The Right Equipment, The Right Environment: An independent assessment improves Mr W's care

Author: Rehab and Community Care Medicine Spring 2008
Published: 15 October 2008

Mr. W. is a 43-year-old male who was in a serious motor vehicle collision in 2004. He sustained severe traumatic brain injury, costal and lower extremity fractures, and internal injuries. He remained in a coma for two months and was not expected to survive.

Two months post collision, he was transferred from a large trauma centre to a 25-bed complex continuing care unit in a hospital closer to his family in order to facilitate family visits. Within a month of his transfer, he began to make unexpected progress; he began to breathe independently, was extubated and began attempting to speak. He demonstrated limited active movement in his right upper extremity and hand and was capable of self-feeding and of limited washing and dressing his upper body. However, Mr. W. continued to present with severe cognitive limitations, difficulty with receptive and expressive language, hemispatial visual neglect, and paresis involving all four limbs. He also had flexion contractures of the left upper extremity, hips, knees and spine.

To address Mr. W’s mobility needs, the hospital occupational therapist (OT) and physiotherapist (PT) provided Mr. W. with a wheelchair that enabled him to leave his room and access his hospital floor. However, given that the impairments from his brain injury included impulsivity, impaired judgment, erratic movements, disrupted sleep/wake cycle and a voracious appetite, it was not safe for him to be left unsupervised. Mr. W. was found in potentially unsafe circumstances, including approaching hot meal carts, grabbing medication trays and entering other patient rooms.

Limited by restraints

Due to the staff’s perceptions of Mr. W’s behaviour as agitated and dangerous, chemical and physical restraints were frequently used to manage his activity level. As a result, he was routinely sedated to the point of being unable to communicate or swallow safely. Nursing staff frequently tied his wheelchair to a wall or his bed to impede his mobility. Mr. W. became very frustrated by these restraints and began striking out. Staff were unable to identify the connection between their approach and his behaviour; as a result, they further limited his mobility and independence.

A new assessment

Given that Mr. W’s mobility had created significant difficulty for the unit, his case manager arranged for a thorough seating and mobility assessment.
is family was concerned that he appeared to be very uncomfortable while seated in his current wheelchair.In addition, his family was distressed that he was being tied in his chair, which was tied to the hallway railings or his bed. Given the lack of seating expertise on the unit, an OT from the community was brought in to complete this assessment.

As a result of a thorough assessment, a wheelchair was recommended.
During the second visit, Mr. W. was observed sitting in the prescribed wheelchair in an ideal position and independently propelling in a purposeful manner. However, the nursing staff was very dissatisfied as he had returned to moving about the unit freely. As such, they had returned to using restraints.

During the third visit, Mr. W. was soHeavily sedated that he was unable to sit upright or communicate. Review of his medical chart by the unit staff demonstrated that since the delivery of the new wheelchair, medication prescribed for Mr. W. was routinely administered to manage his “aggression.”

Detailed recommendations

A detailed report was submitted highlighting the challenges on the unit that were affecting Mr. W’s needs.It identified that the main concern was not Mr. W’s seating and mobility needs, but rather that his needs in general could not be addressed appropriately in his current environment.

Fifteen recommendations were made which included provision of a wheelchair and provision of a support worker. In recognition of the unit on which Mr. W. resided and the challenges of the nursing staff, a Broda wheelchair was recommended to enable him to be positioned properly and comfortably without independent mobility. It was anticipated that the Broda chair would eliminate the need to physically or chemically restrain him when he did not have a support worker with him. Training related to Mr. W’s needs was strongly recommended for all unit staff to improve his overall care.

Other recommendations addressed the implementation of services to address his ongoing physical and cognitive limitations and to improve his communication to increase his independence and access to rehabilitation programming. The final recommendation was to transfer Mr. W. to an environment that would support his overall needs.

A change in environment

Upon receipt of the report, funding approval was provided to Mr. W. for a manual wheelchair and a Broda chair when he did not have individual supervision. Funding was also provided for the services of a support worker for several hours, four days per week.

A plan is currently being devised to arrange for Mr. W’s discharge to his family home with the implementation of environmental modifications. Prior to discharge, training for the family and any involved support workers will be needed to ensure a positive provision of care that addresses all areas of his daily living and enables him to achieve maximum independence.