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WELCOME TO CARDIAC MEDICINE AT AT THE ROYAL VICTORIA INFIRMARY OCCUPATIONAL THERAPY DEPARTMENT Last updated Aril 2010 CONTENTS 1 Introduction to the Royal Victoria Infirmary Hospital 2-4 Wards and Specialism 5-7 Ward Profiles 8 Palliative Services 9-12 Frequent presenting conditions 13 Classes of Cardiac Disease 14 Cardiac Rehabilitation & Heart Failure Programme 15 Falls & Syncope (FASS) 17 Assessment/screening tools 18 Supervision 19 Prioritisation criteria 24 Theoretical Models guiding practice and recommended reading Last updated Aril 2010 ROYAL VICTORIA INFIRMARY HOSPITAL, NEWCASTLE UPON TYNE Welcome to the Royal Victoria Infirmary hospital (RVI) occupational therapy service in Medicine. The RVI is a regional, specialist hospital providing care and specialist services to local people and to clients from other geographical regions of the United Kingdom. The occupational therapy role within this healthcare context is to provide timely and safe discharge to clients. There are eight wards within this specialty, staffed by 1.8 whole time equivalent senior occupational therapists 2 basic grades and two part time assistants.. The purpose of this handbook is to offer you the student an over view of the possible learning experiences and resources available to you on this placement. Last updated Aril 2010 Ward 22 – Diabetes, Endocrinology Ward (Acute Medicine), consisting of 6 x four bedded bays and five individual cubicles. Conditions seen include: Diabetic keto-acidosis, Hypoglycaemia, Hypothyroidism, Urinary Tract Infection. Ward 49 Cardiology Ward, consisting of 4x six bedded bays and five individual cubicles. Procedures/conditions seen include: multiple conditions such as Myocardial infarction, Angina, Arrhythmias. This ward also generates a high proportion of the OT caseload and is visited most days to collate information and current condition of clients. Last updated Aril 2010 WARD PROFILES Ward: 22 Ext: Nurses Station Doctors Room Sisters Office Consultant: Diabetes 1. Prof R Taylor, Professor of Medicine and Metabolism & Diabetes 2. Dr S Marshall, Consultant Physician/Reader in Diabetes 3. Dr N J Leech, Consultant Physician, Diabetes Endocrinology: 1. Dr R A James, Consultant Endocrinologist 2. Dr Quinton, Consultant Endocrinologist 3. Dr S G Ball, Consultant Physician Endocrinologist General Medicine 4. Dr Jay General Medicine 5. Dr Wynne General Medicine Ward Manager Ellen Horsburgh (Ward Sister) Ward Clerk: Patricia Hands (Pat) Team Divisions (Nursing): Divided into two teams Team A, beds 1 – 12 and cubicles 1 – 3 Team B, beds 13 – 24 and cubicles 4 – 5 Ward Round: Variable MDT Meeting: 2. pm Tuesday Social Round (OT, SW and nursing staff, Ward 22, Day Room). Method of referral to Occupational Therapy: Via social meeting, Tuesday and Thursday handover Informally on Ward, By telephone Social Worker: Helen Warwick – 24594 Physiotherapist: Rotational (Junior Physiotherapist) Part-Time Physiotherapy Assistant Method of communication With Ward: Via handover, nursing kardex and telephone Last updated Aril 2010 (Diabetes and Endocrinology) Door Coded 20122/20121 24360 20119 Rehab room (located Door coded Outside Wards 22 and 23): Ext. 20127 Last updated Aril 2010 Ward: 49 (Cardiology) Ext: Nurses Station Doctors Room Sisters Office Consultant: Ward Manager 1. Dr Skinner, Consultant Physician, Cardiology 2. Dr Adams, Consultant Physician, Cardiology 3. Dr Mc Neil, Consultant Physician, Cardiology 4. Dr Irvine, Consultant Physician, Cardiology 5. Dr Haq, Consultant Physician, Cardiology Marian Phebey (Ward Sister) Ward Clerk: Anne Herron Team Divisions (Nursing): Divided into two teams Team 1, beds 1 – 12 and cubicles 28, 29 Team 2, beds 13 – 27 and cubicles 25, 26, 27 Ward Round: Variable MDT Meeting: Wednesday 2pm Method of referral to Occupational Therapy: Via Wednesday mdt meeting, Informally on Ward By telephone Social Worker: Helen Warwick – 24594 Physiotherapist: Laura Cliffe band 7 Physio Rotational junior and assistant 25649 25090 24202 Method of communication With Ward: Via handover, nursing kardex and telephone Rehab room (located Near wards 48 & 52): Door coded Last updated Aril 2010 Due to the nature of some of the conditions within acute medicine the occupational therapist is sometimes required to deal with issues of a sensitive nature e.g. patients with a palliative condition. PALLIATIVE OCCUPATIONAL THERAPY The OT role is central to the assessment, preparation, planning and co-ordination of clients who wish to return to their home. Palliative care involves working with clients who have to live with a degree of uncertainty as to the course their illness may take and the length of life they may expect. This client group can account for approximately 25% of the caseload at any one time. Before approaching the client the MDT documentation is reviewed and discussion takes place within the team as to the clients understanding of their condition, their physical, psychological, and emotional state. This information guides the OT’s professional approach. This area can be emotionally demanding and the OT requires support mechanism’s for herself i.e. supervision, MDT support and reflection. This area can also be very rewarding in which the OT is not only central to satisfactory and safe discharge, but also in that we may enable the clients wishes and views to be fulfilled. This means all clients irrespective of age, illness, disability or any other circumstances are considered as people first. Throughout the intervention the aim is to enable the client to take back some control in their life whilst not distracting them from important issues they may have to deal with. Our greatest contribution is to observe, listen and work holistically with each client to achieve their particular aim, to ensure they have quality of life. Most importantly we allow the person time to talk, space to think and to remain in control. Last updated Aril 2010 Information on frequently presenting conditions with patients from Ward 22: Diabetes – any disorder of metabolism causing excessive thirst and the production of large volumes of urine. Used alone, the term most commonly refers to diabetes mellitus. Diabetes mellitus – a disorder of carbohydrate metabolism in which sugars in the body are not oxidized to produce energy due to lack of the pancreatic hormone insulin. The accumulation of sugar leads to its appearance in the blood (hyperglycaemia), then in the urine; symptoms include thirst, loss of weight, and the excessive production of urine. The use of fats as an alternative source of energy leads to disturbances of the acid base balance, the accumulation of ketones in the bloodstream (ketosis), and eventually to diabetic coma. Diabetic ketoacidosis – a condition in which acidosis is accompanied by ketosis, such as occurs in diabetes mellitus. Symptoms include nausea and vomiting, abdominal tenderness, confusion or coma, extreme thirst, and weight loss. It is a life-threatening situation. Hypoglycaemia – a deficiency of glucose in the bloodstream, causing muscular weakness and in-coordination, mental confusion, and sweating. Hypothyroidism – subnormal activity of the thyroid gland. If present at birth and untreated it leads to cretinism. In adult life it causes mental and physical slowing, undue sensitivity to cold, slowing of the pulse, weight gain, and coarsening of the skin. Last updated Aril 2010 Urinary tract infection – urinary tract is the entire system of the ducts and channels that conduct urine from the kidneys to the exterior. It includes the ureters, the bladder, and the urethra. Exacerbation of COPD – generalised airway obstruction, particularly of the small airways, associated with varying combinations of chronic bronchitis, asthma, and emphysema. The term was introduced because these conditions may co-exist and it may be difficult to decide on which one is producing the obstruction. COPD is generally progressive, may be accompanied by airway hyperactivity, and may be partially reversible. Chest infection/bronchitis – characterised by a chronic productive cough for at least three months in each of two successive years for which other causes have been excluded ie infection, cancer, and chronic heart failure. Dementia – a chronic or persistent disorder of behaviour and higher intellectual function due to organic brain disease. It is marked by memory disorders, changes in personality, deterioration in personal care, impaired reasoning ability, and disorientation. Information on frequently presenting conditions with patients from Ward 49: CARDIOPULMONARY DISORDERS Cardiopulmonary disorders encompass cardiovascular disease and chronic obstructive pulmonary disease. CARDIOVASCULAR DISEASE – affects the blood supply, tissues, and muscles in and around the heart and vascular system of the body. Diseases include: Last updated Aril 2010 Arterial hypertension – is elevated systolic blood pressure (BP) at or above 140mm of mercury and/or diastolic pressure blood pressure at or above 90mm of mercury. Treatment with drugs known to lower blood pressure. Orthostatic hypotension - is an excessive fall in BP it is not a disease but a manifestation of abnormal regulation. Syncope – sudden, brief loss of consciousness, with loss of postural tone (faint). Arteriosclerosis – generic term for several diseases in which the arterial wall becomes thickened and loses elasticity. Atherosclerosis is the most common form that can result in reduced blood flow. Coronary artery disease – includes Angina and Myocardial Infarction (MI). Angina is due to ischemia precipitated by exertion and relieved by rest or nitro-glycerine. MI is necrosis within the myocardium due to abrupt reduction of the coronary flow within the heart muscle. Heart failure – is myocardial dysfunction resulting from a haemodynamic, renal and neurohormonal response in which the plasma volume increases and liquid accumulates in the lungs, and abdominal organs such as the liver, and peripheral tissues. Shock – is a state in which blood to and perfusion of peripheral tissues are inadequate to sustain life because of insufficient cardiac output or maldistribution of peripheral blood. Arrhythmias – include bradycardia (slow) or tachycardia (fast). Usually not clinically significant unless they are sustained and cause dizziness or syncope. Cardiac arrest – the absent or inadequate ventricular contraction resulting in circulatory failure. Last updated Aril 2010 Valvular heart disease – occurs when the mitral, tricuspid, and aortic heart valve fails to function correctly. Endocarditis – inflammation of the endo-cardium of the heart. Pericardial disease – congenital disorders and acquired disorders. Disease of the Aorta and it’s branches – includes aneurysms, aortic dissection, inflammation and occlusion. Peripheral vascular disorders – affects the arteries, veins and lymphatics of the extremities. CAUSES The causes of cardiovascular disease include blood clots, thickening of the arterial walls, bacterial infections that result in damage to the valves, high BP, arrhythmias, and other contributing or lifestyle factors, such as diet and nutrition, lack of exercise, high stress jobs, and poor health. This also includes: Risk factors like age, sex, family history, smoking, and obesity. Metabolic diseases such as diabetes. Congenital conditions, cysts or absence of the parietal pericardium. CLASSES OF CARDIAC DISEASE Class 1 – these clients have cardiac disease but not the resulting limitation of physical activity. Ordinary physical exertion does not cause undue fatigue, palpitations, dyspnoea, or anginal pain. Class 2 – cardiac disease is present and there is some resultant limitation of physical activity. Comfortable at rest. Therefore ordinary physical exertion results in fatigue, palpitations, dyspnoea, or anginal pain. Last updated Aril 2010 Class 3 – cardiac disease present and results in marked limited physical activity. Comfortable at rest. Less than ordinary physical activity causes fatigue, palpitations, dyspnoea, or anginal pain. Class 4 – cardiac disease resulting in an inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or anginal symptoms may be present even at rest. Any physical activity will increase discomfort. CARDIAC REHABILITATION Once clients are discharged from the acute setting local clients may return for out patient services in cardiac rehabilitation (CR). The goal of CR is to return the client to the highest possible level of functional capacity through education, excise training and psychosocial support. This is carried out in the group setting at Freeman Hospital in the evening. HEART FAILURE PROGRAMME The service provides a weekly rehabilitation session (Wednesday morning) supporting home based physical activity, and providing information and support to people with heart failure and their relatives. Besides improving/sustaining functional activity and quality of life, the service will hopefully contribute towards meeting the NSF target of reducing readmissions from heart failure. Role of occupational therapy The senior occupational therapist, responsible for the occupational therapy interventions for patients attending this group, provides assessment and Last updated Aril 2010 intervention for the patients. The occupational therapist works closely with other members of the team, ensuring an interdisciplinary approach to patient care. Aims of occupational therapy within the heart failure group On a weekly basis, participants have the opportunity to discuss their perceived condition and activities/goals. The aim of occupational therapy within the group is mainly educational: Teaching participants how to pace activities of daily living Offer information on support networks for carers Information on various benefits available Opportunity to learn and practice relaxation techniques The occupational therapist is available during each session to offer support to patients, discuss any changes/anxieties/problems with regard to activities of daily living, and depending on the needs of each individual, provide any necessary equipment to maintain independence with daily living. FALLS AND SYNCOPE SERVICE (FASS) In April 2005 the Newcastle Integrated Falls Service was launched, which comprises 4 main services: Falls and Syncope Unit at the RVI(FASS) Melville (Freeman Hospital) and Belsay (Newcastle General Hospital) Day Hospitals Osteoporosis Services (Bone Clinic at Freeman Hospital and Fracture Clinic at Newcastle General Hospital) Community Resource Teams for Older People (North, West and East Teams within the Primary care Trust (PCT) Last updated Aril 2010 This development was in response to the National Service Framework (NSF) for Older People. The OT service (9 hours) is provided via FASS at the RVI for people who are at risk of falling or have a history of falls. The aim is to reduce the environmental risk to people of falling at home. Occupational Therapy analyses the activities an individual engages in as part of their daily living to identify potential risks. Subsequent information and advice given to people, who have had a fall, increases their awareness of the risks of further falls and how to prevent them. The aids and adaptations provided enable the individual to become more independent in Activities of Daily Living. Information is gathered to highlight activities the individual was performing at the time of the fall. Advice and information is given to the patient to enhance the individual’s self-efficacy in fall-risk situations. Information on frequently presenting conditions with FASS patients: Syncope – Defined as transient loss of consciousness with loss of postural tone but with spontaneous recovery. Carotid sinus syndrome - a pocket in the wall of the carotid artery, at its division in the neck, containing receptors that monitor blood pressure. Assessment tools used within acute medicine: Last updated Aril 2010 Functional Assessment Form (FAF) – within this functional assessment form the modified barthel score is incorporated. This is a standardised tool, which is scored at the end of the Occupational Therapy intervention and scores functional activities. The Mini Mental State Examination (MMSE) – The patient is tested on aspects of cognition such as memory, orientation, attention, language and praxis. The Middlesex Elderly Assessment of Mental State MEAMS – was developed to detect intellectual impairment due to organic brain dysfunction in the elderly. It aims to survey the main areas of cognitive performance using a range of 12 subtests sensitive to the functioning of different cortical areas. Assessment/Screening tools used with FASS patients: Home falls and Accidents Screening Tool (HOMEFAST) – The HOMEFAST was developed in Australia as a screening instrument to assist in the identification of older people living in the community who are at increased risk of falls, trips, or accidents at home. This is applied in practice as a screening instrument to identify a possible 25 home hazards or combinations of hazards, which may put people at increased risk of experiencing a fall in order to enable an effective preventive intervention. The hospital anxiety and depression scale (HAD) – A self-assessment scale designed to detect the mood disorders of depression and anxiety in non-psychiatric populations attending at other hospital departments e.g. medical clinics, post natal clinics. However, experience has shown that it may be used with equal reliability in community or general practice settings. This is used in practice to detect how experiencing a fall has had an effect on patient’s confidence. Last updated Aril 2010 Tinetti Self Efficacy Score – Patients are asked to record on a scale of 1 to 10 (1 being extremely confident and 10 having no confidence at all) how confident they feel about activities of daily living. This scale is scored out of 100. Functional Assessment Form – see above. SUPERVISION Supervision is central to your learning and induction to the occupational therapy service. Formal supervision will be held either daily or weekly depending on your way of learning and your supervisor’s time. Informal supervision will be available as appropriate throughout the placement. It is a necessary requirement for the student to plan and prepare for supervision by having their personal agenda items. Last updated Aril 2010 NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST – REHABILITATION DEPARTMENT OCCUPATIONAL THERAPY – REFERAL CRITERIA FOR MEDICAL WARDS RVI 2009 HIGH RISK REFERALS – URGENT < TWO DAY ∆ RESPONSE MEDIUM RISK – THREE DAY RESPONSE ∆ LOW RISK REFERAL – Dependent upon capacity after high-medium risk. Can these needs be met in the community ? Referrals to occupational therapy must include a deficit within a functional area shaded below Level of function – recent deterioration - mobility – major difficulties, supervision required to mobilise safely, at risk of falls - cognitive function - prompts / supervision constantly required to maintain safety - transfer – unable to transfer safely without assistance or equipment - self care – assistance needed with all aspects of personal self care Social circumstances - lives in house with stairs - lives alone/carer working full time - Inadequate services in situ Discharge plans - Patient condition palliative and no support services to follow Limited life expectancy with discharge imminent Level of function – gradual deterioration - mobility, recent provision of frame - partial assistance with self care - domestic tasks - previously completing main meal increased difficulty reported - problems with grip in the dominant hand - fatigue and stamina problems – increasing problems resulting in increasing fatigue Level of function – minor deterioration - independent mobilising, problems identified with long distance mobility – requiring potential wheelchair assessment - residual problem that is being addressed by local services - patient independently self caring on ward but identifies difficulties with bath or car transfer issues Social circumstances Social circumstances - supported at home by home care or family, carer concerns - - known to services previously - - lives in supported accommodation - Discharge plans - Further rehab required prior to discharge - Palliative condition - Will remain on acute ward at least 7 days Housing inappropriate for long term need, but few issues at present Supported at home by home care / family Patient is known to local services in place of residence with regular therapy input Discharge plans - Awaiting transfer to long term care - Not medically stable for intervention Medically stable for intervention Patient must have deficits within the shaded area and one or more of the categories to be included within that criteria Service is from Monday to Friday 8:30 –16:15. The Occupational Therapists can be contacted on Extension 21266Dawn Tweedy SROT Last updated Aril 2010 ∆This is an example of the framework used for prioritising referrals. It is aimed to identify those at high risk who require our most urgent attention, not necessarily those who would benefit most from Occupational Therapy. It is designed for use at point of referral based on information provided by the referrer at the time. Response times may be subject to variation depending on caseload and staffing levels. These response times do not relate to timescales for discharge; this will be dependent on needs and resources available to access. Reviewed Aug 02 to be reviewed April10 Last updated Aril 2010 Theoretical Models Guiding Practice Bio-Mechanical Approach Compensatory Approach Rehabilitation Approach Problem Solving Approach Recommended reading: Childs, L., Kneebone, I.I (2002) Falls, fear of falling and psychological management. British Journal of Therapy and Rehabilitation, Vol 9, No 6, p 225-231. Fuat, A et al (2005) The diagnosis & management of heart failure across primary-secondary care: a qualitative study. British Journal of Cardiology, Vol 12, (3), p 233-8. Hagedorn, R. (1996) Occupational Therapy Perspectives and Processes. Management. Churchill Livingstone. Chapter 11. Case Hammond, J.M et al (1998) Patients’ perceptions of exercise based cardiac rehabilitation. British Journal of Therapy and Rehabilitation, 5, (8), p406-8, 421-3. Husband, H.J., Tarbuck, A.F. (1994) Cognitive rating scales: A comparison of the Mini-Mental State Examination and the Middlesex Assessment of Mental State. International Journal of Geriatric Psychiatry, vol 9, p 797-802. Mackenzie, L., Byles, J., Higginbotham, N (2000) Designing the Home Falls & Accidents Screening Tool (HOMEFAST): Selecting the Items. BJOT, 63, (6), p 260-369. McQueen, J.M (2003) Falls management and prevention: a day hospital perspective. British Journal of Therapy and Rehabilitation, Vol 10, No 3, p 115-121. Tinetti, M., Baker, D., McAvay, G., Claus, E., Garrett, P., Gottschalk, M., Koch, M., Trainor, M., Horwitz, R (1994). A multifactorial intervention to reduce the risk of falling among elderly people living in the community. New England Journal of Medicine, 331, (13), p 821-27. Tipson, R. (1997) The exercise component of cardiac rehabilitation. British Journal of Therapy and Rehabilitation, 4, (6), p316-22. Welch, A & Foster, S. A. (2003) A Clinical Audit of the Outcome of OT Assessment and Negotiated Patient Goals in the Acute Setting. BJOT, 66, (8), p 363-368. www.cardiomyopathy.org www.bjcardio.co.uk www.heartuk.org.uk www.britishheartfoundation.co.uk Last updated Aril 2010 www.library.nhs.uk Last updated Aril 2010