CFU

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  • My patient
  • My name is MP, I'm now 88 years old but I used to be the matron of a cardiology ward.
  • Medical history
  • I could walk before this... I don't want to lose my mobility.
  • 4 years ago...
  • The ideal
  • MP worked as a matron on a cardiology ward for over 30 years before retiring to the midlands. She lives nearby to all of her children and grandchildren who she sees daily.
  • Current situation
  • "I'm a burden to all my family and the care staff. I don't like to bother them."
  • MP spent 10 weeks in hospital with diverticulitis. She was bed bound and was discharged in a wheelchair. She also suffers from congestive heart failure and arthritis in her shoulders.
  • The discharge plan
  • Mrs MP, we are going to arrange some physio for you at home to make sure you get back on your feet!
  • MP should have had physical rehabilitation or follow up care arranged during her discharge to ensure she didn't lose her mobility and independence. Her GP should have been made aware of her mobility previous to admission and at discharge.
  • Successful discharge
  • DISCHARGE PLAN- Refer back to GP Arrange physio in community Social care visits at home Follow up appt in 6 months Ensure MP is coping Increase mobility RESULT- Increased psychological wellbeing Maintains independence Stays in own home Reduced readmission rate Increased quality of life!
  • MP moved into a residential home 3 years ago after feeling unsafe at home alone. Following her discharge no follow up was arranged and she continued to rely on her wheelchair. She now requires help for all basic tasks.
  • Discharge planning should involve the MDT, patient and family. Previous mobility and ability to cope at home should be taken into account (NICE).
  • 1. Schwanen, T. Banister, D. Bowling, A. Independence and mobility in later life. Geoforum. 2012. 43 (6) 3. NICE pathways - transition from hopsital to home (2015). 4. Maramba P, Richards S & Larrabee J (2004) Discharge planning process: applying a model for evidence-based practice. Journal of Nursing Care Quality 19. 123-129.
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