The
UDHC project employs a case-study-design, integrating units of
single-patient-case-studies that will be guided chiefly by the M-health
specialist, doctors and research analysts covered by the project budget. They
will thematically analyze individual patient records created by the Tele-health-workers
(aka Patient-information-communication-managers PICMs) including their updates
and prepare situational, problem-based, patient-case-studies based on the SOAR
model linked here: http://www.qihub.scot.nhs.uk/knowledge-centre/quality-improvement-tools/case-study.aspx
They shall integrate similar single-patient-case-studies to achieve insights
into suitable scale-able strategies that can best prevent and optimally manage
such cases in future.
Situation (S of SOAR)
·
What was the
background to the current state?
·
What was happening?
·
What was the problem?
·
How was this
identified?
Subjective
(S of the traditional SOAP
format) data from patient’s
voice:
Sample: Narrative
data from patient’s voice
Blogged
online patient record here http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=1593
(Online-record
created and shared after gathering signed informed consent form here: https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg09I4FagtiihDdCFigbPw8p5Kfa_wp9bHQu1u3e0K-8x-ZEJmjqeoF5EIz1L1wWw4rN9IEQ4ijS27z39mkcH3PXNDzYJuG7lq-4kjXM-VT1D6WWP3-a6plkreJTLh9bG2XIb2cmNjLPpQ/s1600/consent+form.jpg,
and here: http://www.udhc.co.in/STATICS/docs/udhc-english.pdf
Resources on how to gather the patient’s voice in narrative:
http://staff.esuhsd.org/danielle/english%20department%20lvillage/CAHSEE%20English/The%20Autobiographical%20Narrative.pdf
Objective (O of the traditional SOAP
format) data from
patient’s clinical findings:
Sample: Video link to this patient's gait:
Assessment (A
of the traditional SOAP format) from the above
Subjective and objective data of the above sample Case-situation/scenario
Case-Summary
(Diabetes with pain abdomen and diarrhoea and Paralysis of one leg): Link to
the summary here: A 35-year-old man was recently interviewed by our
Patient-information-communication-manager in LNMCH for registering into an
online-health-record. This patient had previously presented
to a community hospital with eighteen months of chronic abdominal pain. The
pain was epigastric, mild, and associated with occasional diarrhoea. After
being admitted to the hospital, the patient was diagnosed with
Insulin-Dependent Diabetes Mellitus (IDDM) and was started on subcutaneous
insulin injections. His condition improved and he was discharged. After a brief
respite, he suffered from severe abdominal pain for which he returned to the
Primary Health Centre nearest to his village. He was given an intramuscular
injection of an unknown substance into the left gluteal region to relieve his
pain.
After receiving the intramuscular injection,
the patient was unable to rise from a supine position. He discovered that he
was unable to move his left leg. The patient returned to the same PHC two days
later, where nothing was done for his left leg weakness, but instead he was
given another intramuscular injection in the contra-lateral gluteal region. The
patient was later admitted to the PHC for thirty days, but no therapeutic steps
were taken to resolve the loss of mobility and the patient noticed no
improvement in his condition. The patient returned to his home for two weeks,
hoping for an improvement in his condition, but there was no change. Six weeks
after the injury, the patient presented to a tertiary care hospital with foot
drop, mild paraesthesia and tingling sensations in the left leg.
Sample Assessment-Problem-List:
Injection nerve palsy,
Insulin dependent
Diabetes,
Chronic abdominal pain
and diarrhoea
Resources: Unpacking
the process of interpretation in evidence-based decision making
Assessment of Health
related quality of Life (resources): http://www.cdc.gov/hrqol/hrqol14_measure.htm
Dermatology quality of
life index: http://www.bad.org.uk/shared/get-file.ashx?itemtype=document&id=1653
PLAN for the patient:
Objective (O of SOAR)
Objective (O of SOAR)
·
What were the aims of
the project for this individual patient?
·
What was hoped to be
achieved for him/her?
Case-objective: Through the above mentioned patient with paralysis of one leg
following an injection, we found that ‘injection nerve palsy’ was a significant
problem in Central India not just for the particular patient who presented to
us but also in a few more similar patients we came across and we realized that
a fresh approach was necessary to prevent this problem from recurring. Our
objective was to reduce this problem by identifying training lacunae in
injection practices and instituting training beginning with our own nursing
staff and publicize our actions through appropriate channels to scale our
action. We also needed to take care of his insulin dependent diabetes by
optimizing the dose and frequency of his insulin injections as well as his
diarrhoea and pain abdomen by investigating it further. We also needed to
follow him up with intermittent screening for any further complications such as
weekly for BP and annually for retinopathy.
Action (A of SOAR)
·
What action was taken?
·
What were the
implemented improvements (tools/techniques)?
For the problem of ‘injection nerve palsy’ on
reviewing the literature, we found that informational interventions that
disseminated proper training to develop an anatomical understanding
of the sciatic nerve can be effective and we took the nursing staff of our
hospital to the dissection room and demonstrated the anatomy of the sciatic
nerve along with the measures to prevent such injuries by demonstrating proper
techniques (ventro-gluteal in supine position instead of the currently
prevalent practice of dorso-gluteal in lateral position) and monitoring the
staff as they practised on cadavers. For the patient, an ankle-foot orthosis (AFO) was used to provide foot
dorsiflexion during the swing phase and lateral stability at the ankle during
stance. Since the patient also
complained of paraesthesia, pregabalin was prescribed to manage this symptom.
Unfortunately, because of the patient’s poor socioeconomic condition, he was
not in a position where he could afford these medicines. Hence, to alleviate
his pain, less expensive medications, paracetamol and diclofenac were
prescribed. Along with these treatments, the patient was put on regular insulin
for his IDDM and the dose and frequency was optimized. His diarrhoea was
further investigated and basic stool examination did not reveal any abnormality
and he was managed as autonomic diarrhoea and pain. Once discharged from our
hospital he was followed up by our THW, who collected information not only about his
afore mentioned problems but also on his weekly fasting and post-prandial blood
glucose values as well as his Home BP recordings using a portable blood glucose
monitor and portable BP monitoring standard oscillometric device. Annual
Fundoscopy screening was planned to be done through tele-ophthalmology
techniques.
Results
·
What is the situation
now?
·
What was achieved
through the action(s) and were objectives met?
The patient with injection nerve palsy is still living with his
gait disturbance due to the nerve palsy and is still using a
posterior AFO although he finds it uncomfortable while walking. The fit of his
AFO is less than ideal, and the authors are searching for financial resources
to supply this patient with a model that will fit. His diabetes is well
controlled. He still continues to have episodes of abdominal pain and diarrhoea
although the duration and frequency is less than before. After training our own
nurses in using a ventro-gluteal-supine approach we are trying to scale to
propagate this safer injection approach to other nurses and any practitioner
who administers injections to patients. We still need to gather more robust
evidence through a funded RCT where one can compare the two approaches and
establish the superiority of the ventro-gluteal-supine approach as a fool-proof
and consequently safer method.
Case-Study published in journal here: http://www.ncbi.nlm.nih.gov/pubmed/26931130,
http://casereports.bmj.com/content/2016/bcr-2015-211127.abstract
