Case Scenario- rural

Andy, a 63 year truck driver, was just returning to the worksite after a delivery in the country.  As he approached the traffic lights leading into town, he suddenly felt dizzy and then lost his vision.  Although in a panic, he was able to radio for help and a co-worker brought him to the local Healthcare Centre.  On arrival at the HCC, his vision was improving, so the ER physician did not feel admission was warranted.  Arrangements were made for the patient to be seen as an outpatient at a tertiary Stroke Prevention Clinic the following day. 

When the patient realizes he is improving and will not be admitted, what questions/ concerns might he have?

(What caused the event?  What tests will I need?  Is it going to happen again?  Can I go back to work? )

As a HC Provider in ED, what support/ assistance can you provide to the patient/ family during this transition?

(Confirming and validating patient’s fears, concerns and questions.  Providing information regarding cause of stroke/TIA, http://www.heartandstroke.ab.ca/
outlining the plan of care at this point, confirming patient has transportation to get to appointment in tertiary SPC, ensuring patient knows location of SPC, advising patient if symptoms get worse to call 911)

As a HC Provider in ED, what inter-departmental/ inter-facility communication needs to occur to ensure continuity in this patient’s care, and what tools could be used to support that?

(telestroke consult with stroke neurologist, completing all aspects of the SPC referral form to ensure adequate information is provided, faxing referral to the right location and attaching supporting documents as necessary for a complete history of event and investigations completed while in ER.  Clarifying whose responsibility it is to ensure documents are faxed)

Andy was seen at the SPC where he had a head CT and CTA and was found to have had a small ischemic stroke.  A repeat visual exam at the SPC confirmed a persistent loss of peripheral vision and a mild balance problem.   Andy was advised not to drive due to the visual deficits, and could therefore not return to work.   He was given a prescription for Aspirin 81 mg and Crestor 10 mg daily and was advised to buy a BP monitor and check his BP daily.   He was also advised that he would be scheduled for a Holter Monitor test and should have some rehab therapy to assist with recovery.

What would be the patient/ family concerns during this transition?

(Will my vision ever return?  How do I tell my boss?  Will I lose my license?  Living in the country, how will I get around?  Worried about losing independence, what will be the financial impact of not returning to work?  How will this affect my wife and family? Why am I on these medications?  Will I have to take them forever? What is a Holter monitor?)

As a HC Provider, how could you support Andy and his wife during this transition?

(Provide info regarding driving after stroke and outline Andy’s responsibility in notifying the MVB.  Provide information or who to contact regarding alternate transportation options in the community, Provide letter for employer as requested, offer referral to Social Worker regarding financial concerns.  Outline realistic expectations for recovery.  Provide information regarding medications and testing.  Assure patient that you will communicate his plan of care to appropriate team members.  Advise Andy to make an appointment with his family Dr within a week or two to ensure on-going follow-up)

As a HC Provider, what inter-departmental/ inter-facility communication needs to occur to ensure continuity in patient care?

(Referral to rehab needs to be completed and faxed in a timely way.  Advise Andy that he can be pro-active and contact the rehab department to confirm referral.  SPC needs to have access to community rehab list to ensure therapists are available in that community.  May need to phone and confirm that therapist is trained in visual rehab therapy.  Letter to family physician needs to be forwarded in a timely manner.  CT/ CTA and bloodwork results will be available on Netcare.  Requisiton for Holter Monitor needs to note that results are to be sent to the family doctor as well as the stroke neurologist)

Andy was seen by his family physician within 1 week of the SPC consult.  His doctor reviewed recent fasting bloodwork and his blood pressure readings since the SPC clinic visit.  Andy was known to have mild hypertension for a number of years, but was reluctant to take medications.  Most of the recorded BP readings this week were greater than 155 systolic and greater than 100 diastolic.  Andy was advised that he needed to be on anti-hypertensives  to control this risk for stroke.  As well, his fasting lipids were elevated.  His Holter monitor results were not available at this appointment.  Andy told his physician that he had an appointment with the OT at the Healthcare Centre that same afternoon.

What would be the patient/ family concerns at this time?

(Andy needs to know more about managing risks for stroke, need to feel supported by PCN staff and able to provide input in care decisions and goals for reducing risk)

As a HC Provider,(PCN physician or nurse) how could you support Andy and his wife at this time? 

As a PCN nurse or physician, what interdepartmental/ inter-facility communication needs to occur to ensure continuity in patient care?

Focusing on Questions

Questions and Transitions

The conversation today was on developing questions and where they might be appropriately asked.

A transitioning example:

From the Healthcare Professionals' future care perspective:
A stroke patient transitioning from Emer discharge with HC potentially will have a number of different future care options to be decided. 

From the Healthcare Professionals' informing ( teaching ) patient of the diagnosis perspective:
At the same time Patient and families need to learn what has happened medically and what their next steps are going forward.

Colleen offered to take some time to rewrite questions with the above in mind.

See you all Monday.

This is proof of concept that I can actually do this!

Check list on writing a case scenario

Present the Situation: 

Do not give any signals that one solution might be preferred.

Provide Relevant Details: 

provide  relevant details about goals, strategies, dilemmas, issues, conflicts, roadblocks, appropriate research, relevant financial information, people, and relationships.

Use Dialogues: 

Make the characters come alive with dialogue. Straight narrative is boring.

Challenge: 

Leave the reader with a clear picture of the major problems--either ask or imply what is to be done now?

Case Studies vs Learning Objectives: The Table

Making the case . . . comparing our learning objectives to our cases.





Links to case studies:

28 y/o female admitted through the ED for right sided numbness

Andy, Rural 63 year old truck driver

Comparing Case study Branching Learning Approaches

We are planning a case study here.

Key Components of Transition

These key components of transition, taken from page 4 of the best practice document, encapsulate for me the direction I would like to see the module take and the scope of coverage:

All members of the healthcare team for stroke patients and families are responsible for taking action to ensure successful transitions and facilitate a successful return to the community following stroke.

Key components of successful transitions include:

 collaborative goal setting between the healthcare team, patients and families, where patients and family members actively participate in discussions and planning with the healthcare team and are involved in shared decision-making;

 ongoing education for patients, families and informal caregivers that reinforces key information and verifies understanding;

 patient, family and informal caregiver education needs to occur for all stroke patients, regardless of setting; this includes in the emergency department, primary care, acute inpatient care (regardless of location of patient within the hospital), rehabilitation settings, outpatient and community settings;

 skills training appropriate to needs and goals of patients to facilitate safe transitions;

 discharge planning that begins soon after stroke admission and all relevant support services, such as home assessments and access to ambulatory and community-based rehabilitation;

 assessment of family and informal caregiver capacity to provide ongoing care for the patient with stroke, as well as their individual support needs and potential burden of care;

 timely transfer of medical information between stages of care to ensure smooth transitions in care;

 identification of and linkages to community resources, long term care and home-based care;

 ongoing surveillance of physical, psychological, social and emotional recovery, coping and adaptation following discharge from inpatient acute care and rehabilitation settings.