Wednesday, March 23, 2016

UDHC case study: from online-patient-record-blog to published journal article

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 

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 here

Blogged online patient record here

(Online-record created and shared after gathering signed informed consent form here, and here

Resources on how to gather the patient’s voice in narrative: here

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.

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




PLAN for the patient:

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.



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