We join Rebekha Bell, a Band 5 Hospice at Home Nurse in our Herts team, on a late shift:
A late shift runs from 1.30 to 9.30pm and typically involves making some planned visits during the afternoon before assuming on-call responsibilities after 5pm. Each day two nurses from the team will be rostered onto a late shift, one covering Dacorum and one covering St Albans and Harpenden.
Rebekha arrives at Rennie House in Tring.
Her first job is to log onto the Rennie Grove Patient Database, Infoflex. She reads the Bulletin Board which is set up to give quick updates on important changes affecting patients so Rebekha checks the key information and important messages relating to the Herts Team patients and then checks the worksheet to find two allocated visits for that afternoon.
Rebekha speaks to the team’s Triage Nurse to see if there are any urgent SOS visits that need to be made before checking the supplies in her equipment box.
The Herts Team operate a Triage system between the hours of 9am and 5pm. The Triage nurse will take all new referrals, calls from GPs, hospitals and other healthcare professionals relating to the team’s patients as well as all calls from patients and families who have concerns and may need to be visited. The Triage Nurse then liaises with the nurses and allocates visits. This system means that the nurses visiting patients can focus on delivering care rather than fielding phone calls.
Rebekha leaves for her first visit of the day to Brenda, who lives 15 miles away. Brenda is 48 years old and has breast cancer with bone metastases. She receives a weekly scheduled visit from the Rennie Grove nurses to monitor and help control her pain.
Brenda is taking two types of pain medication one slow release and one faster release. Rebekha talks to Brenda about her pain and reviews her pain diary which records how much of each medication she has been taking. Today Brenda is uncomfortable and it becomes apparent that her medication needs adjustment.
Rebekha calls one of the Team’s senior nurses – a Clinical Nurse Specialist (CNS) – to discuss Brenda’s case and makes a recommendation that Brenda’s dosage should be increased. The CNS approves this and Rebekha explains to Brenda how to increase her dose and asks her to continue with her pain diary.
Back in the office later, Rebekha will fax or phone the details of this change in dosage through to Brenda’s GP.
The regular monthly check of Brenda’s Just In Case medication is also due during this visit and Rebekha checks the box, recording batch numbers and expiry dates.
Just in Case medication is tailored to each patient dependent on their disease. Appropriate medication and at the right doses is included in each box. The GPs prescribe this medication but the nurses are responsible for utilising it and monitoring its use.
Rebekha leaves Brenda and drives 6 miles to her second visit.
Rebekha arrives at John’s house. John is 77 and has lung cancer with metastases. He is now approaching end-of-life and is on a syringe pump which delivers his medication and needs reloading every 24 hours. Rennie Grove is sharing this care with the District Nurses with each team taking it in turns to visit every other day.
John is unresponsive, but Rebekha monitors his facial expressions and talks to his wife about how he has been. She asks if he has been agitated at all or if they have needed to call out either the District Nurses or Rennie Grove nurses for extra injections for pain during the last 24 hours.
As the family had called out the Rennie Grove night team when John had become agitated during the night, Rebekha adjusts the dosage in the syringe pump in order to keep John’s pain under control.
Rebekha assesses John thoroughly and carries out some personal care to make John comfortable. She waits a little while to ensure he is settled and talks to his family about what to expect during the next few days. At this stage, this does include a conversation about what to do if John dies. Rebekha reassures the family that they can call Rennie Grove at any time of the day or night if anything changes or they are worried.
Rebekha leaves John’s house and once in the car she calls the Triage Nurse to see if any emergency calls have come in. They haven’t and Rebekha returns to the office in Tring.
She arrives at Rennie House. Rebekha contacts Brenda’s GP and liaises with the District Nurses about John. She updates Infoflex with the outcomes of her visits.
Time for a break.
The Triage Nurse leaves and on-call starts.
After 5pm all calls to Rennie Grove are handled by Bucks Urgent Care who take the details of the call and pass it onto the on-call nurses or to the night team between the hours of 9.30pm and 7.00am.
A call comes in from the other late shift Team Herts Nurse, who has been called by a family whose relative has died in St Albans. Two nurses are needed to attend to perform last offices. Rebekha leaves the office.
She arrives at Joan’s house and meets her colleague, Margaret, outside the house. Joan, 84, died at 5pm from Motor Neurone Disease.
The nurses go in together to console and support the family and explain to them what they need to do to verify the death.
Although this will already have been explained to them at previous visits, it is always good to talk it through again as a reminder as in the distress of the moment families are often confused about the process.
Rebekha and Margaret complete the verification of the death and perform the last offices. While the paperwork is being completed, Rebekha gets a call from Bucks Urgent Care asking her to visit a patient who has become agitated.
Rebekha and Margaret spend a few minutes talking to Joan’s family about what they need to do next and reassure them that one of the team will be in touch in the next few days.
Rebekha leaves to attend her emergency visit in Leverstock Green.
She arrives at Dave’s house. Dave is 46 and has a brain tumour. He has become agitated, aggressive and uncontrollable and his wife is very worried. Rebekha assesses Dave and sees that he needs an injection to calm him down. This possibility had been anticipated and the required medication is in his Just in Case box. Rebekha gives the injection and stays to make sure it has worked and that a second injection is not needed. She takes this opportunity to talk to Dave’s wife and reassure her.
Once Dave is comfortable, Rebekha leaves and returns to the office.
She arrives at Rennie House. Update Infoflex on Dave. Update the Bulletin Board with any key developments on patients. Handover to night team.
Leave for home.