Patients with learning diffi culties use the healthcare system more than the general population. Unfortunately, many healthcare professionals have little experience with these patients. However, understanding common illness patterns and using different techniques in communication can result in a successful consultation. Patients with learning diffi culties often have complex health needs. There are many barriers to assessing health care, which may lead to later presentations of illness. Patients may have a high tolerance of pain — take this into consideration when examining them.
Associated health problems
Patients with learning diffi culties have a higher incidence of certain problems:
• Visual and hearing impairment.
• Poor dental health.
• Swallowing problems.
• Gastro-oesophageal refl ux disease.
• Constipation.
• Urinary tract and other infections.
• Epilepsy.
• Mental health problems ( i incidence of depression, anxiety disorders, schizophrenia, delirium, and dementia), with specifi c syndromes having their own particular associations (eg Down’s is associated with depression and dementia; Prader–Willi with affective psychosis).
• Behavioural problems (eg Prader–Willi, Angelman syndrome).
Leading causes of death
These include pneumonia (relating to refl ux, aspiration, swallowing, and feeding problems) and congenital heart disease.
The patient’s perspective
Past experiences of hospital are likely to have a big impact on the patient’s reaction to his/her current situation. Most patients have problems with expression, comprehension, and social communication. They fi nd it diffi cult to describe symptoms — behavioural change may the best indication that something is wrong.
Tips for communication
• Explain the consultation process before starting.
• Speak fi rst to the patient, then to the carer.
• Use open questions, then re-phrase to check again.
• Aim to use language that the patient understands, modifying this according to comprehension.
• Patients may have diffi culties with time, so try to relate symptoms to real life temporal events (eg ‘did the pain start before lunch?’)
• They may not make a connection between something that they have done and feeling ill (eg several questions may be required in order to establish that they have ingested something).
• Take particular note of what the carer has to say — information from someone who knows the patient well is invaluable.
Patient transfer
The need to transfer
When patients have problems that exceed the capabilities of a hospital and/or its personnel, transfer to another hospital may be needed.
Timing the transfer
Do not commence any transfer until life-threatening problems have been identifi ed and managed, and a secondary survey has been completed.
Once the decision to transfer has been made, do not waste time performing non-essential diagnostic procedures that do not change the immediate plan of care. First, secure the airway (with tracheal intubation if necessary). Ensure that patients with pneumothoraces and chest injuries likely to be associated with pneumothoraces have intercostal drains inserted prior to transfer. This is particularly important before sending a patient by helicopter or fi xed wing transfer. Consider the need to insert a urinary catheter and a gastric tube.
Arranging the transfer
Speak directly to the doctor at the receiving hospital. Provide the following details by telephone or telemedicine link:
• Details of the patient (full name, age, and date of birth).
• A brief history of the onset of symptoms/injury.
• The pre-hospital fi ndings and treatment.
• The initial fi ndings, diagnosis, and treatment in the ED and the response to treatment.
Write down the name of the doctor responsible for the initial reception of the patient after transfer. Establish precisely where within the receiving hospital the patient is to be taken. Where possible, prepare the receiving unit by sending details ahead by fax/email. Pre-printed forms can help in structuring the relevant details and avoiding omissions.
Preparing for transfer Transfer team
If the patient to be transferred may require advanced airway care, ensure they are accompanied by a doctor who can provide this. The accompanying nurse should be trained in resuscitation with a good knowledge of the equipment used during transfer.
Equipment
‘Transfer cases’ containing a standardized list of equipment must be immediately available and regularly checked. Take all the emergency equipment and drugs that might prove necessary to maintain the ‘Airway’,
‘Breathing’ and ‘Circulation’ (ABC) during transfer. In particular, take at least twice the amount of O 2 estimated to be necessary (a standard ‘F’
cylinder contains 1360 L of O 2 and will therefore last <3hr running at 10L/
min). Before leaving, ensure that the patient and stretcher are well-secured within the ambulance. Send all cross-matched blood (in a suitably insulated container) with the patient.
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PATIENT TRANSFER
Monitoring during transfer
Minimum monitoring during transfer includes ECG monitoring, pulse oximetry, and non-invasive BP measurement. If the patient is intubated and ventilated, end-tidal carbon dioxide (CO 2 ) monitoring is mandatory.
An intra-arterial line is recommended, to monitor BP during the journey.
Make allowances for limited battery life on long transfers: spare batteries may be needed. Plug monitors and other equipment into the mains supply whenever possible.
Accompanying documentation Include the following:
• Patient details : name, date of birth, address, next of kin, telephone numbers, hospital number, GP.
• History, examination fi ndings, and results of investigations (including X-ray fi lms).
• Type and volume of all fl uids infused (including pre-hospital).
• Management including drugs given (type, route, and time of administration), practical procedures performed.
• Response to treatment, including serial measurements of vital signs.
• Name of referring and receiving doctors, their hospitals, and telephone numbers.
Some departments use standard forms to ensure that important information is complete.
The relatives
Keep the patient’s relatives informed throughout. Explain where and why the patient is going. Document what they have been told. Arrange transport for relatives to the receiving hospital.
Before leaving
Prior to transfer, re-examine the patient. Check that the airway is protected, ventilation is satisfactory, chest drains are working, IV cannulae patent and well secured, and that the spine is appropriately immobilized, but pressure areas protected. Ensure that the patient is well-covered to prevent heat loss. Inform the receiving hospital when the patient has left and give an estimated time of arrival.
After leaving
Communicate to the receiving hospital the results of any investigations that become available after the patient has left. Contact the receiving doctor afterwards to confi rm that the transfer was completed satisfactorily and to obtain feedback.
Intra-hospital transfers
In many respects, the only difference between intra- and inter-hospital transfers is the distance. The principles involved in organizing a transfer are the same, whether the patient is to be conveyed to the computed tomography (CT) scanner down the corridor, or to the regional neurosurgical unit miles away.