Practice Placement Case Study

Presentation
Participants name:-
Occupational Therapy in Emergency
Medicine 
 National Service Framework for Older People (2001) called for an action plan to improve
discharge process through a more integrated multidisciplinary service  Ability to
perform basic activities of daily living often overlooked (Smith and Rees, 2004)  OTs
well placed to provide assessment and intervention at time of initial admission 
Addresses the unmet functional and performance needs of older adults (Cusick, Johnson
and Bissett, 2009) 3
Overview of Case Study Referral

   Sheila (pseudonym) – 84 years old  Admitted to the Emergency Department (ED)

following a mechanical fall at home  Sustained left lower limb injury and decreased
mobility  Referred to OT to assess potential for safe and appropriate discharge home
from ED Presenting Situation  No fracture sustained  Sheila currently ‘off legs’ and
reportedly has been unable to weight bare since admission to ED  Past Medical History
– cerebrovascular event (CVE) 4 years ago resulting in expressive dysarthria and left
sided weakness
Falls and Older People

 Prevalence
  30% of people aged over 65 and 50% of people aged 80 and over fall at least once a
year  More than 600,000 people per year aged 65 and over are admitted to A&E
following the result of a fall Cost  Estimated cost to the NHS of £2.3 billion per year 
Injury, pain, loss of confidence, emotional distress and loss of independence (Boye et al.
2013)  Often, falls go unreported and unacknowledged, preventing appropriate
assessment and onward follow- up by falls prevention services 6 (Great Britain.
Department of Health, 2007; National Institute for Health and Clinical Excellence
(NICE), 2013; College of Occupational Therapists (COT), 2013)
Assessment Process Information Gathering

  • Reviewed medical and nursing documentation • Not awaiting further medical assessment or
intervention • Sheila medically fit for OT to assess the potential for safe discharge home Initial
Interview • Consent gained from Sheila for OT assessment • Lives alone in a bungalow • Has
twice a day long term package of care to assist with personal ADL • Reportedly mobilises with
walking stick on her right side • Independent with all transfers on and off bed, chair and toilet –
has assistive equipment to aid her • Reportedly falls ‘often’ at home Verification • Contacted son
who lives locally to verify information from Sheila • He assists her with domestic ADL during
the week • Happy with Sheila’s current support from care agency • Is worried about her frequent
falls • No other concerns about his mother’s well-being apart from her falling and sustaining
more serious injury Assessment of Occupational Function • Assessed Sheila’s ability to remain
independent in her functional occupations – transfers from lie to sit to stand and mobility with
front wheeled frame • Sheila’s confidence reduced since fall and feeling more unsteady as a
result of this • Identified how Sheila’s current function compares to her pre- morbid level
Occupational Performance Adapted from law

  Maintains core professional values  Flexible in its approach to addressing

occupational performance (Maclean et al. 2012)  Demonstrates the importance of
‘interdependent interaction’ (Law et al. 1996)  Provides a meaningful framework to
address the challenges of an acute setting (Maclean et al. 2012) Person
EnvironmentOccupation Occupational Performance • Role • Motivation • Interests •
Needs • Cultural • Socioeconomic • Institutional • Physical • Social • Self-care •
Productivity • Leisure Person-Environment-Occupation Model
Mobilises with support of walking aid

  • Left sided weakness – limits occupational function • Able to perform domestic and
personal ADL • Has support at home from carers to assist with ADL she struggles with •
Independent with all transfers – has some assistive equipment • Active in social
community • Motivated to go home • Wants to remain as independent as possible in ADL
• Feels she is managing with current levels of support • Has family and friends around her
• Lives in a bungalow that is all on one level • Has equipment to aid occupational function
• Lives close to local amenities • Able to enjoy gardening and the view from bedroom
window • Reports falls have been a result of left leg weakness rather than environmental
factors Result of the transactive relationship between person, environment and occupation
Maintaining the desired level of occupational performance
Aims and Objectives of Occupational Therapy
Intervention

 Strengths and Needs Identified from Assessment  Mobilises independently with aid of
stick  Independent with all functional transfers – has assistive equipment at home  Has
in place twice daily package of care to assist with personal ADL  Good level of support
from son  Motivated to return home and remain as independent as possible  Aware of
own capabilities Strengths  To regain pre-morbid levels of occupational function Needs
  To discharge home from ED today To independently transfer from lie to sit within 15
minutes To mobilise independently up to 10 metres with support of walking aid within 1
hour To walk to toilet with supervision and complete all personal care, within 1 hour To
independently stand with support of walking aid for 20 seconds To mobilise 4 steps from
bed to chair with support of walking aid within 15 minutes To mobilise up to 5 metres
with supervision, within 30 minutes (Social Care Institute for Excellence, 2013) To
increase confidence in mobility To be independent with personal transfers To
independently transfer from lie to sit within 15 minutes To independently stand with
support of walking aid for 20 seconds To mobilise 4 steps from bed to chair with support
of walking aid within 15 minutes To mobilise up to 5 metres with supervision, within 30
minutes
 OT to encourage independence in transfers by ensuring the bed is lowered to appropriate height • Sheila to transfer from lie
to sit with independence. OT to provide assistance if needed • OT to ensure Sheila is wearing non-slip footwear • OT to
continue to advise on risk assessment and prevention to ensure safe transfers • OT to provide Sheila with information pack
containing information on future support services • OT to locate front wheeled walking frame and ensure frame is fixed to
an appropriate height for Sheila • OT to advise on safe transfer method to reduce risk of injury or fall • Sheila to stand and
gain balance with support of walking frame. OT to provide assistance if needed • Sheila to stand with support of walking
frame for 20 seconds • Sheila to mobilise from chair to toilet with support of front wheeled frame. OT to supervise • Sheila
to complete all personal care and transfer independently from toilet. OT to assist if needed • Sheila to mobilise back to the
bed with support of front wheeled frame. OT to supervise • With Sheila’s consent, OT to refer Sheila to the local falls
prevention service for further support • OT to issue front wheeled walking frame for Sheila’s temporary use at home • OT
to contact Sheila’s care agency to inform them to re- start package of care on discharge • OT to advise on weight bearing
technique to prevent pain or further injury • Sheila to mobilise to chair with supervision of OT • Sheila to mobilise out of
the bay with support of front wheeled frame. OT to supervise • Sheila to mobilise up to 5 metres with supervision from OT
• OT to ensure Sheila can change direction safely by assessing her ability in figure-of-8 walk test. OT to monitor Sheila’s
gait and balance and advise on safety techniques Short Term Intervention (up to 30 minutes) Long Term Intervention (up to
1 hour) Further OT Intervention to Support Discharge
Intervention - Referral to Falls Prevention
Service

  Falls are leading cause of accident-related mortality (Jones and Whitaker, 2011)  The
majority of risk factors that result in falls can be prevented (COT, 2013; NICE, 2013) 
The most effective prevention is a multifactorial falls risk assessment undertaken by a
falls specialist (Great Britain. Department of Health, 2001)  Ensures appropriate follow-
up and assessment in order to reduce the risk of further falls  Shown to decrease the rate
of older people falling in the community (Logan et al. 2010; Campbell and Robertson,
2013)  Further information, advice and referral is often overlooked by the MDT (Lee et
al. 2013) 17
 Further Considerations for Discharge Planning 18  MDT liaison  Contact Family 
Equipment provision  Documentation Staff nurse, ED coordinator, ED consultant, care
agency Inform of plan for discharge, arrange transport home Ensure patient receives
appropriate guidance/information Documentation of all patient / community contact
Subjective Objective Analysis Plan (COT, 2010; Health and Care Professions Council
(HCPC), 2012)
Ethical Considerations in the Emergency
Department

  Intervention carries higher risk due to the emergency nature of patient presentation 
Important to respect the patients wishes even if it contradicts your planned intervention 
Family dynamics  Duty of care to all people (Mid Staffordshire NHS, 2013) 19 ‘The
Standards of Conduct, Performance and Ethics’ (HCPC, 2012)
institute for Health and Clinical Excellence
Guidelines

 for the Assessment and Prevention of Falls in Older People (2013)  National Service
Framework for Older People. Standard six: Falls (Great Britain. Department of Health,
2001 - Modified 2008) Best Practice Guidelines  Urgent Care Pathways for Older
People with Complex Needs – Falls Care Pathway (2007)  College of Occupational
Therapists Falls Management Guidance (2013
Ongoing Assessment and Outcome
Measurement

  No standardised occupational therapy outcome measures used on a regular basis in this

setting  Not widely used in ED due to the short period of time spent with patients
(Cusick, Johnson and Bissett, 2009)  This despite evidence that standardised
assessments contribute to a more holistic approach to risk identification in acute hospital
settings (Robertson and Blaga, 2013)  Barthel Index of Activities of Daily Living and
Functional Status Assessment of Seniors in the Emergency Department (FSAS-ED) can
more reliably determine the current occupational function of older adults in ED (Veillette
et al. 2009; Bissett, Cusick and Lannin, 2013) 21
  Reflection Occupational Therapy in Emergency Medicine Loses the occupational focus
Limited evidence Close MDT working Limits time spent in hospital