Welcome

to

St Joseph’s

Rehabilitation Unit

Open Day

Wednesday 13th October

Topics for this afternoon

• Introduction to the unit and the team

• Patient Demographics and Statistics

• St Joseph‟s MDT Falls assessment screen

• COOP/WONCA – QOL Outcome Scale

• Case Study

• New developments for Older Patients

attending Beaumont & St. Joseph‟s

Hospital

Introduction

Liz McArdle

Clinical Nurse Manager

• Rehabilitation

• Our Mission Statement

• The Rehab unit

• Communication within the unit

• Interdisciplinary Team working

This presentation

What is ‘Rehabilitation’?

• “The rehabilitation process should ideally help the patient in the process of moving from being a patient to being a person and only stop when a new, stable state has been reached” (Wade, 1999)

• The purpose of rehabilitation is to restore some or all of the patient's physical, sensory, and mental capabilities that were lost due to injury, illness, or disease. Rehabilitation includes assisting the patient to compensate for deficits that cannot be reversed medically (http://medical-dictionary.thefreedictionary.com/)

What is ‘Rehabilitation’?

Our Mission Statement

St Josephs‟ Rehabilitation unit aims to assist

patients to reach their full potential through

an interdisciplinary team approach. Using a

person centred and holistic approach to

care, patients are encouraged to reach their

maximum level of independence. The unit

aims to deliver the highest quality and

standard of care for older people.

St Joseph’s Hospital

• Under the management of Beaumont

Hospital Board

• Therefore strong links with the services

and departments in Beaumont

Rehab Unit Accommodation

• 18 beds– 2 single rooms ensuite

– 1 x 4 bed room ensuite

– 4 x 3 bed rooms ensuite

• CNM, SLT and MSW office on the ward

• Nursing station on the ward

• OT Kitchen on the ward

• Rehab Gym on the ground floor

• Dining room/recreation room on the ward

• Garden

Ward

OT Kitchen

Garden

Services Available2 Physiotherapists

2 Occupational Therapists

1 Medical Social Worker

1 Speech and Language

Therapist

2 Rehabilitation Assistants

1 Porter

1 Dietician (1 day per

week)

1 Pharmacist

1 Ward Secretary

11.5 Staff Nurses

1 CNM 2

3 Healthcare Assistants

Housekeeping staff

Medical staff:

1 Reg and 1 SHO

Dr Deepak Gopinathan,

Consultant on site

Dr Donegan and Dr Moore

visit 1 day per week

Communication within the unit

• Progress meeting

– Once weekly on ward

• MDT

– Once weekly ward round and MDT meeting

• Communication Board

– Therapy and activity times recorded

• Staff picture board

Interdisciplinary team working

• Joint therapy sessions

• Progress and MDT meetings

• Activities on the ward

– Meals in the dining room

– ADL‟s

– Social activities

• Patient Centred Goal setting

– Number of Pilots since 2005/2006

– Now tailored to be more efficient

• PCCC

• Public health nurse

• Community rehab team

• Baggot Street Stroke Unit

• Community therapists

• Home care packages

• Home help

• Home first

• Meals on Wheels

• Etc

Community links

Patient Demographics and

Statistics

Noeleen Hughes

Senior Dietician

Patient Demographics and

Statistics

• Each profession collects information about

a patient and their progress on admission

and discharge

• New data collection system developed in

2009 to include all professions

• Based on Microsoft excel

Patient Demographics and

Statistics

• Presenting data on all patients discharged in 6 month period of July to December 2009:

– Number discharged

– Age profile

– Main Diagnostic categories

– Location discharged to

– Length of stay

– Referrals to community services

Number Discharged• Total No. of Patients: 74

Male/Female

Male

Female

Sex N %

Male 31 41.9%

Female 43 58.1%

Age

• Mean age: 79.22

• Age range: 63 - 91

Group N %

60 – 69 7 9.45 %

70 – 79 27 36.48%

80 – 89 39 52.7%

> 90 1 1.35 %

Age

Age Categories

60-69

70-79

80-89

>90

Diagnosis

Group N %

1: CVA 17 22.97%

2: Deconditioned 20 27.02 %

3: Recurrent Falls 13 17.57%

4: Parkinsons 8 10.81%

5: Hip Replacement 4 5.41%

6: Lower Limb Fracture 2 2.71%

7: Upper Limb Fracture 1 1.35%

8: Other 9 12.16%

Diagnosis

Diagnosis

CVA

Deconditioned

Recurrent Falls

Parkinsons

Hip Replacement

Upper Limb #

Lower Limb #

Other

Discharged to

Location Number(%)

Beaumont Hospital 4 (5.41%)

Home 59 (79.73%)

Unit 2A 5 (6.76%)

Long term care setting 5 (6.76%)

Other (RIP) 1 (1.35%)

Discharged to

Discharged to

Beaumont Hospital

Home

Unit 2A

Nursing Home

Other

Length of Stay

Group N Mean SD Min Max

CVA 17 89.7 64.4 12 213

Deconditioned 20 42.7 28.6 13 111

Recurrent falls 13 36.7 41.1 5 169

Parkinson‟s disease 8 37.3 27.8 11 92

Hip Replacement 4 17 11.8 7 34

Lower Limb fracture 2 37 16.9 25 49

Upper Limb fracture 1 48

Other 9 26.8 17.2 7 53

Referrals to Community Services

Total Number

discharged home

62 (59 DC home directly +

3 DC home from 2A)

Number % of Total

Home Care Package on Adm 9 14.5%

New Home Care Packages 10 16.1%

Total DC home with HCP 19 30.6%

Home Help on Adm 15 24.1%

New referrals for HH 11 17.7%

Total DC Home with HH 26 41.9%

Day care service referrals 9 14.5%

Meals on Wheels 8 12.9%

Referrals to Community Services

Services Number % of Total

PHN 62 100%

Community

Rehab Team

25 40.3%

Home first 4 6.4%

Community OT 20 32.2%

Community SLT 4 6.4%

St.Joseph’s MDT Falls

Assessment Tool

Ciara O‟Reilly

Senior Physiotherapist

Standard practice

• Medical: Review of Medications and

medical factors contributing to falls risk

• Nursing: Stratify assessment

• Physio: BERG, TUAG, Rhomberg, gait

and transfer assessment

• Occupational therapy: Functional

assessment, cognitive assessment, home

environment assessment.

HSE falls and fracture

prevention 20081

• Older persons who:

1. Have recurrent falls (2 or more in the last year)

2. Had an unexplained fall

3. Have problems with gait and balance or

4. Have a fear of falling

should undergo a multi-factorial assessment carried out by an experienced clinician.

• Following a multi-factorial assessment older people should receive a tailored multi-factorial intervention as clinically indicated.

ST. JOSEPH’S REHABILITATION UNITMDT Falls Assessment Form

Medical Nursing

Admission Admission

Discharge Discharge

Physiotherapy Occupational Therapy

Admission Admission

Discharge Discharge

Section 1: Medical

QuestionScoring Adm Score D/C Score

Does the patient have any of the following conditions?ÿ1 Arthritisÿ2 Parkinsonism (PD/MSA/PSP/CPD/Vasc)ÿ3 Dementiaÿ4 Visual impairmentÿ5 Diabetes-including hypoglycaemia, PVD, footcareÿ6 Cardiac conditionÿ7 Respiratory conditionÿ8 Lower limb amputationÿ9 Peripheral neuropathyÿ10Stroke/ Higher level gait disorder due to cerebrovascular diseaseÿ11Vestibular conditionsÿ12Orthostatic hypotensionÿ13Other medical condition that affects patient’s balance or mobility

None apply (0)1-2 applies (1)3-4 applies (2)>5 applies (3)

Action Taken

Question Scoring Adm Score D/C Score

Does the patient take any of the following medications?ÿ1 Sedativeÿ2 Psychotropic ÿ3 Diureticsÿ4 Analgesiaÿ5 Anticonvulsantsÿ6 Antiparkinsonian medsÿ7 Antihypertensivesÿ8 Vasodilator/ cardiac medsÿ9 Antidepressantsÿ10 Vestibular suppressants

None apply (0)1-2 applies (1)3-4 applies (2)>5 applies (3)

Delirium: If present (1) Not present(0)

Section 2: Nursing

QuestionScoring Adm

Score D/C Score

Action Taken

Mental Status Forgets limitations (1)Orientated to own ability (0)

Disorientated to their surroundings

Yes (1)No (0)

Environmental factors altered Yes ÿNo ÿ

Nocturia Yes (1) No (0)

Sleeping Tablet Yes (1) No (0)

Falls history None in last 12 months (0)1 or more between 3 -12 months ago (1)

1 or more in last 3 months (2)

Complete falls mechanism below

Fall mechanism Fall 1 Fall 2 Fall 3

Slip/ Trip

Lost balance

Collapse

Leg/s gave way

Dizziness

Section 3: Physiotherapy

QuestionScoring Adm score D/C score

Timed up and go <13.5 seconds (0)>13.5 seconds (1)

BERG balance scale >45 (0)36-45 (1)<36 (2)

Sensory integration and balance tests Foam with eyes closed > 30 sec (0)Foam with eyes open >30 sec (1)Firm base eyes closed> 30 sec (2)Firm base eyes open >30 sec (3)Firm Base eyes open <30 sec (4)

Does patient have foot problems: (Please Specify)(e.g. Bunions, gout, toe deformities)

No (0)Yes (1)

Footwear Assessment:

An inaccurate fit Poor grip on soles Flexible heel counter Heels >2cm high/ < 3 cm wide In-flexible sole across the ball of the foot No fastening mechanism Slippers/inappropriate footwear

None apply (0)One applies (1)Two applies (2)Three applies (3)

Mobility : Independent, no aid needed (0)Independent and gait aid needed (1)Supervision needed (2)Physical assistance needed (3)

Lower limb muscle strength: No weakness (0)Weakness present in one lower limb (1)Weakness present in both lower limbs (2)

Does the patient have an uncorrected sensory deficit?

Vision: Yes (1) No (0)Somatosensory: Yes (1) No (0)

Question Scoring Admission Score D/C Score

MMSE Normal = 0 (24-30)Mild -mod = 1(16-23)Mod-severe = 2 (0-15)

Functional Performance Independent (0)Supervision (1)Assistance x 1 (2)Assistance x 2 (3)

Personal CareWashing =Dressing=Functional T/FsChair =Bed =Toilet =

Personal CareWashing =Dressing=

Functional T/FsChair =Bed =Toilet =

Fear of FallingFalls Efficacy ScaleInternational (FES-I)

> 23 (0)< 23 (1)

Home environment Home Ax carried out Yes No Risks within Home environment Yes (1)

No (0)

Visual Perceptual Deficits Yes (1)No (0)

References

1. HSE Strategy to Prevent Falls and

Fractures in Irelands ageing Population,

2008

COOP/WONCA

Una Donnelly

Senior Medical Social Worker

What is

the COOP/WONCA?

• The aim of COOP/ WONCA charts

are to provide a patient-centred

instrument to measure an individuals

viewpoint on their functional status

and quality of life.

• Our aim in using this instrument is to

seek the patients perspective.

COOP/WONCA

• Health status, functional status and

quality of life are closely related.

• Reflect a patient rather than disease

oriented approach.

• Provides relevant information for

individual and personal care.

The concept of Quality of Life

Functional Status

HealthQuality of Life

COOP/WONCA Charts

• Charts measure 7 core aspects of functional status and quality of life.

– Physical Fitness

– Feelings

– Daily Activities

– Social Activities

– Change in Health

– Overall Health

– Pain:

COOP/WONCA Charts

• The instrument consists of 7 Quick and simple questionnaires in chart form

• Each chart consists of:

– a simple title

– a question referring to the status of the patient

– 5 point ordinal response scale ranging from „not limited at all‟ to „severely limited‟

– Each step of the scale is illustrated with a simple drawing

• Each item is rated on this five-point scale ranging from 1 („no limitation at all‟) to 5 („severely limited‟)

• Scoring: Min score=7, Max score= 35.

COOP/WONCA Charts

• The Coop/Wonca charts reflect the patients‟ assessment of his/her functional capacity and quality of life at the given time.

• Patients are asked to use the time scale of the

past two weeks.

• Administration: The patients themselves answer the questions. If the patient cannot complete the charts, a Healthcare Assistant who knows the patient well assists.

• Questionnaire is administered within 2 days of admission and just prior to discharge

The use of COOP/WONCA

Charts

• Scores can be directly compared with the

individual patient's earlier scores.

• The questionnaire gives important information

about:

– Social and functional capacity

– Patients views on their quality of life

– Outcome of interventions during inpatient

stay.

– Provides information concerning the patient‟s

coping with illness

Case Study

Sinead Duddy

Senior Occupational Therapist

Anne Healy

Senior Speech and Language Therapist

Case Study

• Mr John Smith

• 65 years old

• December 2009: Presented with

cerebrovascular accident (CVA) with

dense right hemiparesis and aphasia

• CT Brain: Left middle cerebral artery

infarct.

Arterial circulation of the Brain

History

• Past Medical History:– Heavy Smoker

– Work related back injury (x20 years ago)

– Excessive Alcohol consumption

• Social Background:– Lived with wife & son in two storey house

– Daughter and another son living in Dublin

– Retired Builder

– Fully independent

– Complex family dynamics

Beaumont Input

• Admitted to Beaumont via A&E and

transferred to Acute Stroke Unit

• Assessed by Acute Stroke Unit MDT

Beaumont Input

• Initial presentation

– Hoist transfer

– Full assistance for washing & dressing

– NG feeding due to dysphagia

– Severe aphasia

• Rehab process commenced in Beaumont

• Transferred to Rehab Unit in February

2010

MDT Assessment in Rehab Unit

Dietician

Medical

Nursing M.S.W.

O.T.

Physio

SLT

John

Profile on Admission

• Dysphagia resolved

• Communication

– Severe aphasia: Both expressive & receptive.

– Following brief one step commands

– Unable to communicate any needs verbally

– Communication folder developed in Beaumont and some use of same

– Inconsistent yes/no response

– Severe reading and writing deficits

Profile on Admission

• Cognition

– Difficult to assess due to aphasia

– Impulsive

– Decreased safety awareness

– Information processing difficulties

Profile on Admission

Physical

• Right upper limb– Increased tone

– No muscle activity/active range of motion

– Pain in shoulder during passive ranging

• Right lower Limb– Increased tone

– Reduced power

– Muscle activity at hip and knee

– No muscle activity at ankle and foot

– Standing with assistance of 2

Profile on Admission

Functional

• Seating– Independent sitting balance

– Using an orthopaedic chair on the ward

• Transfers– Step transfer with assistance of 2

– Sit to stand with assistance of 2

– Bed mobility with assistance of 1

Profile on Admission

Functional

• ADLs– Required assistance of 1 when washing &

dressing

• Mobility– Stepping with assistance of 2

Profile on Admission

• Continence– Catheter in situ

• Mood– Depression

• Social– Living in family home but separated from wife

– Poor relationship with children

Rehabilitation Process

• Interdisciplinary working: Speech, Physio, Nursing, O.T., Medical Social Worker, Dietician.

• Daily therapy sessions from O.T, Physio and SLT

• Daily rehab assistant programmes

• Joint sessions

• Training for staff re John‟s specific communication needs

Rehabilitation Process

• Communication Rehab

– Severe word finding difficulties and

comprehension deficits

– Development of a picture and word based

communication book

– Writing using the left hand

– Attention and concentration

– Increasing fluency in speech

Rehabilitation Process

• Physical Rehab

– Strengthening & Conditioning

– Stepping, transfers

– Gait & Balance re-education

– Motomed

– Upper Limb positioning/passive ranging

– Resting hand splint

Rehabilitation Process

• Functional Rehab

– ADLs

– Transfers

– Walking to dining room/ bathroom etc

• Activities carried over on the ward

– Walking to bathroom and dining room

– Regular ADL sessions

– Conversation group and social activities

Rehabilitation Process

• Continence

– Catheter removed

– Continence promotion implemented

– Skin integrity – Waterlow score monitored

constantly

• Pain and mood

– Review and treatment by medical team for

upper limb pain and low mood

Rehabilitation Process

• Emotional support • Relating to the impact of stroke for John and family

• Complex family relationships

• Implications of complex family dynamics in

planning for and meeting Johns future care needs.

• Discharge Planning• Information on future care options

• Assistance with Nursing Home Support Scheme

process

Rehabilitation Process

• Family Education

– Daughter instructed re: supporting

communication, conversation techniques, car

transfers, passive ranging of upper limb, use

of splint.

• Education re medications

– Information provided in accessible format.

– Training re taking medication with family

support

John on Discharge

Persisting difficulties

• Moderate aphasia

• No muscle activity in upper limb. Required splint for positioning due to increased tone.

• Reduced power in lower limb particularly in ankle, with mildly increased tone.

• Supervision required when transferring and mobilising due to some impulsivity and decreased safety awareness

John on Discharge

Participation in daily life

• Engaging in conversation well

• Quite successfully when supportive

conversation techniques and

communication book used

• Communicating needs successfully but

difficulty with conversation about abstract

topics

John on Discharge

Participation in daily life

• Independent bed mobility

• Supervision for transfers with tripod stick

• Mobilising indoors and outdoors with tripod

stick & supervision

• Minimal assistance with personal ADLs

• Fully continent

John on Discharge

Participation in daily life

• Improved relationship with family

• Daughter and son providing more support

Discharge

• Discharged to Nursing home in June 2010

• Supervision and assistance with daily

tasks required could not be provided at

home by family

• 6 months post CVA

• 4 months in Rehab unit

Benefits

• Hoist transfer → Supervision with transfers

• Wheelchair dependent → Mobile with tripod stick

• Full nursing care → Supervision with ADL‟s

• NG feed → Independent with feeding

• Incontinent → Continent

• Unable to communicate needs → Communicate messages and engaging in conversations

• Improved relationship with family

COOP/WONCA – John’s opinion

• No admission scores- unable to engage due to

aphasia

• On discharge,

– Physical Fitness: 4 – Light walk at a moderate pace

– Feelings: 3 – Moderately

– Daily activities: 3 – Some difficulty

– Social activities: 5 – Extremely

– Change in Health: 1 – Much better

– Overall Health: 1 – Very good

– Pain: 1 – No pain

New developments for Older

Patients attending Beaumont

& St. Joseph’s Hospital

Dr. Alan Moore

Consultant Geriatrician

Background

• Large growth in older populations in both

HSE Dublin North & Dublin North Central

• Increasing need for both rehabilitation and

complex discharge planning

• Low number rehabilitation beds for older

adults: 0.67 beds per 1,000 >65s

• Target is 3 per 1,000 (The Years Ahead)

Changing face of Geriatric

Medicine Services

• More activity in the community &

Community Hospitals

• Greater access to multi-disciplinary input

in primary care teams

• Increased survival rates for cardiovascular

disease, stroke and cancer

• increasing care needs as many of these

survivors have functional dependence

Access difficulties

• Day Hospital

• Rehabilitation

• Complex Discharge Planning

• Acute Hospital Admission

• Respite

• Emergency interventions for dementia patients

• Long term Care

New Developments

• New Professor of Geriatric Medicine

• Prof. David Williams

• New teaching module & curriculum for

medical students at RCSI

• Planned development of St. Joseph‟s

Hospital as major teaching site for RCSI

What is new in Beaumont/St.

Joseph’s Hospital

• New Acute Stroke Unit (2009)

• 24/7 thrombolysis access

• Specific Stroke Rota

• New weekly stroke rehab MDM

• New carotid disease weekly MDM TIA

rapid access clinic in development

Benefits of new stroke

service

• All patients with a stroke or TIA under

Neurology or Geriatric Medicine

• Director of Stroke (Dr. J. Moroney)

• New Stroke Nurse Specialist (Ms. Joan

McCormick)

• Improved identification of rehabilitation

candidates

Rehabilitation Access

• Significant difficulty

• Better outcomes with quicker access

• No currently agreed plan to improve

capacity to full MDM with Geriatrician lead

rehabilitation at either St. Joseph‟s,

Beaumont or Clontarf sites

• Early Supported Discharge?

Other developments: Raheny

Community Nursing Unit

• 100-bedded unit

• Nearing HIQA registration completion

• Our hope is that a medical model/high

dependency model will be accepted by

HIQA, HSE & Beaumont Hospital

New Day Hospital

• Funding has been obtained

• HSE independent

• Early stage of development

• Likely St. Joseph‟s Site

• 5-Day per week service

• Hospital has agreed to staff with multi-disciplinary team

• Likely to take 2 years to start

Nursing Home State Support

Scheme

• Local Placement Forum meetings for HSE Dublin North began in 2009

• Held weekly or fortnightly

• Geriatric Medicine/Psychiatry of Old Age Assessment

• Less LTC patients in Beaumont over 65 during 2010

• Numbers beginning to increase again

Nursing Home Outreach

• Working Group at Beaumont

• Report completed

• Funding allocated

• Resource to concentrate on Long term

care units with greater dependency levels

and larger in-patient numbers

• Likely to commence in 1-2 years time

Negative Developments

• Loss of Falls Nurse (Ms. Joan Naughton)

• Loss of Bone Health Nurse (Ms. Elaine

Butler)

• Loss of fracture liaison service for

osteoporosis patients

• Loss of Occupational Therapy post for

Ward 2A

Dementia

• Largest Area of Concern

• National Strategy in place in most

European countries

• Memory Clinic for earlier diagnosis at

Beaumont

• Very significant difficulties remain relating

to respite, support at home, Day Centre

waiting times & emergency interventions

Conclusion

• Some positive developments but historic

under-resourcing and lack of infrastructure

still influence patient care

• Very large demographic challenge in HSE

Dublin North

• 17,000 residents approaching age 80

• Economic situation

Thank you