Dr Amy Heskett works as a Speciality Doctor within the West Kent Urgent Care Home Treatment Service. This team aims to prevent hospital admissions by working alongside GPs, nurses, carers and paramedics to provide a holistic management plan. She writes a blog about her experiences on her blog communitydoctoramy.wordpress.com and can be found on twitter @mrsapea
The West Kent Home Treatment Service provides home-based medical treatments to avoid hospital admissions when appropriate. Referrals come from GPs, Community Nurses and Paramedics; but more importantly our team widens as soon as we start to work with patients, their family and carers.
A day of referrals began with a call from a Paramedic who had attended V after she had fallen in her bedroom, but luckily sustained no injury. This was on a background of dementia and the need for daily support from her son to assist with meals, prompt medications and support trips made outside the home. V’s only other medical history was that of hypertension and one fall a year ago. V was normally able to get herself to the toilet and used a stick to mobilise slowly indoors; while carers attended once a day to provide personal care.
The Paramedic had already obtained a collateral history that V’s gait had been getting gradually unsteady over the last few weeks. The Paramedic reported V’s vital signs were within normal limits, that the ECG was sinus rhythm and there were no signs of infection. The family had identified V had been more dependent since a hospital admission a year ago, therefore they were keen to keep mum at home if possible. The paramedic had already moved the commode next to the bed to minimise transfers; he also established access was possible via a keysafe and that family were happy to stay overnight.
We headed straight upstairs and found V lying on her side in a hot bedroom; there was occasional confused speech and evidence of inattention. Additional clinical signs identified were evidence of urinary incontinence, a reduced skin turgor, dry mucous membranes and a moisture lesion of 2cms on the sacrum.
Clinical assessment in a person’s home often has to be made in a random order because it is dictated by the need to quickly determine suitability for treatment at home. In this case the family were understandably concerned and exhausted; the main thing to determine was whether urgent treatment was required, if the family/carers were able to support V and whether there were any advanced decisions.
The family went to have a well-deserved break while we placed a cannula, took a blood sample and our HCA encouraged V to remove her cardigan and sit in a more supported position. During this our portable analysers had confirmed a normal white cell count and revealed a sodium of 118 mmol/L with a raised urea. I attached a 250ml bag of Normal Saline to drip slowly through the cannula and left V with the HCA so that I could discuss the plan with V’s family.
V’s son already knew that her condition was serious and understood blood tests indicated a severe change in blood chemistry that could cause her to become suddenly unwell. It was likely the sudden arrival of summer and the use of a thiazide diuretic had caused dehydration, a delirium and a reduction in functional level. I discussed the risks of management at home, but the family stressed that V had previously stated she would not want to be hospitalised. My discussion led to the topic of resuscitation status and the family felt this would not be in their mother’s best interests or in keeping with V’s wishes.
The current dossett (containing statin, thiazide and aspirin) was stopped until a new one could be issued without the diuretic. I arranged for the Rapid Response nursing team to attend in the morning and reassess observations and progress. A DNAR form was completed and a care plan was left in clear view and communicated to the GP and ambulance service via their patient database. Returning upstairs I found the HCA had placed a newspaper on a table and was looking at stories and surrounding family photos with V while she sipped at a cup of tea. This expert process of re-orientation was made simpler because V was in familiar surroundings.
Re-assessment the next day found V more alert; we were able to encourage her to the commode, obtain an MSU and place some barrier cream on her sacrum. Although the family had seen progress they understood that V was still very vulnerable and that they could call for support if required. A repeat sodium was 122 mmol/L and within a few days V’s mobility improved; carers were able to support her once again and V responded well to their familiar routine.
Prior to discharge V’s son understood that his mother could deteriorate again and therefore the family moved her bed downstairs to allow easier care if the need arose again. Furthermore, the family recognised there had been a progression in V’s dementia and agreed to a hospice referral for further support.
The Paramedics act as our eyes and in the above case the safety of the social network was balanced against the perceived risks of transfer to an acute hospital. In this way they act as our frailty detectors and recognise a further ambulance will be called unless a clear plan is made. Admission avoidance requires the extension of the role of every team member and is demanding on both clinical and emotional levels. However, the chance to be involved in every aspect of care and to receive support from a variety of team members makes the challenge a rewarding one.