Dave Caesar: The remote patient

Bill and Daphne have been together for 48 years. They are a single entity: totally interdependent, with a whole lifetime of shared experience and adventure. Their two children were raised in a secure and supportive home, and have flourished. One lives and works in London, and the other moved with her family to Canada.

Now Bill and Daphne live in a small cottage just inside the city bypass, and they are both in their 79th year. They have their hearts set on a huge family reunion to mark their Golden Wedding Anniversary in 15 months’ time.

Unfortunately, Daphne’s health has not been good over the last three or so years. She has suffered a number of heart problems, which has left her with an irregularity of the rhythm of the heart, feeling short of breath, and with limited mobility. On top of this, she suffered a stroke at the turn of the year that has left her with poor function of her right hand side. Since her discharge from hospital, Bill has had to care for her every day, helping with bathing, transferring and preparation of food and drink.

They remain entirely free from social services while in this arrangement, and are fiercely, and rightly, proud of this status.

As is often the case, life attempts to throw a spanner in the works, and when Bill trips while doing some gardening one Tuesday morning, the slightly precarious situation has potential to unravel.

Bill is unable to get up from the path where he fell, due to pain in his hip. He manages to crawl and drag himself back to his back door, where he can shout to Daphne to let her know he is hurt. He knows this is a bad injury, and he is able to call for an ambulance from his house phone.

The ambulance crew arrives, check that Daphne has 
access to something to drink and eat, and transport Bill to the Emergency Department at the RIE.

When Bill arrives, he is met by our triage team, who quickly realise that not only is it likely that Bill has broken his hip, but that there is also a remote patient who has just lost her main carer.

This now precipitates two streams of activity, one for Bill and one for Daphne.

For Bill, we start our newly introduced Hip Fracture Fast-Track protocol. This aims to provide rapid and consistent pain relief, X-rays, blood tests, nursing and medical assessment, as well as review by one of the Emergency Department senior clinicians and admission to a bed in the orthopaedic service, all within two hours of arrival. This requires all the components of the system (including the teams in the ED, X-Ray, and orthopaedics) to be geared up to achieve this effectively, and is being regularly reviewed to ensure compliance. It should greatly improve the experience of patients with hip fractures, of whom we see 2-3 per day at the RIE (the highest in Scotland).

Daphne’s situation is, if anything, more difficult to solve – not least because she is not present in the ED. However, we do our best to reassure Bill that his other half will be looked after while he is being treated and rehabilitated in hospital.

We rapidly contact our in-house Occupational Therapist, who has excellent links with the community services that may be available, and is able to arrange rapid home assessments and reviews for patients. We also contact our colleagues in Social Care, who, together with our OT, are able to put together a package of care that will be able to support Daphne in her own home while Bill is in hospital.

The importance of achieving this is not because we wouldn’t want to care for Daphne in a hospital setting, but because we know that hospitals are, by their very nature, often not the best places for people. Being admitted to hospital has traditionally been regarded as safe and risk-free, but we are understanding more now that, especially for frail and elderly patients, being admitted to hospital can make it more difficult for people to manage at home in an independent fashion. It can be the first step on a pathway towards institutionalisation that can be difficult to reverse, no matter what the motivation of the patient or the staff who are caring for them. It also opens the door for increasing medical investigations and treatments, all of which have their drawbacks, complications and side-effects.

Bill has his hip fracture operated on and fixed soon after admission, and is back at home within 10 days of his fall, where he is reunited with Daphne. She has been cared for over that short time by a crisis care team, and while Bill gets his mobility fully back to normal, they allow some extra help in the house to tide things over.

Their planning for their Golden Wedding is now back at full steam ahead.