Medically fit, awaiting social.

In the last two weeks, I have written that statement at least six times every ward round.
Its appalling that in this age of bed shortages and numerous hospital-acquirable-infections (from pneumonia to MRSA and Clostridium difficile diarrhoea), that people who are as well as they will ever be, spend weeks, verging on months waiting for a "social sortout".

This phrase "social sortout" covers a gamut of things. From those who need a little bit a help at home, to those for whom their own home is no long a safe place, and who need care 24-7, be it in a residential home or a nursing home.

Social problems include diffulty with activities of daily living (ADLs)*, mobility and vulnerability.
These are identified on the first day of admission, in both the nursing clerk-in and the doctor's social history. With most patients, this is less important than the reason they are in hospital, so it gets put on a back burner, and forgotten until the patient is getting better. However, there are some patients, who end up in hospital purely for social reasons.

For instance, the 75 year old lady who has been living in a residential home (RH) for the past 5 years. She is gradually getting less mobile, needing increasing amounts of help with ADLs, and urinary incontinence is becoming the norm, rather than an accident. She now fits the criteria for a nursing home (NH). However, as it is a hassle for the RH that she is currently living in, they send her into hospital, with a lame excuse (eg urinary incontinence, which has been going on for the past six months), where she is then thoroughly investigated, for infections, and has a dementia screen (which includes a CT of her brain). Three weeks (or so) later, it is finally concluded that there is nothing really 'fixable' with this lady, and that she just needs more help. At which stage, the "social sortout" starts. Usually one can tell, when a patient is admitted for social reasons, but there is very little that can be done about it. And as doctors, we are bound to look for anything that we can 'fix'. So this little old lady, who could have had a transition from RH to NH, instead spends a month or two long detour at the local NHS hotel at the expense of the taxpayer (in a different context, she might be a politician!).

Then there is the 'fiercely independent'. The ninety-something year old gentleman, who refuses help in any shape or form. Still insisting on doing his own cooking, cleaning, etc., despite accidents, like leaving the gas on, the front door open and falling over the flowerpot/rug/footstool. By the time an offspring/helpful neighbour has convinced him that he needs help, and he grudgingly agrees to have someone do the cleaning, and bring in the groceries, something else usually happens (eg, him being found on the main road 3 miles away at 2am, with no idea where he's going or why), resulting in a visit to the local hospital. Where once again, us medics try to work our magic and 'fix' him.

When a patient is declared medically fit, the first step is that the nurses have to fill-out an Easy Care document, which is a long list of questions ranging from how the person manages their day to day activities, to whether they feel safe where they were living prior to admission.
Then an occupation therapist (OT) assesses the patient, to determine whether they need aids to optimise their independence. This includes assessing the patient washing, and in the kitchen. They also visit the patient's home, to identify any potential dangers, and any areas that the patient may need help with should they go home (eg chair raisers for low-set chairs from which an elderly patient may find it difficult to get up).
After this comes the social worker. For some of my patients, the wait to be allocated a social worker has been upto two weeks. The social worker takes into account the OT and the physiotherapist's assessments, as well as the findings of the Easy Care. They then attempt to sort out the best possible arrangement for the patient: be this home help a few times a day/week, meals on wheels, different housing (warden aided flat**/RH/NH).

Through all of this process, the wishes of the patient and family are taken into account as far as possible. The reason I say 'as far as possible' is that some patients are just not realistic.

Mrs DH is a 70 year old. She came to hospital after a fall, due to very low blood sugar. We then found that she was mostly blind (CT of her brain showed that this was the result of a previous stroke). This had had a number of implications: she had not been able to lock her front door (could not see the keyhole), and had been burgled; she could not identify money, and was being robbed; she could not operate a microwave (her gas had been shut-off months earlier, after a few 'accidents') and this coupled with being unable to read best-before-dates, meant that she ate poorly, and when she did, it was probably not safe; she could not find the toilet in a hurry, and there was faeces all over her flat (as the OT found out).
And she still wants to go home. She admits to understanding that she cannot manage, but is adamant she wants to go home.

It is incredibly frustrating to me, as there is nothing that I can do for 'social' patients, except be watchful, just in case they pick up an infection in the meantime.
And its usually frustrating to the patient - very few people actually like being in hospital.***

Maybe I should not complain. After all, its the reason why despite having over twenty patients to look after, I have been able to see them all and finish all my jobs with three hours to spare in the afternoon for the past week.
On second thoughts, I hate that part of the day - there's only so long one can stretch a cup of coffee!
There - I've gone and done it. I've jinxed this week. According to Sod's law, it will probably be extremely hectic.****
Ah, there but for the grace of God.....


*ADLs = washing, dressing, cooking, eating, cleaning, shopping etc
**WAF = a block of flats with a 'warden' who is available 24-7 for assistance; residents can alert the warden by pulling an alarm that is usuually present in all rooms of the flat. Some residents have a 'life line' which is a chain they wear with an alarm on it, which is activated when pressed.
***herein lies the story of patients who like hospitals - more later!
**** A colleague of mine is unable to understand how a number of seniors (registrars and SHOs) - reputedly intelligent and rational individuals - get really superstitious, and touch wood when (on the rare occaision) talk turns to how quiet the day has been!