Two tins of soup by Libby Johnston

When asked to submit something for the blog quite some time ago, the suggestion was that the subject be something that readers would find moving in some way. Recent press has been highlighting the degree of loneliness some are experiencing and how it can effect wellbeing physically, mentally and isn’t always visible to others.

In the run up to Christmas festivities I went to one of the so-called Pound shops. It leans towards my frugal nature and there is nothing like a bargain. However many use such shops to survive with a limited budget.

As I wandered down the first aisle a rather frail but spritely elderly woman moved to allow me to pass and I thanked her and we exchanged pleasantries. As I made my way through the aisles and shelves she seemed on the same route and I couldn’t help but overhear her saying ‘Merry Christmas’ to virtually every person she encountered. I made my way to the checkout and there she was again in front of me in the line. As I looked at her clothes, I could see that she had many layers of threadbare jumpers and no coat on what was a cold day.

She seemed to know the person at the checkout and was asking if they were ready for the holidays and he asked her the same to which she answered yes this was her last shopping trip. On the conveyor belt were 2 tins of soup. He commented, ‘No turkey’? She shook her head, saying nothing and placed the tins of soup in her shopping bag, continuing to wish everyone around her a Merry Christmas and the same to us as she trudged out of the shop, bag in hand. My heart was full as she had shared the joy of the season with everyone she encountered in the shop and yet there was a loneliness to her life.

As a nurse and midwife (retired), it’s always been in my nature to reach out and help others in need. I desperately wanted to ask this dear lady if she was having a Christmas meal with anyone and if not invite her to share ours. I feared she might only be facing a tin of soup. However, she had disappeared from sight and I will never know.

It left me feeling a touch of sadness for her. There is much awareness about people being lonely and particularly at this time of year. Many organisations, charities are endeavouring to help those who may be lonely. There will always be those who won’t want help and soldier on like this woman who found some company, even joy in sharing festive greetings in a shop. A lesson perhaps for the less lonely to be bolder in reaching out to others not only at Christmas but in everyday life.

The government is investing in ‘loneliness’ as it is felt it has been shown to impact health and wellbeing. This is highlighted in this article in The Guardian:“UK to tackle loneliness crisis with £11.5m cash injection”

The money will help establish projects that will bring people together and in so doing reduce elements of loneliness, improving health and wellbeing.

 

“Loneliness and the feeling of being unwanted

is the most terrible poverty.”

Mother Teresa

‘Docere’ by Sonia Cherian

The word ‘Doctor’ is the agentive noun of the Latin verb Docere which means ‘to teach’. The title ‘Doctor’ refers to a person who is recognised to have acquired sufficient knowledge in a subject to be a teacher of that subject. The role of the doctor as a teacher helps educate patients about their condition. A well-informed patient is crucial to the success of any treatment plan. In an era of increasing demands on the healthcare system coupled with  changing patient expectations, the doctor’s role as a teacher has a unique significance.

The supreme court ruling in the Montgomery case (Montgomery v Lanarkshire Health Board, 2015) was a watershed moment from a medicolegal perspective. Mrs Montgomery, a small built diabetic patient had complications during a vaginal delivery which resulted in her son being born with severe disabilities. The case hinged on whether the health board had provided her with all the information which could have helped her make a decision between a normal delivery or a caesarean section. Her obstetrician felt that the risks of shoulder dystocia during normal labour was not significant enough to discuss with her thinking that this information may have resulted in the patient choosing a caesarean section which had its own risks. The supreme court felt that had the risks been explained fully to the patient, she would have opted for a caesarean section and the baby would have been born unharmed. This ruling established that a patient should be told whatever they want to know, not what the doctor thinks they should be told. Mrs Montgomery was awarded a compensation of £5.25 million and the ruling fundamentally changed the law on decision making with the transition from ‘medical paternalism’ to ‘patient autonomy’. The ruling makes it clear that any intervention must be based on a shared decision-making process ensuring the patient is aware of all options and supported in making an informed choice by their healthcare professional.

The General Medical Council (GMC) document on Good medical practice advises to work in partnership with patients:

• You must listen to patients, take account of their views, and respond honestly to their questions.
• You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.
• You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.

(https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-3—communication-partnership-and-teamwork#paragraph-46)

The Realistic Medicine agenda led by the Chief Medical Officer (CMO) of Scotland makes shared decision making and a personalised approach to care its key themes. (https://www.gov.scot/publications/practising-realistic-medicine/)

‘The King’s Fund’ research recommends that patients should be given a chance to take an active role in decisions about their care and treatment by providing the right opportunities, information and support. Services should reflect the needs of patients by meaningfully involving patients and carers in service commissioning, planning, design and improvement. (https://www.kingsfund.org.uk/publications/shared-responsibility-health)

An informed patient can positively contribute to decision making regarding a personalised approach to his or her treatment. This would also mean that patients are more open to share the responsibility of these decisions and be prepared to live with the consequences of their choices thus reducing the risk of complaints and litigation. Patient decisions are not only influenced by medical considerations but also by non-clinical issues which are of relevance to that individual patient. Values, beliefs and life experiences that have a personal significance can influence choices. Our role as clinicians is to support the patient in the decision-making process by providing expert medical advice through a dialogue. Unlike emergency situations where decisions have to be made quickly to save the life or limb of a patient, the vast majority of treatment decisions are taken in primary care or in an elective setting in secondary care. Many conditions have a variety of treatment options, each with its own benefits and risks. In some situations, having ‘no treatment’ is also a reasonable option.

Many patients are well-researched about their condition having read various articles on ‘Google search’. However, for a non-medical lay person to comprehend the vast, often confusing and sometimes contradictory online information can be challenging. This may leave patients with incomplete and out of context information. Hence the information that the patient could assimilate online is quite different from the knowledge that he or she needs to make personalised treatment choices. The clinician has the unique role as a teacher to help transform the information the patient has into knowledge whereby safe personal choices on treatment could be made.

Discussion regarding the various methods of Patient education is a topic on its own and is beyond the scope of this blog. Though innovative ways to deliver succinct information using digital media seems to be the way forward, these would never replace the warmth and compassion of a caring competent clinician who would help patients make the right balanced choices. This would only be possible with the provision of time and resources to improve meaningful information sharing during consultations.

The CMO’s annual report (2016-17) acknowledges that the main barrier to healthcare professionals having more in-depth discussions with patients is the issue of time. “Simply offering the standard treatment or investigation may be quicker, but not necessarily what is in the patients’ individual best interests. It is essential that in order to provide high quality, personalised care clinicians are in a position to make the time to have these important discussions. If we are able to move towards engaging in these conversations as a part of routine practice, it is likely this will in some circumstances save time where patients decide against investigations or treatments that they do not feel are right for them.”

The second Citizens’ Panel Survey (August 2017) revealed that the behaviour/style of the doctor and how busy they are (or are perceived to be) had an impact on patients’ inclination to ask questions. The current legal and regulatory requirements make it the responsibility of the clinician to provide adequate time to the patient so that they are well informed prior to making a decision.  However, the Scottish Public Service Ombudsman (SPSO) has commented in the CMO’s Annual report (2016-17) that this responsibility is not that of the clinician alone. This process would require policy changes within the organisation and a change in culture that encourages and fosters patient centric multi-disciplinary team working.

The GMC guidance, the Supreme court ruling, the concepts of Shared decision-making, Patient centric care and Realistic medicine all point to the pivotal role of patient education  thus highlighting the importance of what it truly means to be a doctor : ‘A Teacher !’

Therefore, let us all remember to ‘teach before we treat !’ and support each other in patient education with the ultimate aim of delivering holistic patient care.

 

Dr. Sonia Cherian is a GP at NHS Dumfries and Galloway as well as a GP Appraiser and CPD Adviser at NHS Education for Scotland

 

 

 

The Paper Boat by Patricia Cantley

I’ve been reading a lot recently about the word Frailty and its importance within Medicine for Older People. We see a lot of frail people and as geriatricians they are our core business both inside and outside the hospital.

Healthcare professionals have debated over the last few years how to define Frailty, and even how we might begin to measure it. It is no longer adequate simply to shrug and say “we know it when we see it”.

From a patient or relative’s point of view however, the word Frailty seems to be at best somewhat vague and at worst, derogatory and demotivating. When we ask patients how they feel about the word, whether in large surveys or on a one to one basis, they do not like it.

One strategy that I have found useful over the years, especially when talking to relatives of the patients under my care, is to paint a picture that they can relate to by using a simple analogy. I’m sure others have used similar techniques – indeed I learnt this one from a consultant colleague many years ago.

So when I am talking to a family member about their older relative, I sometimes liken their clinical situation to a fragile yet beautiful paper boat sailing round a pond of their choice.

A while back I used this particular strategy for a very elderly man under our care who was going through a very complex and unstable time. At one point, there seemed to be a lull in the medical winds that were buffeting his fragile frame and I sat down with his daughter to chat things through. She was desperately seeking reassurance, but also wanting honest facts about what to expect over the months to come.

She smiled as I described my image of a beautiful paper boat, brightly painted and currently sailing proudly in the sunshine on the still pond, giving pleasure to all around. I explained that the difficulty was in not knowing what weather was ahead, and the problems forecasting accurately. If the weather were to remain fair with barely a trace of wind, then there was no reason to think that the boat would go down and indeed it might sail on for quite a while. If, on the other hand, the wind got up, or worse, if it started to rain, that frail wee boat would go over quite quickly with little we could do to save it.

As younger and healthier individuals, we react more like little tug boats of wood and steel… we would simply bob up and down until the storm had passed. Though a big enough hurricane could be too much for us too…

The chat developed a bit more as we translated some of this into more medical language and formulated a plan over what would and wouldn’t be reasonable things to try, should that wee boat capsize over in a high wind. We agreed that we’d want to try as much as we could, maybe including intravenous therapy but that at the end, a call to the family rather than futile attempts at CPR would be the right strategy. I noted it all down, and his daughter undertook to update the rest of the family.

As is the way in modern medicine, our paths diverged and he was discharged from our service. I didn’t keep in touch, though I knew his daughter had my mobile that she could call if she wished.

Many months later, a text came through…

“Dearest Trisha, I am sending this sad message to you to let you know that last night the paper boat went down in a storm. It was all very sudden at the end, but we were well prepared, and for that we thank you.”

I called the patient’s daughter later that afternoon and we chatted about what had happened. I don’t think we used the word frail at any point in her father’s journey, but she knew what we meant, and I think it did help. It was also lovely to be able to talk afterwards and listen to how the last chapter of the story had unfolded. It is rare as hospital doctors that we get to do this kind of post bereavement support and for me, it was well worth while being home a little late (again) that evening.

Every doctor I’ve met has tales of when things go well, and we all have our share too of when they haven’t. We must never be complacent, and a strategy that works with one family may not work with another.

We need to learn a lot of facts as doctors, but there is also an important place for the use of stories in medicine. We can learn and teach what has worked for us, and consider how others might adopt and adapt similar approaches.

I had another text, more recently, from a previous trainee. Also a happy story, they wanted to tell me of a scenario in another hospital in another city, where they explained to a family the fragility of another paper boat. Intense medically focused discussions had failed to convey the precarious nature of the situation, but the visual image of a brightly painted origami boat had been something of a breakthrough. I was touched by the kindness of the younger doctor that they thought to feed back to their former teacher in this way.

I’m still not sure what the best way to define Frailty is, but I’ve tried a few ways of describing it in the clinical situation. I’d love to hear tips from other people, in particular from patients and relatives, about what has worked best for them.

Patricia Cantley works as a consultant physician in the Midlothian Hospital at Home Team, offering an alternative to hospital admission for frail and older patients. She also works in the Royal Infirmary in Edinburgh and in the Community Hospital in Midlothian. She tweets under her married name of Elliott as @Trisha_the_doc

This blog originally appeared on the British Geriatrics Society blogsite on the 9th July 2018. Many thanks to Patricia for the permission to republish on dghealth.

Get up, Get dressed, Get moving by Amy Conley

Think about an older person, someone in their eighties – let’s say it’s your Granma…

Your Granma lives in her own house; she’s not quite so good on her feet anymore, but she gets about OK.  Stairs are difficult but she manages – and she manages to get up and dressed, make her breakfast and her tea, feed her cat, read the paper, get to Tesco in the car with you.

Then your Granma gets ill – she has say, a chest infection.  She is admitted to hospital.  You pack her bag – nightie, toothbrush, comb.  She is admitted to the ward – she is poorly, needs antibiotics and a drip for a few days. So, on goes the nightie and your Granma is in bed; that’s what you do in hospital – you are poorly and tired and you need to rest in bed.

Your Granma is in bed in her single room.  She needs the toilet but doesn’t think she should get up by herself – she is a patient in a nightie so needs help.  But she can’t see very well or hear very well and can’t find her glasses or hearing aids.  She can’t find the buzzer to buzz the nurses and she can’t hear when they are near.   She thinks maybe she could get herself to the toilet, but she can’t see her walking sticks and is scared she will fall. 

Time passes.  Your Granma is incontinent in the bed.  She is embarrassed and frightened – what will the nurses think?

Now she is scared to drink and eat because she doesn’t want to need the toilet and be incontinent again.  And she doesn’t want to bother anyone.  The physio comes to see her, tries to get her up.  But she is still embarrassed and frightened.  She has no clothes to wear.  And she has only those foam slippers she got from the nurse.  So it’s best just to stay in bed.

Your Granma stays in bed for longer and longer.  There is nothing to do.  There is a TV but she can’t see it or hear it without her glasses and hearing aids.   She is getting mixed up now; she can’t remember when she came here or why or what day it is.  She thinks she can see cats in the corner of her room.  She still won’t eat, so she has no strength and feels weak. She doesn’t want to get up.  Her bottom and back hurt.  Her leg has swollen up – they said it is a blood clot.

The physios keep coming back.  They try to get her up; two of them struggle to get her to stand.  She is stuck in bed. 

Your Granma’s chest infection has been treated and she has no acute medical illness, but now she is immobile, confused, dehydrated, incontinent, her muscles are weak and she cannot walk anymore, or get herself washed or dressed. 

Your Granma is not going to manage at home anymore; she has to go to a care home.

 

“GET UP, GET DRESSED, GET MOVING”

At DGRI, we are launching our campaign on Monday 23rd July– the aim is help our patients maintain their function, mobility and independence while in hospital, and for them to return home as soon as possible, as able as possible.

 

WHY HAVE THIS CAMPAIGN?

• Most patients in hospital are over 65
• In hospital, older people spend up to 83% of their time in bed
• 65% of people’s functional ability declines during admission
• 60% immobile older patients in hospital have no medical reason to stay in bed
• If you are over 80, 10 days in hospital ages muscles by 10 years
• 1 week of bed rest equates to 10% muscle loss
• These changes are “deconditioning” –  “reconditioning” takes twice as long

WEARING YOUR PYJAMAS IN HOSPITAL

• Affects your confidence and self-esteem
• Changes how you interact with healthcare staff and other people
• Is usually unnecessary no matter why you are in hospital
• Doesn’t feel very dignified when you are trying to eat your dinner

 

STAYING IN BED IN YOUR PYJAMAS

• Reduces muscle strength
• Reduces confidence
• Reduces function
• Increases blood clots, delirium, pressure sores and infections
• Leads to reduced appetite, low mood and anxiety
• Reduces social interactions
• Lowers pain thresholds
• Can make blood pressure drop
• Causes constipation and incontinence

WHAT CAN HEALTHCARE STAFF DO?

• All of us can and should help patients get moving – nurses, doctors, AHPs, porters, domestic staff, pharmacists…
• Ask the patients how they normally get about and what they normally do
• Make sure patients can access buzzers, water, remote controls
• Encourage patients to get dressed and sit up in the chair

 

WHAT CAN PATIENTS DO?

• Tell us how you normally get about and get things done and what you need to help you
• Try to do things that you do at home – wash and dress, eat and drink on your own if able
• Sit up in your chair and for meals
• Drink lots
• If you can’t get out of bed, do little things – wiggle your toes, do a crossword – every little movement  helps

 

WHAT CAN VISITORS DO?

• Tell us what you do at home
• Bring in glasses, hearing aids and walking aids
• Bring in comfortable day clothes and well fitting shoes
• Encourage you to sit up in the chair and for meals
• Take you for a walk
• Bring in photos, books, puzzles, crosswords

THE BENEFITS

• Speeds recovery
• Reduces time in hospital
• Encourages patient and carer involvement in healthcare and recovery
• Helps to retain patients’ individuality and self-esteem
• Helps patients to quickly return home, mobile and functional

 

If you or your family are worried that it is not safe for you to get up or you might do the wrong thing – ASK US!  We will tell you what is safe and OK for you!

#endpjparalysis

#goinghome

Amy Conley is a Consultant in Geriatric Medicine at Dumfries and Galloway Royal Infirmary

‘What I am told I forget…… by the Renal Team

…what I am shown, I remember.

              …what I do, I understand.’

Confucius was credited with many words of wisdom in his 72-years.  I couldn’t vouch for the authenticity of them all – but if he did utter these words he was indeed a man before his time.

The truth behind these words was apparent to me at our recent Kidney Care Planning Education day. The Kidney Care Planning Service has undergone a bit of a re-incarnation in the last couple of years. Formerly known as the Pre-dialysis service, it is simply the care of patients with an eGFR of less than 20mls/min, as they are more likely to progress to end stage kidney failure and need to plan for such an eventuality. However, the term ‘pre-dialysis’ implies that these people are all heading towards dialysis – when in fact many will choose an alternative path. The younger fitter patients should be hoping to get a pre-emptive kidney transplant from a relative or friend, while some of our elderly, frailer patients may well not benefit from dialysis at all and will survive just as long on conservative (nondialytic) care. So when Tanya Harkness took up the mantle of lead Nurse for the pre-dialysis service, she quite rightly felt a new name was required. Many renal units use the term Low Clearance Clinics, but a straw poll of non-renal staff suggested this was more reminiscent of a rehabilitation clinic for inattentive bus drivers… So, after much discussion amongst the renal team, the more accurately named Kidney Care Planning (KCP) service was born.

The aim of the service remains unchanged and while we do take bloods and treat symptoms, easily 80% of what we do is talk. More specifically we provide as much information as we can to help every person decide which treatment option is going to suit them best. We do this with clinic visits and home visits. We provide information leaflets, website addresses and even YouTube videos – all with the aim of imparting information. Yet still we are sometimes asked a question that blindsides us – that either leaves us thinking ‘How did you not know that from all the conversations we have had?’  or ‘Crikey- that’s a good question that I have no idea how to answer!’ Because at the end of the day none of us handing out this information have ever experienced what they are going through – the actual treatments, the fear and anxiety, the dread of what their lives will become or the understandable desire to block it all out and pretend it’s not happening.

Which brings me back to Confucius! The subject of teaching is vast, with as many different approaches as there are pizza toppings. Yet 500 years BC, Confucius nailed it with this simple truth – when we actually do something, we come to understand it. So who better to teach our patients, than other patients who have been in the same boat.

We have held education days in the past, usually in a hotel function room with talks given by members of staff. Tanya was keen to resurrect the concept, but made it quite clear from the outset that there was ‘No way on God’s earth’ I think was the phrase that she was ‘EVER’ standing up in front of a room full of people to give a power point presentation. (Why not, I have no idea as I am sure she would be excellent….but there we are!)

So a new format was devised between the whole community team – a less formal approach, like an open day, where patients could turn up and wander at will from room to room – talk to the team leads, watch demonstrations, see the equipment and most importantly meet other patients.

The date was chosen to coincide with a visit from Ewen Maclean, Kidney Care UK Patient Support and Advocacy Office, Scotland. Ewen, himself a renal patient, is a mine of information about the support available to kidney patients, grants and how to apply for them and the political landscape that shapes kidney care in the UK.

We no longer had need of a hotel function suite – if there is one thing we are not short of at Mountainhall it’s space! (And the parking is pretty easy too – sorry!!) So, we sent a personal invitation to all our KCP patients, laid on refreshments and opened up the old pre-assessment unit for the day.

The Renal Community Team (Left to right): Fiona Gardiner (Renal Dietitian), Robert McLemon (Transplant) Ian Mottram (Haemodialysis – both home and in-centre), Wendy Brown (Peritoneal Dialysis) Margaret McDonald (Clinic Health Care Assistant & Phlebotomist), Linda Stiff (Vascular Access), & Tanya Harkness (Kidney care planning).

As well as written information everyone had something practical for patients who attended and the responses we had were truly illuminating. Ian had a haemodialysis machine with all the lines and bucket of dialysis fluid set up and received the comment ‘Oh, I didn’t realise it would be so small-I assumed it’d be really big.’ And why not –historically dialysis machines took up a whole room, which must be a really intimidating thought if you are going to be hooked up to one- but it has NEVER occurred to me to comment on the size of a dialysis machine in my many dialysis related conversations.

Robert had asked 3 transplant patients, with more than 50-years of experience between them to attend. I am not sure if any of them showed their scars where the transplant was placed but they had experienced all the ups and downs of transplantation and immunosuppressants so there was no glossing over the bad bits.

Linda was showing patients how to feel  their fistula and what to listen for – explaining how the noise it makes can change if a stenosis is forming – and she was able to give those with a fistula their own stethoscope to involve them in their own fistula care.

Our renal dietitian was also on hand to give practical advice on managing fluid balance, as well as providing visual aids on potassium, phosphate and salt restrictions-something that renal patients universally struggle with!

One of the biggest successes of the day came from Wendy who had persuaded one of her Peritoneal Dialysis (PD) patients & their families to come and chat so they finally actually knew what the PD catheter looked like when it was inserted and could see for themselves how an exchange worked. But more importantly they could ask someone having the treatment what it felt like, how it impacted on their lives, whether it interfered with their sleep, whether it actually helped! One of our patients who had been set on coming to the hospital for haemodialysis when his time comes, has now changed his mind. We have been sure for many reasons that he would be best suited to PD, but fear was driving his decision. One hour watching a gentleman of his own age performing an exchange and listening to his stories of how life continues almost as normal around PD, has achieved what 5-years of reassurance from us could not…

The feedback Tanya received was overwhelmingly positive, but patients are generally nice, so it is the more subtle signs that have persuaded us this is the right approach. The questions and comments patients have since made in clinic prove that they have valued and retained some of the information they learnt that day. One patient commented how reassuring it was to see dialysis patients who looked well and still lived a normal life. And I hope through this some of the fear for the future has abated.

I expect in the future we will still be blindsided by hitherto unasked questions, but it is not only the patients who are learning, as I finish with yet another Confucius quote:

‘He who knows all the answers, has not been asked all the questions!’

We would like to express our sincere gratitude for all the patients and families who came that day, especially for those who came to share their experiences with patients in the early stages of their kidney care planning journey. We are also grateful for the patients who gave their consent for us to take photographs and use them in this blog.  We hope to make “Kidney Care Planning Education day” an annual event from now on.

 

Other useful renal websites:

Patient focussed resources:

Kidney Patients UK / The National Kidney Federation, the largest kidney patient charity in the UK, run by kidney patients for kidney patients, website provides lots of useful information.

Kidney Care UK – formerly the British kidney patient association, very helpful brochures available online.

Think Kidneys – NHS England’s campaign to raise awareness of the importance of kidney disease. Lots of useful resources can be accessed with just a few clicks from this page.

Clinician focussed resources:

Renal Fellow Network – A USA based website with worldwide contributions distilling vast amounts of renal knowledge into bitesized articles, a great resource to start learning about renal medicine.

UKidney – online education on Nephrology, hypertension and kidney transplant.

#NephJC is a fortnightly Twitter-based Nephrology Journal club with visual abstracts, free access to the articles provided by major journals and regularly includes participation by the authors and other worldwide experts in the field.

 

This blog was written by Dr Alison Almond, Associate Specialist in Nephrology, with contribution from rest of the Renal Team, NHS Dumfries and Galloway.

 

Dietitians do Prevention by Laura King

Next week sees the return of Dietitians’ week and the theme this year is ‘Dietitians do Prevention’ with each day having sub-themes. Follow #DietitiansWeek on Twitter, Facebook and Instagram for some insights into our involvement in a wide and varied range of preventative activities.

Here in NHS D&G we have dietetic teams working across these areas which may come as surprise to the majority of folk working in the acute hospital who perhaps associate us mainly with artificial feeding and oral nutritional supplements for those who have scored 2 or more when nutritional screening is done on the wards.

As a small team we recognise that we have to play a role in educating and enabling patients, their families and carers to prevent over and under nutrition by supporting self-management, the dietitian can’t come shopping with you, cook your meals and help you to eat them and make the best choices, so we have to rely on using our communication skills to educate and inform patients and those close to them to help have a healthy, balanced diet that meets their needs.

We factor in ‘what matters to you’ and our assessments incorporate a huge range of factors as this poster illustrates:

Our Team works in the following areas all of which have significant roles to play in prevention:

Community Nutrition Support  (Kerry, Alexandra, Jackie, Jennifer, Lis, Dillon and Carole) – We provide practical, evidence based dietary advice, specifically tailored to each individual. Through dietary advice we aim to prevent and treat a wide range of medical conditions and empower people to make appropriate diet and lifestyle choices. Community Dietitians see patients in a variety of settings including community hospitals, nursing and residential homes, clinics and patient’s own homes. Our role identifies, prevents and manages malnutrition in the community. We liase with individuals to create realistic and achievable goals to optimise/improve their dietary intake.

Various medical conditions require an individual to be provided with their nutrition via a tube. We are responsible for managing these patients in the community, either in their own home or in a nursing home/community hospital setting.

We deliver educational talks on various topics including cardiac rehabilitation, stroke, Parkinsons disease and pulmonary rehabilitation.

Renal (Fiona) – Supporting patients with advanced kidney disease in managing complex nutritional requirements. Preventing further complications that can arise from inability to excrete electrolytes and fluid overload as well as avoiding weight and muscle loss for this group of patients who have increased requirements for protein once dialysis has commenced.

Gastro (Gemma and Sarah) – Preventing complications from poor management of coeliac disease such as the obvious GI disturbances through to the ‘hidden’ consequences such as increased risk of bowel cancer and oesteoporosis. Supporting patients living with inflammatory bowel disease to manage their symptoms and optimise their health and well being. Preventing the often crippling effects of irritable bowel syndrome by supporting patients to use the low FODMAP diet to identify trigger foods and modify their diets in a safe and sustainable way.  Preventing malnutrition in liver disease which is often masked by fluid shifts.

Paediatrics (Mhari, Anne and Tracey)  – Supporting parents & their child in managing children with complex needs, tube feeding, diabetes, gastroenterology issues, cystic fibrosis, weight management, faltering growth and allergies – preventing short and long term consequences of under nutrition.

Diabetes (Katy, Nicola, Sally, Sheena, Wendy): We are an integral part of the diabetes multi-disciplinary team providing a dynamic and evidence based service. We deliver quality assured education, and aim to support patient driven care and safe self management to those living with diabetes and their family. We also provide continuing education and support for health care professionals working with individuals with diabetes.

Weight Management (Katy, Nicola, Sally, Sheena, Wendy): We provide person centred, safe and evidence based advice to individuals with complex needs and requirements. This encompasses a variety of approaches to help aid weight loss and improve quality of life.

Mental Health and eating disorders (Sam and James) – Supporting recovery from mental health crises and from the consequences of living with disordered eating behaviours.

Catering (Debbie)- Working with Catering to achieve menus for inpatients across the region that offer a varied, balanced diet to support their recovery and prevent complications such as poor wound healing and  pressure ulcers. Also ensuring guidance for Catering teams to create therapeutic or special menus for patients’ individual dietary requirements. Training staff who make and deliver food, fluid and nutritional care to patients in hospital.

Acute (Laura, Anneka, Laura, Jennifer, Laura and Sheree) – seeing patients identified as being at risk of undernutrition to assess their individual needs and support recovery. Preventing increased length of stay, poor wound healing, pressure ulcers and other complications of malnutrition and providing advice for discharge to help patients stay well and continue their recovery once home with or without the support of the community dietitians as appropriate.

All this activity is coordinated and supported by our Head of Dietetics (Lorna).

The acute team are planning to pilot some staff education sessions on B3 and D7 to support ward staff in preventing malnutrition as well as identifying the patients who need our one-to-one support, so please get in touch with Dietetics on 01387 241568 if you would like to know more, want to arrange any training on your wards or if you have any questions about this blog post and what we do.

Meanwhile here are some pictures of the acute team (Anneka, Jennifer, Laura and Laura) ….

Laura King is Lead Acute Dietitian at Dumfries and Galloway Royal Infirmary

What Matters by Ken Donaldson & Alastair McAlpine

I recognise that it is a bit cheeky of me to put my name to this as I haven’t written any of it. A few months back I was scrolling through Twitter and came upon this thread that really moved me. The messages are simple yet immensely powerful. I have therefore simply taken some screenshots from Twitter and published them here. As you can see this is by a Doctor called Alastair McAlpine who is a Palliative Paediatrician in Cape Town, South Africa. Read on…..

Cathy’s Journey by Amy Conley

Friday night, admissions unit is where we first met Cathy……

I say met; we heard her before we met her – Cathy was shouting out, incoherent, clearly agitated. In her room, we found a tiny lady lost in a huge nightie, scrunched up on the bed, clinging onto the bedrail.  Cathy was 95, frightened and distressed.

Cathy had been transferred from another hospital, for assessment of pain.  It was impossible to know if Cathy was in pain or not – she couldn’t tell us.

We looked at her notes…

With a diagnosis of dementia and arthritis, Cathy had been living fairly independently with carer support, hadn’t been in hospital for some years.

A few weeks before, carers worried that Cathy may have fallen, an ambulance was called.  Cathy went to ED – no broken bones, but concern that Cathy couldn’t mobilise safely resulted in admission.

Over the next 6 weeks, Cathy was moved seven times between three different hospitals, from community to acute and back; staff worried about pain, falls and possible injuries, worried they were missing something, worried that more tests were needed…

Over this time, staff reported increasing difficulty with Cathy’s behaviours and confusion; she was distressed, agitated and uncooperative. Other patients were frightened.  Staff felt unable to manage.  Cathy was prescribed sedation.

Cathy by now was very confused, unable to communicate what she needed, not eating, not drinking.  She had become incontinent.

Back to Friday night…….

The sight of Cathy was heart-breaking; crying out, unable to tell us why, unable to understand what we were doing. She was dehydrated, in pain and encumbered by various medical contraptions.

We talked to Cathy’s family.  We decided that Cathy didn’t need any more interventions or hospital moves.  We did our best and made her comfortable.

Cathy died six days later…

 

Cathy, like many people admitted to hospital, was frail; she was frail before she came to hospital that first time.

If we had recognised her frailty at the hospital’s front door and intervened, well, perhaps Cathy’s story might have been different – different conversations, different interventions, different decisions and different plans made.

We talk a lot about frailty but it’s not always easy to explain or to understand.  Frailty is one of those words that get bandied about but what do we mean when we call someone frail?

The dictionary definition is “the condition of being weak and delicate”, something we all feel at times, but not really helpful in identifying frailty in our patients.

Within medicine, after years of vagueness and uncertainty, we have defined frailty as “the reduced ability to withstand illness without loss of function”.

 So……

A minor illness or injury, that would be no more than troublesome to you or I, affects a frail person more profoundly, leaving them struggling to walk, to wash or to dress, to eat or to communicate.

In reality though, how do we recognise the frail patient?  Does it matter?  Does it make any difference?

Age alone does not make people frail – people don’t become frail simply because they live too long.  Frailty doesn’t come with a diagnostic test, but there are signs we can look for – older people, with cognitive problems, mobility problems or functional problems, people on many medications or who live in care homes.  People who present to us with falls, incontinence or confusion.

“Frailty is everyone’s business”

The population is getting older and frailer, particularly here in Dumfries and Galloway.

Older, frail people have higher demands on health and social care services and more unplanned hospital admissions.  Once admitted, frail people are more susceptible to hospital-acquired infections, delirium, nutritional problems, falls and skincare issues.

In comparison to other patients, frail elderly patients are more likely to have prolonged hospital stays, to lose their mobility and functional abilities; they are more likely to be admitted to residential care, more likely to die.

I am a geriatrician.  I’m not at the glamorous end of medicine and I don’t have a bag full of fancy equipment, tests and treatments.  But within our medical specialty, we do have one intervention that has been shown to improve outcomes for the frail elderly –Comprehensive Geriatric Assessment

CGA means that frail older people are much more likely to be well and living at home 12 months after admission, and much less likely to be admitted to care homes or to die within those twelve months.

CGA is a multidisciplinary assessment of a patient and their physical, psychological and functional needs.  It allows us to develop a personalised, holistic and integrated plan for that patient’s care, now and in the future.  We think about how patients walk, talk, eat, drink, see, hear, think, remember, socialise, mobilise, and take their medications.  We think about how we can make all of those things better and easier for frail elderly people and their carers and families.

We all need to understand and recognise frailty.  Think about it, see it and talk about it, and allow a person’s frailty to influence decisions for their care and future.

Over 18 months we are working collaboratively with other health boards and Health Improvement Scotland to improve recognition of frailty at the front door.

Hopefully, if we get it right we can influence a better outcome, one that recognises and considers the specialist needs of our frail elderly people, one that supports them to continue to live happily and safely in a place that they can call home…

 

“We’ve put more effort into helping folks reach old age than into helping them enjoy it…”

Frank A. Clark, American Politician 1860-1936

 

If you have an interest in frailty and want more information or to become involved in our project please contact   amy.conley@nhs.net or lorna.carr2@nhs.net

Amy Conley is a Consultant in Geriatric Medicine at Dumfries and Galloway Royal Infirmary.

 

 

 

 

Outpatient Parenteral Antimicrobial Therapy (OPAT) – from Cellulitis to Meningioma by Audrey Morris and Shirley Buchan

OPAT as a service has been in use in many countries for the last 30 years. It is a method of delivering intra-venous antimicrobial therapy in an outpatient setting, as an alternative to remaining an inpatient.

The advantages of providing this service for the patient means that they have a reduced hospital stay and can return home and rehabilitate in their own environment. In certain cases the patient can continue to work whilst receiving IV antimicrobial therapy therefore causing them minimal disruption to their daily life. Psychologically the patient feels happier, eats better, sleeps better and is more likely to recover quicker in their own home.

In DGRI the service started in 2012 under the “What if?” project. Its main aim at this point was treatment of non-complicated cellulitis leading to the reduction of patient admissions for short term IV antimicrobials. In the intervening years we have developed to become more involved with complicated infections requiring longer lengths of treatment i.e. up to 12 weeks of IV antimicrobials, but the patient is otherwise fit enough return home.

 
From January 2016 to the end of March 2017 we have released 1419 beds, an average of 3.2 per day. We have treated patients with Cellulitis, Osteomyelitis, Infected Joint Replacements, ESBL, UTI’s, Pseudomonas, Osteoradionecrosis, Lyme disease, Endocarditis, Discitis, Peripheral Vascular Disease, Actinomycosis, SAB, Urosepsis, E-Coli ESBL and Meningioma.

 

Why do we need OPAT?

 
In December 2015 a 30 year old man, who we will call John, was referred to us. He is a high functioning gentleman with Spina bifida who regularly competes in Shot Putt events, all over the World. He had been admitted 6 weeks previously with an infection of his hip. He was clinically improving and ready for home. His family were also keen for his discharge. On discharge John was keen to return to weekly training but due the nature of his infection this had to be put on hold. He attended the clinic daily for 12 weeks either at Dumfries or nearer his home at Castle Douglas Community Hospital, even attending on Christmas day. John had a Hickman line in-site and he decided that in order to assist us he would dress according to which lumen we were using, red top red lumen white top white lumen. He made a good recovery and was discharged from us a year ago. John still phones us now and again and had informed us he is back to full fitness, competing again and even throwing further than before. His one regret he told us, was that due to illness he was not selected for last year’s Paralympics but he is working hard to go the next event in 2020.
So why do we need OPAT? To give people like John an effective patient-focused service as good as inpatient care in an out-patient environment. Our aim is to provide patient centred care nearer to home. In some cases we train the patient or their relative/carer to administer IV antimicrobials in their own home, leading to increased independence and putting the patient at the centre of their own care.

 
Main aims of OPAT.

 
Clinical
To provide a high quality efficient clinical service using robust pathways, guidelines and protocols.
Reduce inpatient time and therefore reduce the risk of hospital acquired infections.
Develop the service to meet the changing demands on an overstretched service. With the opening of the new hospital imminent and the call for care nearer to home OPAT can help reduce demands on beds.
Patient.
Improved quality of life for patients. They eat better, sleep better and generally feel better in the own home environment.
Increase patient involvement in delivery of care, continuity of care and communication.
Provide ongoing support at home and utilise a pathway for re-admission if required.
Organisational.
Reduce the length of inpatient stays therefore utilising acute beds more efficiently.
Structured pathway from referral to discharge.
Staff development.

Patient journey from Inpatient to OPAT patient.

 
We aim to make the transition from inpatient to OPAT patient as quick and painless as possible but have to follow guidelines. Once a patient has been identified by their Consultant as a potential OPAT patient the first step is to complete an SBAR referral form (In Beacon use ‘search for document’ option). On receipt of this we visit the patient to assess them and their needs for OPAT. There are certain criteria which must be met but these are listed on our SBAR referral form and should be considered prior to referral.
The patient is then seen by our Consultant and the OPAT nurse team. If they are suitable and want to become an OPAT patient then the discharge process can begin.
So in summary OPAT provides patient centred care led by a small dedicated team. It clearly reduces the length of inpatient stays, which can be from 2 days to 12 weeks. Patients are very much involved in the method of delivery of their care, they can opt to be trained to do it themselves at home or we try to deliver care as near to their home as possible. We work around their commitments e.g. an elderly patient who has carers in the morning can get a later appointment or in the case of the patient who continues to work we can see them early in the morning to allow then to get to work. Patients feel better at home, they sleep better, eat better and psychologically feel better. They are more in control of their treatment and have continuity of care.

In the words of one of our patients we “made a bad situation better”.

Audrey Morris & Shirley Buchan are Clinical Nurse Specialists in the OPAT team.

The Pneumonia in Bed 5 by Sian Finlay

Although it is sometimes easy to forget it amongst the busyness of front line clinical duties, I am a person.  I suspect many of you are too.  Occasionally I am unwell, but I consistently find that I still remain a person during this period – I have never yet become a disease!  So why is it that when patients come into our care, we so often default to calling them by their diagnosis instead of their name?  Go onto any ward and I guarantee it will not be long before you hear someone described as ‘The Chest Pain’ or ‘The Pneumonia’.  Many handovers will include phrases such as ‘He’s a UTI’.

No, he isn’t! He’s a PERSON who has a UTI!

A common (and potentially even worse) variant of this is the ‘bed number’ name, exemplified by ‘Bed 3 needs the commode!’  Sometimes attempts are made to justify this practice with the excuse that it protects confidentiality, but let’s be honest here.  The truth is that it simply demands more mental effort to remember the patient’s name and we are taking a short cut.  All very understandable in a busy environment, and I really don’t blame anyone.  You might think it is just semantics anyway – what does it matter if we call someone ‘The GI bleeder’?  Well I argue that it does matter.   More than you think.  These patients are people, no less complex and emotional and fragile than you or me.  By depersonalising them, we are subtly starting down a path which allows us to forget this; which allows us to view them as tasks in our day rather than the individuals they are.  If you are unconvinced, try this little exercise; read these 2 sentences and see if they elicit the same emotional response in you:

Bed 5 is agitated.

Tommy is agitated.

Would you agree that the second sentence immediately makes us feel more empathy and compassion towards its subject?

Many people will be aware of the late Kate Granger, the inspirational doctor who responded to her diagnosis of terminal cancer by establishing the ‘Hello, my name is..’ campaign.  Sadly Kate died last year, but her campaign lives on and has touched many of us in the healthcare profession.  But Kate’s work didn’t begin and end with wearing a smiley badge with our name on it; it is in essence about remembering the humanity of our patients and treating them as fellow human beings.  And I can only imagine Kate’s fiery reaction if she ever overheard herself being referred to as ‘Bed 5’!!

But we are all under pressure.  What if we genuinely can’t remember the patient’s name and are just trying to communicate information quickly?  Surely that doesn’t make us uncaring?  Of course it doesn’t, but in times of acute amnesia, we could at least say ‘the man with pneumonia’ rather than ‘the pneumonia’.  And that should only be a holding measure until we can remember his actual name – surely essential for safe communication anyway!

I hope I have convinced you that words do matter.  The phrases we use set the whole tone for the level of kindness and empathy we expect in our clinical areas.  So if any of this resonates with you, I hope you will lead by example.  Look at your patients and remember they have hopes and fears and histories and personalities…and almost always names!!

Sian Finlay (aka ‘The Migraine on ward 7’) Acute Physician and Clinical Director for Medicine at NHS Dumfries and Galloway