RT had spent over a year in acute care recovering from necrotizing fasciitis (flesh eating disease) and was waiting for a complex continuing care (CCC) bed. He had complex medical co-morbidities, severe wounds and psychosocial issues including drug addiction. This patient was difficult to manage both financially, physically and emotionally. His prognosis was poor.
His started his journey at The Salvation Army Toronto Grace Health Centre (TGHC) in January 2011. TGHC is a 119-bed CCC, slow-paced rehabilitation and palliative care health centre in downtown Toronto. At admission, RT had multiple severe, deep open wounds over his entire back, legs and arms caused by necrotizing fasciitis. He was clinically depressed and suffering with significant pain from open wounds.
Upon admission, the health team on the 3rd floor CCC unit immediately developed an interdisciplinary care plan to manage the pain, nutrition, depression, and deal with his concurrent addiction issues. The interdisciplinary health team consists of physicians, nurses (registered and practical), allied health team members including a Registered Dietitian, Occupational Therapist, Physiotherapist, Speech Language Pathologist, Pharmacist, Social Worker and Chaplain.
The Registered Nurse from the 3rd floor recalls, “I was concerned about the amount of pain he was experiencing…he would cry each time we did a wound dressing…however, after wound “in house” pain consultants assessed him, we were better able to control his pain…and the allied health team members involvement was critical in his assessment and care plan for wound healing.”
The Registered Dietitian, remembers, “when I first saw RT, his wounds covered a majority of his back and legs and were the worst I had seen…I knew that aggressive and early nutrition intervention was an essential component in his wound healing as oral intake was poor. My decision to provide high calorie/high protein enteral feeding overnight with extra protein supplementation, allowed RT to eat whatever he could during the day. Once his pain was better controlled he started to eat more, and we eventually weaned him off tube feeding completely.
RT’s journey was a struggle from the beginning. The wounds were so severe that the dressings immediately soaked in blood when they were changed. RT was in so much pain he needed the strongest narcotics to make the daily dressing changes bearable. They were fortunate to have a pain specialist from the palliative unit provide consults for pain management and follow up by the pharmacy team.
“The first step in his recovery was providing the special air mattress to relieve pressure for wound healing to begin,” stated the occupational Therapist, who worked closely with the Physiotherapist. ”Then he progressed to sitting up in bed, and eventually to transfer to a wheelchair. An exercise program helped with transfers, participation in activities of daily living (ADLs), and he eventually learned to drive a power wheelchair. He was extremely motivated at this point to get better.
Spiritual Care Services at TGHC were also involved with RT. “Our role was to provide emotional support as RT worked through some of the many changes in his life.” explained the chaplain.
The Turning Point
“Everyone had a different opinion of when RT reached the turning point in his care,” states Brent Martin. However, most agree it was integrated involvement of all interdisciplinary teams members working together with emotional support and personal care. The TGHC’s Executive Director for Patient Care adds,”The interdisciplinary health team came together for this most challenging of patients and with the care received he was better able to control his behavior so it was not detrimental to his healing.
With RT’s medical condition improving, his addiction issues surfaced. He had a history of hard drug use including heroin so after he came back very late one evening in his power wheelchair he was tested and found to have alcohol and marijuana in his system. The social worker explains,” he didn’t feel he had an addiction to drugs and/or alcohol and so did not want to change or attend a program in the community. We explored attendant care, supportive housing and many other options; however RT stated he wanted to go back to living in an apartment in his home town of Trenton. The team felt he would be better in a supportive housing environment, however, we respected his decision to choose living independently.” Due to RTs behavior, a decision was made to remove his power wheelchair for his safety and to provide him with a manual chair, and define clear boundaries of behavior on and off the hospital site.
The new beginning
By the summer of 2012, the social worker discovered a one-year transitional program in a shelter in Kingston Ontario. RT was ecstatic at the prospect of returning close to home and receiving help to once again live independently in his own home. On August 20, 2012, after spending over 20 months at the Toronto Grace, RT left for a new chapter in his life. A week after his discharge, the social worker called and spoke to RT who stated he was doing well, continuing his physical recovery and enjoying the transitional care program. In Dec. 2012, RT sent the health centre a Christmas card with an update. He was now living independently in a one bedroom apartment having left the shelter. In his card he thanked all the staff for their hard work and efforts to get him to the place he was in today.
In summary, this was a shining example of a true team collaborative effort focusing on the individual. After a couple of weeks of treatment, an external wound care specialist saw him and realized that he was already looking better because Toronto Grace staff were treating not just his wounds but treating him as a “whole person.” The CEO states, “We have always felt that in order to provide excellent care, each person’s needs must be met individually”.
This statement by an external partner exemplifies the Grace’s philosophy that every individual has intrinsic value and shows the compassionate and exemplary care received as part of the health care journey.