When Alternative Pathways Work

My crewmate and I were called to a nursing home not far from station. We'd already been warned that there was another ambulance crew on scene dealing with another patient.

We jokingly wondered if the nurses there were beating the patients up.

As we entered the home we were met at the front door by a member of staff (as any regular reader of this blog will realise, this is a rarity). It turned out to be the nursing home's manager. She led us towards the patient.

She also knew about the patient, even though he was only staying there for a week or so while his wife was in hospital herself. Again, a rarity.

As we stepped into the lift we met the other ambulance crew on their way out with their own patient – he told me that he'd had a look at our patient and that, while he had a cut to the head, he was otherwise fine. He also mentioned that it would be a shame to drag the patient out to the hospital.

Our patient was suffering from severe dementia and was described as 'a wanderer'. While wandering he'd had a simple trip and had hit his head against one of those bits of furniture that seem to dislike old people. He was currently sitting in a chair in one of the communal rooms, surrounded by another twenty or so deeply demented, and wandering, patients.

But here is the thing – the patients were all clean, their clothes were tidy and none of them were 'tied down*' to the chairs. There were also four nurses in the room engaging with the patients (even as one of them decided to have a root through our kit bag – and then started swearing at the nurse who told her that the bag didn't belong to her).

So it was obvious that this was one of those good nursing homes that I always believed was out there but seldom witness.

A bit like the Loch Ness Monster.

The cut to the patient's head was pretty typical – it had stopped bleeding and was a minor affair. To drag this demented patient out to the hospital would be rather cruel, so we decided to follow an 'alternative care pathway'.

“Alternative care pathway” is classic NHS gobbledegook jargon for 'the patient doesn't need to go to hospital'.

Instead we decided to call our Emergency Care Practitioner out to see the patient. The ECP is trained to deal with minor wounds and is on hand to see patients in their home. I knew who was working and like all the ECPs on our patch I think he's excellent and would be happy to have him look after my mum.

I have an advantage as, being an ex-A&E nurse, I'm pretty good at knowing what the hospital treatment would be. If the patient were to go to hospital the doctor there would treat him in exactly the same way as our ECP. Except that our ECP would do it better as it's easier to fire an ECP for doing something wrong than it is to fire a doctor.

We met the ECP later in the day. “You rotten sods”, he told us, “I went to that patient – he was so confused he kept trying to hit me. Then he tried to bite me. I closed the wound with some glue, but nearly glued my glove to his head”.

It all worked out in everyone's best interest – the patient wouldn't have to sit for hours in a loud and confusing A&E department getting scared out of his wits and being put in danger of injuring himself again. The hospital wouldn't have that extra patient to see. We were able to clear the scene quicker and were able to go to a more serious call after dealing with the patient – without the ECP we would have still been tied up with transporting him. The nursing home wouldn't have to send a nurse to accompany the patient, thereby reducing the care cover.

And the ECP got to lose a wrestling match with a frail 90 year old man – which is always good for the ego…

*Not literally tied down (although I'm sure that it does happen). But instead patients are hemmed in by trolleys, chairs or other bits of furniture in order to stop them wandering.

If this post makes even less sense than normal please accept my apologies – I've just come off a tiring nightshift and haven't had the chance to sleep yet. I just want to stumble around moaning “Brains… brains….”

7 thoughts on “When Alternative Pathways Work”

  1. *Not literally tied down (although I'm sure that it does happen). But instead patients are hemmed in by trolleys, chairs or other bits of furniture in order to stop them wandering.Though in itself is still a form of restraint. I'd classify patients being routinely restrained in that way as a form of abuse.

  2. I agree. It's why I used the term 'tied down', so that people know that the furniture trip is on a par with it.The problem is that it is tricky to look after such patients with the current resources that a lot of places have (one of the reasons why I supported the nursing ratio petition).

    If you have 30 wanderers and 2 nurses then I can see why they do it, even if it's ethically on wobbly ground. When does 'safety' become 'restraint'.

    Consider cot-sides to beds.

    But yes, I don't like it.

  3. I have issues with restraint in my work too – when does holding a childs arm very tightly so a doc can insert a cannula go from safety to restraint?

  4. I guess in that case what you're talking about is treating without consent. If the child refuses treatment and isn't competent under the Fraser Competencies to give consent, then I guess you'd be looking to get consent from the parents.More info about consent issues with children here:


  5. we always get parental consent, it just sometimes gets very close to sitting on small children sometimes….they can be surprisingly strong when approached with a needle!

  6. In our nursing home 'restraining' residents by using furniture is classed as gross misconduct and anyone found doing so will be immediately suspended pending a disciplinary hearing. We use cot sides only for permanantly bed ridden patients who move around a lot in bed and are at risk of falling out. Cot sides would never ever be used for mobile residents. If our residents want to get up and wander round the building at 4am then so be it, the night staff will just have to keep an eye out. Thank you for pointing out that not all nursing homes are brutal concentration camps who drug the inmates, it's not a view that's expressed very often as nursing home bashing is the new Prada handbag. So much so in fact that my family are finally throwing in the towel after 25 years of service and selling up. So that will be one less decent home open and Manchester will now, as far as I am aware, be left with no specialist top end residential EMI units. Perhaps when people have to keep their elderly relatives at home and grandad has bitten little Johnny, taken a dump in the living room and waved his winkie at Mrs Smith from number 13 before wandering out the door with no trousers on and ending up in Tesco people will actually start to realise the jobs such homes did.

  7. I was reliably informed by the nursing home that my grandfather is a resident of that they're not allowed to put a seat belt on them whilst in a wheel chair. The reason being that they may was to get up and have a walk around (my grandfather is unable to walk i'd like to point out at this point) and that it would be in breach of his human rights! For the same reason he's no longer allowed to have a metal bed rail to stop him falling out of bed at night incase he “wanted” to get out of bed and the rail would then be “restraining” him and again would be a breach of his human rights. A week after they introduced this stupid policy the gentleman in the next room to my gradfather fell out of bed at night and broke his leg! But then I suppose he wanted to fall out of bed, human rights and all……

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