Rotation 3 Fourth Year - Discharge Planning STARES

Situation
An 89 year old man was admitted to Hollywood Private Hospital on the 17/5/10 after a CVA – a left LACS. We were not introduced to the gentleman until the 20/5/10 where he had been to SCGH ED, and transferred to Hollywood Private Hospital. He already had a physiotherapist looking after him, so he was just an interesting case for us to look at until he was transferred down to the rehab ward. Due to other complications with his heart and multiple falls he was having he was a hard man to get in to see and his physiotherapy care could be described as intermittent at best. Once he was stabilised he was sent to rehab ward and was officially a patient of mine.

Task
My task was to assess and treat this patient accordingly.

Action
I decided to do a full initial assessment on the patient as my knowledge of his impairments and social situation was patchy at best. On initial assessment he appeared to have minor right-sided weakness of the UL and LL and some cognitive and perceptual deficits, namely agnosia and dyspraxia. His Berg Balance score was 49/56 with all of his scores being a 3 or a 4 except for single leg stance where he received a 1. He appeared to lose his balance with functional tasks such as dressing and leaned to the right with ambulation. He ambulated with no aids and only supervision for ~80m. I decided to focus his treatment on improving his balance and his awareness of his impairments, especially during functional tasks. He was progressing very well, with his Berg Balance score increasing to 53/56, he was able to keep his balance during functional tasks, he understood that his balance was not great and not admitted so and he had no more falls.

I had taken a social history initially, finding that the patient lived with his wife and they shared most of the tasks around the house. They lived in a retirement village with services and amenities at their doorstep and no stairs at all. He also has 3 very supportive children to help him out. I was very happy with him going home as long as he was supervised at all times and there were services put in place to assist him where needed. The discharge planning at Hollywood Hospital is a multidisciplinary process – generally. However, every now and again a doctor will decide to discharge a patient without input from the nursing or allied health teams. In this case I was convinced that the doctor and social worker were clear on his limitations however, the doctor decided that the patient would be discharged in two days, didn’t tell the patient or the family and had not organised the social worker to discuss the issues related to discharge planning.

When visiting the patient that day one of the nurses mentioned that he was going to be discharged in two days time thinking that the family was aware of the fact. The family were irate, and quite understandably. They demanded a family meeting to discuss the issues and I was able to put forth my opinion on his status and what he required.

Result
In the end it was decided that the patient would go back to his house with his wife and services for meals, cleaning and outpatient physiotherapy. The family was very happy with the outcome as were the medical and allied health teams.

Evaluation
This situation really highlighted the need for appropriate and timely discharge planning that includes every member of the team involved in the care of the patient. A family meeting should have been organised within 7 days of the stroke to discuss with the patient’s family what has happened, what his impairments are, the prognosis and what the plan is for moving forward. This would keep the family involved and informed and would help them in motivating the patient to reach their goals.

Another family meeting should also occur a week or so prior to discharge to discuss issues such as the patient’s discharge destination, the services they require, the skills they need to function once they have left and any ongoing issues either the family or the medical team have in regards to the patient.

This situation also made me realise the need to be on the ball with patient’s care. It is not good enough for me to assume that the doctor is listening to me in the meetings and leave it at that, but instead I need to be questioning them about their intentions for discharge and what they have in place for the patient. This is the second time that the allied health team has had to put their foot down and not allow a patient to be discharged and both times I believe the patient was much better off because of it.

Strategies
As I said above, I believe that it is important that communication between the patient, family, medical team and allied health team is open and regular and that each issue a party has to bring to the table is discussed fully and resolved appropriately. A formal discharge planning/family meeting timeline for stroke should be put in place as this would ensure that everyone is kept informed and all issues are resolved when they need to be.