Chapter 9 E-materials

Author profiles

Beverley Greensitt BSc(Hons) MCSP

Bev qualified from King’s College London in 2004 and following this she has completed a broad range of rotations as a band 5. She has been working as a senior clinician in Acute General Medicine. Whilst working in medicine Bev has developed a portfolio of experience working on Gerontology wards, day hospitals, providing MDT management and rehabilitation to elderly patients. Bev has particular interests in providing clinical education for students and educating about and promoting the role of physiotherapy and rehabilitation in an MDT setting. Bev has found that contributing to the medicine chapters and material has provided an opportunity to clarify the types of experiences encountered and the skills necessary for working in a medicine environment.

Clare Nickols MSc BSc(Hons) MCSP

Clare Nickols qualified from The University of East London in 1996 and completed her junior rotations at The Homerton Hospital in Hackney. Clare then worked at The Royal Hospital for Neuro-disability in Putney for 3 years. She specialised in the rehabilitation of people who have acquired complex brain injuries and challenging behaviour. Clare is currently the In-patient Services Team Leader and Deputy Physiotherapy Manager at Heatherwood Hospital in Ascot. She achieved a distinction in the Masters in Rehabilitation at Oxford Brookes University in 2007.

Appendix 9.1

Daily prioritisation sheet

Guidelines for prioritisation sheet

For any patient you go and see, remember to write your name against the patient’s name.

Emergency respiratory

• Patients who are very sick and require immediate respiratory physiotherapy. For example, those patients you would see in an on-call situation.

Discharges

• Patients who require assessment for discharge.

• Patients who you are seeing who have reached their premorbid level of function and can therefore be discharged from your list.

New patients

• Respiratory – must be seen on the day of referral.

• CVA – must be seen with 72 hours from the onset of their stroke.

• Other – e.g. mobility referrals. Must be seen within 48 hours of referral.

Late referrals

• These are mobility referrals that are given during the day, i.e. not at handover.

Stable respiratory

• Patients who do not require intensive respiratory physiotherapy, e.g. those patients on 2–3 l O₂.

Patients with planned discharge date

• Patients where the plan is to get them straight home, i.e. not for rehab. With these individuals they should be seen daily so they get more input and then you may decide to hand them over to a PTA to maintain their mobility whilst they are awaiting discharge, e.g. for care package.

Clinical priorities

• For example, patients who may need a week of daily input to determine their discharge destination.

Patients that were not seen the day before

• Any patient who did not receive treatment the day before.

Patients on a list for further rehabilitation

• Patients who are on a waiting list for further rehabilitation (CH/ICB). You may decide to alternate these patients between this category and the no times box if you are particularly busy.

PTA patients

• Patients for maintenance work, progression of mobility, passive stretches. These patients MUST be given sit to stand programme and strengthening or balance exercises (this is more important than mobility practice).

• For patients who are doubles, PTAs can go through bed or chair exercises with the patients.

Physiotherapy assistant priorition sheet

Guidelines for physiotherapy assistant prioritisation sheet

Physiotherapy doubles

• Patients requiring two or more people to treat them.

New patients

• New patients handed over from the physiotherapist.

Discharges

• Patients for discharge that day.

• Patients who have reached their required level of function and can be discharged from the caseload.

Patients with a planned discharge date

• Patients who require intensive input and therefore must be seen daily in order for them to return home.

Patients not seen the day before

• Any patient who did not receive treatment the day before.

Patients on a rehab waiting list

• Patients awaiting rehab at either a community hospital or ICB. These patients must have been given a sit to stand programme and strengthening or balance exercises. This MUST be carried out prior to any mobility practice.

Case Study 9.1

Background

• 54-year-old woman.

• Previously fit and well.

• Lived alone.

• Independent with all ADLs.

PMH

• Hypertension.

HPC

• Transferred to an acute general medicine ward from the neurosurgical unit after having a Grade V subarachnoid haemorrhage 2 months previously.

• The patient had been assessed and treated by a rotational band 5 on the ward.

• During this time the patient developed diarrhoea and was unable to sit out in the cirrus chair provided by the OT.

• A stretching programme was devised for the PTA to carry out during the period of bed rest and this was continued for 7 weeks.

• Once the patient’s diarrhoea had stopped, they were able to start sitting out again.

• A joint assessment was carried out with the OT to ensure that the seating remained appropriate in view of her not having been out of bed for 7 weeks.

• The medical team requested that the patient have intensive physiotherapy.

• The band 5 explained to the house officer that due to the size of her case load she had delegated treatment to the PTA who was carrying out a stretching programme. The band 5 discussed what was realistically possible in terms of physiotherapy input, which improved the understanding of the medical team in this case.

• Whilst carrying out the stretching programme, the PTA noticed that the patient’s legs were becoming increasingly tight.

• The band 5 was informed who discussed the patient with a senior colleague.

Reassessment

• A joint assessment was carried out and the following noted:

– Difficult to assess muscle power or sensation as the patient was unable to communicate.

– Increased tone was present in right shoulder and elbow.

– Full PROM in both ULs.

– Increased tone in both legs; hip adductors, knee flexors and TAs.

– Unable to achieve plantargrade in both ankles.

– Patient required maximum assistance of 2 to roll.

– Assistance of 2 required for her to move from lying to sitting and back to lying.

– Full sling hoist required for all transfers.

– Assistance of one required to maintain sitting balance.

– Head held in a position of side flexion to the right.

– Patient began to engage a little more once her head was brought into midline.

– On discussion with the senior physiotherapist, the following plan was made to address the problems:

– Patient to be seen twice a week by the band 5 physiotherapist, PTA to continue with the stretching programme.

– T-roll to manage high tone in lower limbs. For 2 hours on, 2 hours off. Nursing staff informed.

– Scotch and soft casts for TAs (casts made by plaster room). To start wearing for 2 hours per day for the first week and then increase by one hour per week. Chart with instructions placed above patient’s bedspace. Nursing staff to check for pressure sores and to alert physiotherapist if any problems.

– Discussion with regional neuro-rehab unit for botox in view of spasticity in lower limbs.

– Liaise with OT re: head support for patient when sitting out in wheelchair and for footplate adjustment.

Outcomes

• Problems that arose were addressed as follows:

– Twice weekly treatment: occasionally it was not possible, e.g. due to a sick respiratory patient, in which case the PTA continued with the stretching programme. Treatments consisted of the tilt table and sitting balance work. The PTA also incorporated functional tasks into the stretching programme, e.g. assisting the patient to comb her hair with her left hand.

– T-roll: a chart with instructions was placed above the patient’s bed which worked very well.

– Splints: initially the casts worked well. After 3 weeks, the cast for the right leg had to be removed as the patient developed a pressure sore on the posterior aspect of her calf. ROM in her left ankle began to increase gradually.

– The patient was reviewed by one of the consultants working in the neuro-rehab unit and deemed suitable for transfer to the unit. (Botox injections were given after transfer to the rehab unit.)

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