contact (SPOC) on 030 33 33 3001.

Joan Waugh is an Older People Specialist Nurse and ANP for Nithsdale in Partnership  at NHS Dumfries and Galloway

 

 

Coronavirus must be the top priority of the NHS – but not the only priority by John Higgon

At the outset, let me say that this article is not intended to encourage anyone to ignore coronavirus guidance, either at home or at work.  Let me also acknowledge the difficult work carried out by colleagues working with coronavirus patients, and the sadness that has befallen those families who have lost a loved one to the disease.

Now let me set out some facts.  Coronavirus proves fatal in approximately 1% of those who catch it.  For most people, it is a mild-to-moderately severe disease lasting no more than a few days.  Some people will harbour the virus without showing any symptoms of the disease.  Children and adults under the age of 60 have a vanishingly small risk of dying from the disease, provided that they are in reasonably good health.  It is estimated that around 1 in 1,000 people in the UK currently have coronavirus, although that number will change in line with changes in the R number.  There is therefore currently a 1 in 500 probability that, in a clinical situation involving a member of the public and an NHS worker, either one will pose a risk to the other.  (This, by the way, assumes that all infected people will be asymptomatic.  If we assume instead that symptomatic patients will not attend outpatient clinics, and that symptomatic staff will report in sick, that probability reduces further.  And of course the risk of transmission of the virus can be further reduced by social distancing, use of PPE, and so on.)

Against this, the number of routine operations carried out in England and Wales in April 2020 was 41,000, as against 280,000 in April 2019, and the number of referrals to cancer services was down by 60% in April 2020 compared to April 2019.  In my line of work, clinical psychology, outpatient appointments were put on hold for many weeks so that we could be available to provide support to traumatized staff and worried members of the general public.  This was an entirely appropriate response to the threat of a pandemic causing high numbers of hospital admissions and greatly elevated anxiety amongst the general population, but it meant that ‘business as usual’ had to be put on hold for some weeks, to the detriment of patients that had been attending for therapy.

Some of the changes that were brought in to manage the risk of coronavirus transmission may morph into permanent working practices, not because of coronavirus but because those new ways of working have additional benefits.  For example, remote working has the obvious benefit of reducing travel around the region, which is good from a financial and environmental point of view.  But these new ways of working may also restrict clinicians’ ability to work in the most effective way.  For example, as a neuropsychologist I administer tests to patients.  Some of those tests can be administered over the phone or by Near Me, but others cannot be administered remotely: the patient needs to be in front of me.  In addition, meeting the patient remotely means that I am unable to pick up on subtle cues (gait, tone of voice) that would be apparent in a face-to-face situation.

I’m sure many of us have had to get used to conducting meetings via Microsoft Teams (and hats off to the IT department for rolling that out so quickly).  It’s sort of okay, isn’t it, but isn’t it also the case that something is ‘lost in translation’ in these virtual meetings, when compared to face-to-face interactions?

I’ve spoken about my experience, but I’m sure there will be similar pros and cons to remote working in your line of work, and – even whilst you understand the reasons for suspension of ‘business as usual’ – you may share my frustration at feeling that you’re not currently able to provide the service you’ve been used to providing.

Here’s the irony.  I am able to go into a High Street shop to buy a newspaper, or sit in a cafe having a socially-distanced cup of coffee.  But I struggle to be able to see my GP for a face-to-face appointment, and my patients are not always able to attend my clinic in person for a comprehensive neuropsychological assessment.  In other words, society at large has come out from under lockdown, but the NHS has committed itself to an ultra-cautious approach which, ultimately, will hinder our ability to provide high quality health care across the board.  We need to remember that coronavirus patients are not our only patients.

Armies have a reputation for ‘preparing for the last war’, and I fear that is what may happen in the NHS.  The immediate crisis seems to be coming to an end.  A second peak may occur in three months, six months or a year, and if it does, we will be better prepared to respond to it.  In the meantime, we need once more to be flexible, and that means getting back, as soon as we can, to providing the full range of services in the most appropriate manner possible.

John Higgon is the Head of Older Adult, Clinical Health and Neuropsychology Services

Fall in a day’s work….. by Kirsty Edgar

Have you ever fallen over?  I have … it didn’t feel normal. So why do we think falling over if you are frail or elderly is normal, natural or inevitable?  It’s not. There are various reasons for falls including frailty, inactivity, dehydration, medication, poor sleep or indulging in one too many gins on a Friday evening like myself.  So why do we think an ambulance crew taking someone who has fallen to hospital when medically safe to stay at home is acceptable?  It’s not.!                                       I had an exciting experience early this year before the pandemic – an opportunity to shadow the Scottish Ambulance Service (SAS) specifically focusing on falls at home aiming to prevent conveyance to hospital.  My thoughts were around how we respond as community support team(s) to provide an assessment in a homely environment? How could we improve links to existing responder services, health and well-being teams, and technology? With my AHP ambulance colleagues that day I mucked in to help with falls and critical life saving calls including conveyance to hospital. I enjoyed the collaboration and working within my proficiency yet beyond my usual boundaries, quickly I realised why we were developing a regional SAS non conveyance to hospital falls pathway – people who require SAS need them critically and non-injured fallers require community support. We worked with Nithsdale Community to make sure we jointly built on their experience since 2017 on SAS falls.

How could we improve on better use of SAS to get to the urgent needs?

Kirsty Edgar, Occupational Therapist in Reablement STARS with colleagues from the Scottish Ambulance Service (SAS).

The skills of an Occupational Therapist (OT) to assess what has changed in daily living skills (occupations) and the knowledge to call on the person centred approach and environmental assessment are imperative for falls prevention.

I have experience working as an OT in acute and community settings – falls are common practice for OT’s – usually once admitted into hospital or discharged home to the community, however never as the initial responder to not only ensure safety but enable return to confident independent living. For this transition transferable skills were utilised, I had stretched my own boundaries and created stronger networks.  This included collaborating more often with our Community Rehabilitation teams, such as physiotherapy for specialist strength and balance intervention or Pharmacists for medication optimisation.  Key is sharing problem solving to get to person centred solutions based around ‘one team’ thinking; whilst following Covid19 guidance and learning new technology to maximise service-user and staff safety.

So… since 3rd March 2020, 8 days before Covid19 impacted, as a member of the multi-disciplinary reablement service (STARS) I have supported the rapid regional roll out of SAS non-conveyed falls (NCF) regional pathway as a ‘responder’ to reduce pressure on SAS to attend other priorities whilst ensuring robust support and community links for the fallen person at home. At 3 months 99 of 110 people were prevented from being conveyed.  Our target was 95% median prevention of admission; despite Covid19 we achieved 94%. There has been a decrease of 10% average weekly conveyance of falls patients and we anticipate a minimum £100K cost saving from this pathway – although it is likely to be much more – as that is only SAS attendance alone not admission into hospital.  It has been a rewarding outcome for us all.

However what matters was the experiences for the people falling and their families – did that improve?

“..Best thing turned up so fast and on a public holiday…I liked staying at home”

“Very appreciative of the team, gave stability and increased confidence”

“Happy, very fortunate, best experience after a fall”

Wordle based on the evaluations from service-users who experienced SAS nCF pathway and responders to stay at home.

Our next steps will aim to keep developing with SAS and align to Home Team Developments and Single point of contact (SPoC) across the region.

So let’s look differently at our new normal from fear of falling to embracing the rapid free ‘fall’ of changing to improve and develop.

By: Kirsty Edgar, Specialist Therapist (Occupational Therapy) Reablement STARS.

[The SAS NCF pathway working group meet via MS TEAMS every 6-8 weeks.  If you would like to know more about SAS NCF Pathway please contact myself kirstypaterson2@nhs.net or the pathway lead Wendy Barron at wendybarron@nhs.net.or call 01387 241500 ]