The Uist and Barra Hospital is a small community hospital in the Outer Hebrides, providing in-patient care to a population of just under five thousand. The population has a high proportion of older people with multimorbidity and emerging frailty.
Around five years ago, the hospital was struggling with increasing admissions of older people with complex needs. Every week, there were challenges discharging patients safely, and the process of getting patients fit for discharge was slow.
We responded by making a number of changes to the running of the ward, aiming to identify and act on functional problems early in the admission process. The nursing team were also keen to relax the visiting hours for patients, and we looked at ‘John’s Campaign’ as a model for involving carers on the ward if they wished.
After a slow start, the concept of open visiting started to bed in. For example, one patient with dementia started eating better when her usual family member helped her at mealtimes. Another patient was able to have a ‘film night’ with her daughters for her birthday.
One of the barriers at the start was disruption to the ward round. Waiting for family members to leave the room to allow clinical review, or coming back after the round to see patients who had been busy with visitors, meant the round was getting longer and inefficient.
Around the same time, I started testing a structured ward round approach, with one of the checks being to ask the nurse and the patient what their key concerns were. Patients started asking if their relatives could come back in for particular discussions, and the culture started to shift towards a more patient-focussed ward round in which relatives could be present. Goal setting started to improve, and decisions concerning escalation and onward referral were communicated more effectively to families.
Now, relatives and carers are positively welcomed on ward rounds. Patients and families are more involved with the decisions made about care, and trust in the hospital has grown. The best way to describe how it works is with an example.
Mr A is a very frail man in his 80s. He has slowly progressive metastatic cancer, and he came in with suddenly worsening shortness of breath. On initial assessment, we thought he probably had a pulmonary embolus. When I did the ward round, his sister was present. When I came into the room and introduced myself, she got up to leave. I hesitated, and checked with Mr A whether he wanted her to stay, as I was going to discuss his results with him. He was keen for his sister to stay, because he felt that he wouldn’t remember what I had said properly, and would be unable to explain to her what was going on.
His sister was invited back into the room, and I went over the results that indicated that a pulmonary embolus was a possible cause of his breathing problems, and that the best way to check this was to fly him up to Stornoway for a CT scan. We discussed Mr A’s frailty and considered the stress and difficulty of flying up without the support of his family, against the risks of possible over- or under-treatment without the scan. We also talked about the treatment options for pulmonary embolus. Mr A was able to decide not to fly off the island, with the support of his sister. We agreed a treatment escalation plan that included his wish not to be flown away.
Mr A and his sister felt well-supported, she was able to understand the clinical dilemma, and act as an advocate for her brother. They had been able to express their concerns openly, and were fully involved in the ward round discussion about prescribing and planning further care. In addition, his sister had not needed to arrange to speak to me at a separate time. I did not have to set aside additional time to speak to relatives, or worry that further decisions might be required once more information was available.
Hebridean Adventures in Realistic Medicine 