So at most work places there are inappropriate referrals. I asked about this at my new work, and was told we generally see everyone that gets referred, even if it's only once, to acknowledge the referral. Again, as a result, I see about 30% fewer appropriate patients, as I deal with those who are intubated, have a GCS of 9, or who haven't eaten since the late 80's due to their complete aphagia.
I've developed a checklist for nurses and am hoping to approach my manager with it. Wanted to share it before I did.
- Has the patient already been discharged home? You don't know? Look in their bed. If someone else is in it, they have gone home.
- Does the patient have a large tube in their mouth, helping them to breathe? If I see the patient, I will need to take that tube out to be able to put my spoon in their mouth. If you don't want me to do that, reconsider the referral.
- Is the patient alert? Alert means they can sit up on their own, head off their chest, for about 15-20 minutes at a time. Sometimes they may even open their eyes for you or (gasp) even talk to you. If you want to check alertness, sit on the patient. If they don't respond, they are probably not alert enough for SLT. Check that they're not dead. If they groan, they are alert enough for a physio, but not for an SLT. If they try and push you off, then they are sufficiently alert. Refer to SLT.
- Why has the team made the patient NBM (sorry, nil by mouth)? If it's for surgery, and I feed them, they can't have that surgery, and I'm sure we both know what the team will do to us if I do that. If it's because they are not alert, refer to point 3. If it's because they use a PEG, you may need to do some further investigations (scary, I know). Ask the patient or the family or the nursing home why the patient has a tube coming out of their stomach. If they say it's for feeding because they can't swallow, and haven't done so since the late 80's, then I'm probably not going to be able to change things in a 40 minute assessment. But refer and I will do the hard work of chasing old notes. If they say they don't know, they haven't used their PEG since the late 80's, refer away. Again, I'll do the investigating. If they say nothing, check that it's not because they're intubated, or dead. See point 6.
- Is the patient already eating and drinking a normal diet? Yes? Are they showing any signs of difficulty? No? Any concerns with communication? No? Then I don't need to see them. Really, I don't.
- Is the patient dead? Unlike the kid in the Sixth Sense, we don't see dead people. Dead people should probably stay NBM.
Ok, so maybe the last one is an exaggeration. The rest are all based on real events.
Absolute GOLD Linds!!!! This is certainly the story of every Speechie's life. I certainly spend 30% of my working week with dead/asleep/overly aggressive patients, rather than spending it with patients who actually NEED to see me. What a shame that other medical staff don't think to use their brains before wasting my time!
ReplyDeleteMy favourite referral of the week - 47 year old man with advanced frontal dementia. EXTREMELY aggressive, and extremely impulsive when eating - resulting in occasional aspiration episodes (surprise surprise). When I arrive on the ward the nurses tell me..."it wasn't appropriate to keep him NBM because he's so aggressive and it would only make him worse. He most certainly won't take thickened fluids or puree. If I were you I wouldn't try and touch him or he might hit you. But see what you can do..." Lol!
Another favourite TSH referral of late "can you please see this patient on the Aged Care ward? She's eating the plastic packaging on her meals" Hmmm...does she seem to have trouble chewing the plastic? Is she choking on the plastic? No? Then my work here is done...
This is brilliant. Send it to Sydney and have it 'ratified'.
ReplyDeleteGosh, the nurses in the NHS sound dreadful Linds! Thank god we never sent you referrals like that...!
ReplyDeleteDon't forget the lack of dentures and mouthcare ( what are they again???), and hoirzontal feeding (especially by helpful spouses).
'If they groan, they are alert enough for a physio, but not enough for a SLT'. Dangerous talk very dangerous!
I'm a late comer to these pearls of wisdom Linds. I loved point 1 and I seem to remember being referred a patient who'd already left when I was in the UK. You should get this laminated and put it in your SLT office :) Katrina Blyth
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