Homeless Step Down Pathway Case Study 10

CASE STUDY

By Kattya Mayre-Chilton

Specialist Dietitian B7 DT25287

Mildmay Hospital

This is a case study I would like to bring to everyone's attention given the special circumstances in which it took place. It not common for the therapist to key work the patients on the homeless pathway but I felt compelled to do so given the patient's predicament and complex dietetic intervention. He is not recognised as a resident in this country, nor his home country due to a lack of paperwork and a passport.

He had no traceable next of kin, and even if he were to return home we would not how it would be possible to maintain the necessary level of care given the perilous situation in his native country.

This gentleman, 55 years old from the Union of Soviet Socialist Republics (USSR) era, entered the UK before 1992, as an immigrant smuggled in the back of a truck. He was originally from the Ukraine area of the USSR and had no documents. This was his third admission to Mildmay since 2020. He was referred to dietetic intervention on his third admission when he was transferred after he had a Stroke (left middle cerebral artery (MCA) infarct) with complicating expressive and receptive dysphasia (receptive dysphasia is difficulty in comprehension and expressive dysphasia is difficulty in putting words together to make meaning). He was being fed via a percutaneous endoscopic gastrostomy (PEG) feeding tube (to prevent aspiration pneumonia) due to unsafe swallowing. PEG feed and care and discharge planning requires extensive monitoring and handover from the dietitian, for this reason I volunteered to help the homeless team and key work on his behalf.

This gentleman was always referred through the homeless pathway as he had no immigration status in UK but cannot go back to the dissolution of the Soviet Union, Ukraine zone, as he has no passport or identification to get travel pass. Our housing officer explore this during his admission over 2020 and 2021, where the Ukraine embassy would not recognise him as a citizen because he has no passport. She also identified that he had a daughter but all ways to contact her failed. During his third admission in 2022 and with his complex clinical needs it was even less likely to be returned to the Ukraine war zone and harder for us to locate his daughter.

This gentleman required long term enteral feeding via a PEG due to unsafe swallowing, and being unlikely to be able to meet his nutritional requirements without this support. The PEG was also used to maintain his hydration and delivery of medication such as his medication to treat seizures (Levetiracetam) twice a day; dispersible aspirin daily; to treat ulcers by slowing down the food transition (Propantheline) three times a day; for elevated cholesterol (Atorvastatin) daily; to help with sleeping hormone Melatonin was given daily and 'when required'.

His weight on admission (Aug 2022) was 77.9kg, height 1.86m with a body mass index (BMI) of 22.5kg/m2 classified in the healthy weight range, malnutrition universal screening tool (MUST) score >2. The following graph shows an upward trend for weight gain. He did have a few troughs when he increased his activity levels or when he had episodes of diarrhoea. On discharge (Feb 2023) his weight was 83.1kg with a BMI of 24.0kg/m2 in the healthy range, MUST >2 because he needed PEG support. He gained 5.2kg (6.25%) during this admission.

His estimated requirements targets were calculated, based on his weight, for energy to be 2337kcal,with protein 78-116g and fluids to meet 2.7L per day.

He was nil by mouth (NBM) with regular mouth care. All his nutrition and hydration was delivered directly to the stomach via the PEG, this is known as Enteral Nutrition using a tube feeding. The PEG tube insertion was on the 14 July 2022. It was a 15FG Freka in diameter with a skin gastric lumen distance of 4cm. There were no reported complications. This is important information to handover in case the PEG needs replacing at any point.

At the acute hospital he was started on an overnight feeding regime and this was continued on transfer to Mildmay. This overnight feeding method is advisable to encourage patients to engage with rehabilitation care during the day. However, night staff found him frequently touching the tube which raised concerns of the tube getting dislodged (pulling the tube out or displacing).

His feed was changed to a bolus feed regime, which allowed administration of 200–400 ml of feed down the PEG over 15–60 minutes at regular intervals. Bolus feeding can be similar to a normal feeding pattern, more convenient, and allows freedom of movement for the patient. He tolerated the bolus feed concentration and ingredient content.

The established bolus regime feed volume was seven 200ml bottles of Fresubin Energy Fibre 200ml per day (total vol 1400ml/24hrs); with 50ml water flushes (to prevent the tube getting blocked) per and post each bolus delivery (total of 700ml/24hrs). Total provided by the feed was, for: Energy 2100kcal; Protein 78.4g and Fluids 2625ml/day.

Any additional water to meet his requirements was given with his medication dilution and flushes. He had seven medication events per day. According to our Tube Feeding Procedure and Drugs - Management Administration of Medicines Procedure, all medication needed to be reviewed to enable them to be delivered via an enteral tube to the stomach and checked they did not react to the feed. Each separate medication was recommended to be dissolve or suspend use 15ml of sterile water. Administration involved the use of 30ml of sterile water for flushes (to prevent the tube getting blocked) pre and post each medication (total of 525ml/24hrs).

The staff were trained (Hospital standards) and advised to ensure the patient was always positioned at >40 degrees during feeding and for 30 minutes after feeding stops. Using the appropriate feeding syringe (purple in colour), they feed slowly and gently through the tube, e.g. 250ml over 20 minutes. The prescribed water (50ml) was poured into the syringe and allow to flow through to flush the feeding tube appropriately.

The PEG stoma site care required daily cleaning by nurses, during this cleaning any changes to appearance, colour or discharge were noted, to indicate any possible infection, and the medical team and the dietitian would be informed if any concerns were raised. We were more vigilant in monitoring this as due to the expressive and receptive dysphasia he was unable to tell us if he was in pain or discomfort. We used the communication tool developed by our Speech and language therapist (SLT) to help with understanding if he was in pain or not. He could point at pictures to indicate if he was happy or not. We used this to guide us on his possible preferences. Prior to him being discharged (2/3/23) the PEG stoma site looked clean, clear and slight pink colour, indicating no infection with the established track.

Other stoma site care involved the PEG being advanced and rotated, at Mildmay this takes place every week on Thursdays. This weekly procedure is to prevent Buried Bumper syndrome, whereby holding the visible end of the tube and rotating it 360° (a complete circle) and advanced (push) the tube approximately 2 - 3cm into the stomach and pulling it back to the original position. Prior to him being discharged (2/3/23) there were no issues, and his PEG care was conducted appropriately.

During his admission he had a couple for episodes of diarrhoea, samples were checked and they were not infectious. We hand to closely monitor his tolerance to the feed concentration, fibre content and rate of delivery until we found a feed and rate which he tolerated. Bowels were opening on average twice per day and loose ~200g, this was normal for him. We started to use the validated King's stool chart for enteral feeding to better monitor his bowel habits.

SLTs worked intensively with him to help with communication, capacity and trialled oral options to improve his quality of life. Some of the challenges with oral trials with yogurt or teaspoons of water included coughing and hypersalivation. The nursing team reported that he was not managing oral secretions and he was not swallowing when given teaspoons of water. This was reviewed by SLT with close liaison with the allocated Independent Mental Capacity Advocate (IMCA) to determine if it was in his best interest to remain NBM.

The physiotherapy team worked intensively with him and he was able to leave his room and sit by the nurses desk. There he could interact with everyone on the ward and he was engaged in looking at the newspaper, magazines as well as playing games with staff. On occasion we got to see a smile.

In coordination with our social worker lead a referral was completed for an IMCA to be allocated to represent him because he had no family or contact available. Under the Mental Capacity Act 2005 the role of the IMCA is to legally safeguard his interests with regards to making decisions about where he wanted to be discharged to and about eating options risks and quality of life. The IMCA could not see any reasons why it was not in the patient's best interest given the current situation that he shouldn’t have a nursing care placement. The social worker lead completed a referral for the community social worker allocation. Once one was allocated we organised a discharge planning meeting, she attended and also conducted a capacity review with him. The team with the for the community social worker completed a full discharge decision tool form and the overall agreement was that the best place for him was a nursing care environment, ideally with some neuro-rehabilitation to help him continue to improve. The forms were submitted and the funding borough approved this.

He was reviewed by 4 nursing homes, one specialised in Neurorehabilitation and the others offering more general care. The funding borough referred and selected the nursing home. Once we received the final approval we could proceed with planning for discharge and his transfer. This included calls to the nursing home by various members of staff to see what they had in the facility, what they required for us to send over for a safe discharge.

From a dietetic viewpoint this included the regime, and they requested a month's feed supply (nine boxes were provided). They were supplied by a different feeding company so to prevent delay I wrote to their GP with appropriate prescription for using Nutricia Fortisip Multi-fibre 200ml bottles which were nutritionally complete, high energy (1.5kcal/ml) with fibre, 7 per day, and recommended that on review that the dietitian may want to reduce bolus to 6 per day as his weight was steadily increasing.

I referred to their community enteral nutrition team, nurses sent any additional equipment and information, doctors completed the discharge summary and medication on discharge and all other therapies involved completed their ongoing referrals. The transfer was booked and a member of staff accompanied him.

The staff reported that he looked happy with he arrived at the nursing home and was smiling. We conducted a few follow-up calls to ensure all was going well and the funding borough also requested paperwork to support their funding allocation. The nursing home manager reported that he looked happy, had settled and there were no issues raised, we had a safe discharge.