Optometry Use Case (page 49 of 2) in Use cases (chapter 5 of 5) within Core Information Standard: Reports

Dorothy's story

Ambulance

<img>Blue ambulance icon with a white star on the side.</img>

• Dorothy has a fall at home and a paramedic is called out.
• Once Dorothy is stable, they have a collaborative clinical discussion with a care of the elderly admission avoidance service clinician via phone call; to try to manage Dorothy's needs in the community rather than hospital. This is in line with Dorothy's wishes.
• A referral is made to a rapid response team by the paramedic, so Dorothy can be assessed and treated at home.

Community

• The rapid response team arrive at Dorothy's home.
• An occupational therapist provides some independence aids to minimise the risks of further falls. They also make a referral into community rehabilitation therapy for re-enablement.
• The rapid response on call clinician makes a referral to the virtual ward operating within the same NHS trust to keep Dorothy at home with medication and monitoring.

Pharmacy

• Dorothy is discharged from the virtual ward, then later has an episode of diarrhoea, headaches and blurred visions.
• Her daughter picks up her repeat prescriptions and asks her pharmacist for advice on whether Dorothy's condition is affected by her medication.
• The pharmacist checks her repeat prescriptions for allergies and potential side effects of prescribed medication.

Optometry

• Dorothy has an optometry appointment to rule out any health condition related to eye deterioration.
• The optometrist rules out any health-related eye conditions and prescribes distance vision glasses.
• The optometrist advises more regular visits to monitor any vision related side effects from her prescribed medication.

Section 1: Ambulance (999)

➢ Dorothy is an 81-year-old person who lives alone. Her daughter, Kate, lives a 15-minute walk away and cares for her full-time.

➢ One day whilst Kate is preparing her lunch, Dorothy has an acute episode whereby her cognition appears to be impaired, and as a result, trips down a couple of steps whilst walking into her garden.

➢ Kate calls 999 and an ambulance arrives on the scene promptly. The paramedic assesses her, she has no injuries and no impairment to her mobility. She is visibly confused but stable.

➢ After assessing Dorothy, the paramedic asks the daughter whether she has any health conditions they should be made aware of. Kate informs them that she has Alzheimer's and atrial fibrillation. The paramedic accesses Dorothy's shared care record and can see from her recent admission and discharge details that she has been admitted into hospital six times in the last year. Two of these were for acute delirium and the other four episodes were for urinary tract infections (acute urosepsis). The paramedic takes a range of physiological measurements and assesses that Dorothy’s NEWS2 score is low. The paramedic then takes a urine sample and tests it with a dipstick. Dorothy’s urine is cloudy and has strong odour. The dipstick tests showed positive to blood, white blood cells and nitrates, pointing towards a bacterial infection.

➢ The paramedic evaluates the information accessed on the shared care record. The information presented suggests that Dorothy could potentially be treated in the community which is in line with her pre-expressed wishes. The paramedic makes an informed decision to call the care of the elderly admission avoidance service, who make a referral into the local NHS rapid response service.

➢ The care of the elderly admission avoidance service's clinician makes a 2-hour urgent crisis response referral via the direct phone line for the local rapid response service, who can assess and treat Dorothy at home to avoid an acute hospital admission.

➢ The rapid response service clinician accepts the referral and confirms that a nurse and occupational therapist will arrive within half an hour. The on-call clinician accesses the shared care record to include the relevant detail on the referral form so that other healthcare professionals accessing the shared care record can see details of this acute episode.

Section 2: Community (Rapid Response, Virtual Ward & Falls Clinic)

➢ 25 minutes later the rapid response nurse and occupational therapist arrive at Dorothy's home with IV antibiotics and IV fluids as directed by the rapid response on call clinician.

➢ The nurse moves Dorothy somewhere more comfortable with the assistance of the paramedic, then check her vitals again, her catheter and performs a brief cognitive screen. The nurse records the clinical notes into the EPR system which updates Dorothy’s shared care record.

➢ The occupational therapist can access the shared care record and finds out that Dorothy is quite frequently having slips and trips. The occupational therapist provides some independence aids, including a Zimmer frame, perching stool and chair raisers, to minimise the risks of further falls in the short term. Kate confirms that Dorothy is having problems with steps and edges. The occupational therapist discusses re-enablement goals with Kate, who is Dorothy’s lasting power of attorney, then creates a personalised care plan on the EPR. The occupational therapist makes a referral into the community falls service for further assessment and advice on falls prevention. Dorothy is placed on the waiting list for an initial assessment.

➢ The clinician on call sees Dorothy's updated clinical notes on her record, they arrange a follow-up visit from the rapid response nurse that responded to the referral. They also allocate a health support worker in the service to visit that evening to take and record Dorothy's observations.

➢ The clinician on-call makes a referral into the frailty virtual ward operating within the same NHS community trust to administer IV antibiotics, IV fluids, and monitoring after the rapid response follow-up visit. Virtual wards support patients, who would otherwise be in hospital, to receive the acute care, remote monitoring and treatment they need in their own home or usual place of residence. Virtual wards provide acute clinical care at home for a short duration (up to 14 days) as an alternative to care in hospital.

➢ 3 days later Dorothy finishes her course of IV antibiotics and fluids and is discharged from the care of the virtual ward with a prescription for nitrofurantoin to be taken orally for another 7 days.

Section 3: Pharmacy (NHS funded)

➢ 5 days into her course of oral antibiotics, Kate becomes concerned for Dorothy; Dorothy hasn't finished her meals for the last 2 days. That morning she has diarrhoea and is complaining about headaches and changes in vision including blurred vision and seeing halos around bright objects.

➢ Kate decides to pick up her repeat prescriptions for memantine, an acetylcholinesterase inhibitor and digoxin. She monitors Dorothy closely for the rest of morning. She plans to call Dorothy's GP if her condition doesn't improve after her medication.

➢ Kate arrives at her local high street pharmacy. Kate gives the pharmacist her mother's details; the pharmacist checks them against her record. Whilst Kate is at the counter, she explains that her Mother that has been unwell, asking for her advice on whether this is a side effect from any of her medication.

➢ The pharmacist checks Dorothy's allergies; she has no drug allergies. The pharmacist rules out an allergic reaction.

➢ The pharmacist then checks when Dorothy's last renal check was. It was 6 weeks ago and shows that her kidneys were functioning well, therefore the pharmacist rules out Digoxin toxicity.

➢ The pharmacist notices that Dorothy is 5 days into a course of nitrofurantoin, which she hasn’t been prescribed before. Nitrofurantoin can cause nausea, diarrhoea and headaches. She suspects this is the cause of Dorothy's newly displayed symptoms.

➢ The pharmacist recommends that Kate calls her GP for advice on Dorothy’s reaction to the antibiotics. They also recommend that Kate books an eye examination for Dorothy when she is feeling better.

Section 4: Optometry (NHS Funded)

➢ The GP recommends that Dorothy stops taking the nitrofurantoin immediately as her UTI symptoms are no longer present, and she has taken most of the course.

➢ Dorothy has been accommodating to walking with a Zimmer frame following a history of numerous falls. She enjoys watching TV and watching her grandchildren play in the garden. She is more stable with a walking frame, but her daughter has noticed that since, she’s still complaining about blurred vision. Dorothy has been walking into furniture and losing interest when watching TV. Kate makes an appointment at her local high street optometrist for the next day.

➢ The optometrist suggests distance vision glasses may help when she is walking around. A moderate myopia is found, and a prescription is arranged to address this. Distance glasses are prescribed and are to be dispensed in a week's time. A glasses chain is given to prevent the spectacles slipping if Dorothy is leaning over on her walking frame.

➢ Whilst updating Dorothy's optometry record, the optometrist notices that she is on digoxin and other medication that could potentially impact her vision. The optometrist advises that Kate book a regular eye tests with retinal OCT scans every 6 months for Dorothy.