Tuesday, November 17, 2009

Thinking about my time on ortho/surgery now

Ive been thinking about how things work on the ortho ward... As usual it is fast paced and busy at times and I try my hardest to see all patients with an occupational need!
But of course there are times when that is not possible and I cannot see patients that are lower priority e.g. awaiting a bed in rehab.
At present the process is, that once on the waiting list for rehab the patient is definitely going to have a period of rehab no matter what performance gains they make in the period on the acute ward.
I feel that if a patient could be discharged from the ortho ward and return to the community with support without a period of rehab, then this is appropriate. However there have been a few cases recently where patients have gone to rehab reluctant of whether they really need to.
I'm trying to think about if it is feasible to provide intense input on an acute ward, whilst managing the elective patient, influx of surgical referrals and the other acute patients.
In a perfect situation, all patients could be OT sorted from the acute ward if they are making great gains in their mobility, and their cognitive function is intact enough to be aware of their occupational performance and accept the support they need to make gains in their occupational performance in the community.
The first thing I need to think about is what type of input is necessary to enable a safe discharge for a patient, and not necessarily having a period of rehab.

Lets try an example -A common occurrence

An elderly patient, say an 80 year old patient that lives alone, and has previously been quite independent, and is cognitively intact.

The patient has had a fall and has fractured their NOF. Day 1 after surgery they are referred to rehab, based on the fact that they were previously quite independent, and a period of rehab will help them return to their previous level of occupational performance.

Day 2 the patient is up and mobilizing with the physio and requiring 1 or 2 people to assist them. They are also having some assistance with their personal cares.

Day 3 the patient is accepted for rehab and put on the waiting list, hoping to get over to rehab within a couple of days.

Day 3 or 4 the occupational therapist could do one of three things
a) notice that the patient has been accepted for rehab and try and see them if they can to smoothen the transition from acute to rehab wards


b) not have any time to see the patient because of other patient demands


c) assess the level of occupational performance, set goals and begin working on increasing independence and safety with ADL's

Ideally, c) would be the aim. Either way the patient would be benefiting from commencing OT input.

We have the odd patient, who at day 4 gets up, the pain is under control, they are mobilising quite well and they are having minimal assistance with ADL's
This is when i think it would be appropriate to determine whether the patient could get home from the acute ward, or whether rehab is needed.

Unfortunately, we have limited control, as they are called up for a rehab bed, the patient and family thinks they are going to rehab, and the rest of the MDT are going along with the fact the rehab is the plan.

So here comes my thoughts.

At day 4 we have a better understanding of the impact of the injury on the patients occupational performance and mobility. Is it not more appropriate to assess whether or not rehab is required then? I think so!
Their are political influences currently, that we cannot really change that stops us from saying hang on a minute - they dont really need rehab!

So the patient ends up going over for rehab for a minimum of 10 days - some times not appropriate at all.

Where should our resources be used?
Spending the time - maybe a couple of days in the acute wards more than usual to work on increasing occupational performance, confidence and mobility?
Or should we send the mobile patients that are struggling a little over for 10 days of input?

This is where, i believe we should give patients more time on the acute wards...
But again we come back to the question.....is this feasible??

I dont think this is an easy question to answer, and I dont think in the interim we are going to sort this out.
But perhaps for what it is worth, when we have time to spend more time with the patients awaiting for rehab we should monitor what gains we are making and record if we think patients could have been discharged from the acute ward.

Then we come to the issue of time management on the ward. Definitly, at times we can have more input with the patients awaiting rehab than at other times. It depends on a variety of things...usually whether or not the surgical ward has referred alot of patients for us.

That is another kettle of fish! The referrals from there i mean..
Perhaps some education and setting up some processes for the surgical ward would make us be able to manage the referrals from there alot better, and cut out alot of the inappropriate referrals.

I think thats the place I need to start, then figure out whether or not their is time to sort patients from the acute wards

The patient in the example above, the patient who has had a NOF - fixed with a DHS - no precautions. Can be treated just like any other patient. Depending on the patient, a home visit is not always essential, yes assessing their function and working on activity tolerance and activity performance is needed, but I think it is definitely achievable.

Something to keep thinking about I think


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