Comprehensive Case Study on Home Therapy for Patients with Complex Medical Conditions by Fran Ashworth CIAU

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Fran Ashworth, a Senior Immunology & Allergy Nurse Specialist, presents a detailed case study exploring the feasibility of home therapy for a 59-year-old lady with multiple complex medical conditions. The study delves into the patient's initial assessment, training for self-infusion, and challenges faced due to various health issues. Through detailed analysis and insights, Fran evaluates the efficacy and suitability of home therapy in this particular case, providing valuable lessons and considerations. Confidentiality is maintained through anonymization of names, ensuring a secure environment for learning and discussion.

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Fran Ashworth Senior Immunology & Allergy Nurse Specialist RGN, Dip. Counselling HCP. BA (Hons) Health care Practice, MSC Health care & Social Practice Fran Ashworth CIAU

Sheffield Teaching Hospitals NHS Foundation Trust Northern General Hospital Sheffield Teaching Hospitals NHS Foundation Trust Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Declaration of Interest BPL Advisory Panel CSL Advisory Panel Shire Advisory Panel Supported to attend conference Grifols Octapharma Fran Ashworth CIAU

Case Study Looking at the possibility of home therapy for a patient with multiple complex conditions What lessons have been learnt as a result? Was this the right pathway for this person? Fran Ashworth CIAU

This is a real case history with names changed for confidentiality reasons Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? 59 year old lady referred to Clinical Immunology & Allergy Unit for assessment 2012 The aim was to allow access the Home Therapy Replacement Programme and train her to self infuse with help Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Initial assessment Numerous medical conditions including Probable secondary Antibody Deficiency (IgG levels 1.9) Rheumatoid Arthritis Ischaemic heart Disease PEG fed also Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Cerebral Vascular Accident with left sided Hemiparesis Uncontrolled Hypertension There are other conditions but mainly Under long term care of Psychiatrist for emotional issues triggered by an incident many years previously Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? This has coloured her perception of hospitals and has resulted in a dislike of attending any follow up appointments for all her other conditions which now included Immunology Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? As her levels were low it was agreed with the patient and her carer (husband) Mary would attend every three weeks for an infusion as a day case venous access was very challenging Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Intravenous infusions were administered but frequent adverse reactions made us reconsider the treatment There was always an infection either on board or not yet made itself known Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? By the start of 2013 more appointments had been cancelled or missed and the levels were obviously not improving MDT (Multidisciplinary Team) meeting the situation was discussed. Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? The patients anxiety and concerns were also taken into consideration, it was becoming more difficult emotionally for this lady to attend for the treatment Long discussions were held with her and her carer Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Subcutaneous infusions were discussed in detail Problems identified Increased visits to the unit Transport dependent on husbands work pattern Increasing anxiety Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Other issues were identified: Refused Hospital transport Confided in staff about various issues which had to be discussed before home therapy could be a reality All these concerns from the staff aspect had been noted in previous specialities Fran Ashworth CIAU

PATIENT DAY CASE TREATMENT AREA Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Meetings were held with other disciplines who encouraged home therapy as a positive option Mary did agree to subcutaneous infusions with a view to going out on home therapy within weeks Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? I was totally honest with the couple and advised this may not be an option, and would need longer to ensure the competencies were met in full Mary became quite adamant she would stop her treatment Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Over the following months from early 2013 it was a struggle to maintain her regular attendance at the unit She would not be able to do the infusion at home alone as she was totally dependent on her husband Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? There was support and encouragement from the primary care professionals and other professionals There were always questions but never any real answers to problems which arose every time Mary attended the unit Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Solutions suggested to the couple To find another infusion partner to allow her husband to have some respite: Declined To attend every two weeks instead of weekly: Declined To try and get an agency Nurse to attend to do the infusion: Declined Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Continued to reluctantly attend for infusion but hit & miss due to being unwell Blood Pressure at one visit was 187/119 Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Mary was extremely unwell and needed to be hospitalised No beds available at the time but one was to be saved and staff were to inform the patient when it was ready Bed available, ambulance attended to bring her in but she declined Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Her condition was serious but managed by primary care professional There was a long period between this lady being well and attending regularly for treatment Home therapy training was undertaken after the risks and benefits had been examined Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Checklist Reason Important Points How Assessed Pt. Sign Sup. Sign Comments 9. Swab down the work area with an Alcowipe.Prevents infection. This must be done every time 10. Remove caps and swab Immunoglobulin vials with Mediwipes. Prevents infection. Leave the vials to dry for about 30 seconds 11. Put together syringe and needle. Provide a method for transferring the Immunoglobulin from the vial to the syringe. . Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? March 2014 all competencies had been met Reviewed by Consultant First Home visit 12/3 /14 Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? All went well booked a holiday to Australia In May 2014 All comunication links were opened with Austrailian colleagues, Medical staff identified, etc Infusion, infusion devices etc were supplied Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Letters to Custom complete On return from holiday Extremely unwell, no infusion had been undertaken whilst away Intense Primary Care input Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Not getting any better Infusions started and stopped Levels were dropping On going periods of being unwell Declined invitation to attend the unit for assessment Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? June 2014 Reviewed in clinic September Extremely unwell, pyrexia, dyspnoeic Not infusing therefore levels once again depleting Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Spent three days trying to get this lady admitted, spoke to Primary Care Professional After many sleepless nights and much worry this lady eventually agreed to being admitted Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? This gave time to re-evaluate She described having problems with the infusion Poor venous access to administer intravenous antibiotics Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Difficult admission but a Plan was born To do 10mls of infusion alternate days (Peripheral Inserted Central venous) To have a Picc line inserted and therefore when unwell can remain at home and still have correct and appropriate treatment Continue to attend CIAU for assessment Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Outcome extremely difficult situation, each visit brought its own challenges. With perseverance and multidisciplinary approach: A plan of action to minimise hospital admissions Regular infusions of immunoglobulin Intravenous antibiotics at home Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Regular contact with Patient There will never be a time when life is smooth for this lady but we have ensured we can make it as good as we can. Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? On Reflection the main issues for this person are not the physical conditions which appeared to be a barrier to her home therapy but the emotional issues which prevent her from seeking medical intervention sooner incase she has to be admitted to hospital Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? It wont always feel as tranquil as this picture of my homeland, the waves are waiting to crash the rocks but for now we will meet the needs head on and support this couple to sustain an improved quality of living by reducing hospital visits and delivering a high quality of care and support Fran Ashworth CIAU

Patients with Complex Medical Conditions :Is Home Therapy an Option? Thank you Dr. William Egner Dr. Anna Shrimpton Dr. Ravi Sargur Debbie Hughes All the Nursing Team in Clinical Immunology and Allergy Unit Sheffield Fran Ashworth CIAU