Hospital At Home is a service gradually growing across Scotland and Healthcare Improvement Scotland is helping NHS boards establish and develop their services. But what is it like to deliver such a service? How does it work? NHS Lanarkshire Hospital At Home nurse Richard Wells-Holland explains a typical day.
Experience and research tells us that not everyone needs to go into hospital and not everyone wants to go to hospital either. Some people will be worse off as a result of their illness, either through the risk of delirium, falls or infection. In addition they will miss their family, partner or friends, as well as their own home surroundings and comfort. But, at the same time, they need the kind of interventions and care that a hospital can provide.
Hospital At Home aims to support people by providing the same level of care in the home as they would get in hospital. The service also supports A&E and ward discharges from hospital for those adults who still require acute monitoring, but are safe to be discharged home.
As a Hospital At Home nurse, I’m part of the emergency community service which is managed by Health and Social Care North Lanarkshire, based in the University Hospital Monklands. What is it like to do the job that I do? To support Healthcare Improvement Scotland’s work to develop more Hospital At Home services across Scotland, let me explain what a typical day for me is like…
8.00am: There are various shift patterns within the Hospital At Home service such as 8am to 6pm, 8.30am to 6.30pm and 10.00am to 8.00pm. Today’s shift starts for me at 8.00am, meaning that as the first nurse on duty I am responsible for organising the daily workload for my colleagues coming in later. Today we have 23 patients currently under our caseload and we have three new referrals, two from the care of the elderly wards and one from A&E. So 26 in total at the start of the day and that’s before any referrals from GPs. The team consists of Care of the Elderly consultants, nurses, allied health professionals and assistant practitioners (APRs).
9.15am: I get a call referred by a GP who is wanting an elderly lady reviewed. She lives in a residential living complex and is feeling unwell. She also has reduced consciousness and is suspected of having a urinary tract infection (UTI). Emergency patients like this are reviewed within a one-hour response time with an APR attending first to obtain emergency bloods, followed shortly afterwards by a nurse practitioner who will assess the patient and carry out a diagnosis. This will be followed up by the consultant who will review the clinical notes and plan treatment. When I arrived, the patient was fluctuating in and out of consciousness and had all the symptoms of sepsis. Sepsis can often be treated at home. However, after contacting the consultant on call, it was advised for an ambulance to be called in this instance. Paramedics arrived and she was taken to hospital for further examination. Despite us being a hospital at home service, not every patient can be managed at home, and sometimes hospital admission is required.
11.20am: Another emergency call arrived on my way back to the hospital – this was to go and see an elderly man 18 miles away. One of our APRs was already in attendance and had carried out the initial clinical observations and obtained a blood sample. The gentleman had been found wandering the streets and was becoming more and more confused. His family were all very concerned. He was very polite in his manner, but kept referring to me as his school teacher and he saying he had to get to school. Delirium and the manifestations were discussed with the family. It was explained that admission to hospital may make the delirium worse and trying to keep their dad in a familiar environment with our support would be the best option. The family agreed to keep him at home and to take it one day at a time.
12.30pm: After having some lunch in my car I headed back to the office as there were no other emergency calls. While there, I called the social work department as one of the patients under our caseload needed homecare to assist with her activities of daily living. She had recently suffered the bereavement of her husband who was her main care provider and as a result she was unable to fully look after herself at home. She had no family support and had recently developed a chest infection. I carried out the necessary assessment paperwork and sent it over. Working closely with social care departments can be a key part of what we do for our patients.
2.45pm: I took a call about a 91-year old lady who had had a fall. Prior to leaving, I accessed the patient’s medical records for any additional information. She lived alone and there was a key safe box in place and the entry code was in her medical records. I gained entry and found her in bed lying at a strange angle. She explained that she had fallen in her bathroom early in the morning and was unable to get up. She had banged her left hip off of the toilet pan which was likely a fracture, so we had to get her to X-ray as quickly as possible. Hospital At Home has access to priority X-rays, just as you would expect for an in-patient, so I knew that we would be able to get her condition confirmed as quickly as possible.
4:00pm: I was given another call to attend to an elderly man suffering from increased shortness of breath and green sputum. He was expecting me, as my APR colleague had already been and had taken venous bloods, and carried out an ECG and clinical observations. Communication both verbal and non-verbal play a fundamental role in the nurse-patient relationship and helps in gaining not only trust being built but also leads to vital patient information being obtained. The gentleman explained that he felt extremely short of breath even at times of rest. He also complained that he couldn’t stop coughing.
I explained that he would be started on a course of antibiotics and that we would arrange for him to go to the hospital in a few days’ time for a chest X-ray which he could attend before going home again afterwards.
5:00pm: I headed back to the office which was busy as everyone was trying to get their documentation done and get the results back from the laboratories for their patients’ records such as blood results etc. As an emergency service we get our blood results back the same day, avoiding any delay in treatment for the patients being kept at home.
5:45pm: After discussing my patients in full with the consultant on duty and putting plans in place for the next day, it was nearing the end of my shift. As my route home was passing my last patient, I volunteered to deliver the antibiotics that had been prescribed for him on my way home. That way he could get his first dose that night and it would also give me a chance to see how he was doing and to be reassured that he was coping.
Though no two days are ever the same, this was a pretty typical day: it’s varied, full of communication with a wide range of people and it’s satisfying to help patients stay in their familiar surroundings but get the essential treatment they need.
I’m excited about the work Healthcare Improvement Scotland is doing to increase Hospital At Home services across Scotland – it can only mean better care for patients, as well as being rewarding and satisfying for nurses like myself.
Richard Wells-Holland is a Hospital At Home nurse based within University Hospital Monklands, NHS Lanarkshire.