St Richard s Hospital Hip Fracture. Information for patients, relatives and carers

Transcription

1 St Richard s Hospital Hip Fracture Information for patients, relatives and carers

2 Visiting Times Visiting is restricted to: 3.00pm-5.00pm and 6.30pm-8.00pm daily If you need to visit outside visiting hours please speak to the Ward Sister or the nurse in charge. Relatives are very welcome and encouraged to participate in all aspects of care, but we would request that only one member of the family phones at all times for information, then passes this on to other relatives. Contact Information: Middleton Ward: Occupational Therapy: Physiotherapy: You may be entitled to free parking if your relative is having a significant length of stay in hospital. Please speak to the nurse in charge of your relative s care for further details. If you have some time on your hands or are feeling a little peckish, we have a restaurant on the first floor called The Terrace and a café in the main entrance called The Cloisters. We also have a small shop stocked with essentials in the main entrance. 2

3 Contents Introduction... Types of Hip Surgery... During your stay... p4 p6 p9 Mobility and Rehabilitation... p16 Hip Precautions Occupational Therapy Going Home p22 p24 p32 A BIG thank you....to our front cover model Mrs Shirley Fielden, a fractured hip patient at St Richard s hospital. 3

4 Introduction This booklet has been designed to help you, your family and/or carer gain a better understanding of hip fractures, how they are treated, the rehabilitation process and your discharge from hospital. If there is anything in this booklet you do not understand, please ask any member of the multi-disciplinary team (Doctors, Nurses, Care Workers, Occupational Therapists, Physiotherapists and Pharmacists) who will be happy to help. Did you know. Approximately 81,000 people are admitted to hospital with a hip fracture in England each year. Around 85% are 70 or older. Source: 1. Hospital Episode Statistics

5 What is a Hip Fracture? A hip fracture is a crack or break at the top of the thigh bone (femur) close to the hip joint. They often occur as a result of a fall. National Institute for Health and Clinical Excellence, Treatment for Hip Fractures Most hip fractures require surgery to fix them. A suspected hip fracture is normally confirmed using x-rays. The type of operation you need depends on: Where the break/crack is on the thigh bone. Your age. Your previous level of mobility/function. Whether you have arthritis in your hip joint. 5

6 The 4 Main Types of Hip Surgery 1. Hemiarthoplasty Used when the fracture involves the head of the thigh bone (intracapsular). The head of the thigh bone is replaced with a metal alloy ball and stem, but the socket of the hip joint remains intact. 2. Total Hip Replacement Used when the fracture involves the head of the thigh bone and the hip socket, or if the hip socket is affected with osteoarthritis (intracapsular). The head of the thigh bone is replaced with a metal alloy ball and stem and the hip socket is replaced with a plastic cup. You will need to follow hip precautions for 6-8 weeks after your surgery to help prevent dislocation (see page 22). 6

7 3. Dynamic Hip Screw. Used when the fracture is outside of the hip joint (extracapsular). The bones are realigned in the correct position and fixed together with a plate and screw. 4. Intramedullary Nail Used when the fracture is outside of the hip joint and extends further down the thigh bone (extracapsular). A metal rod goes through the middle of the bone and is held together with screws. You will usually be able to fully weight-bear and start standing/ walking on the day after your operation for all 4 of these operations. 7

8 Hip Surgery Conservative Treatment In some patients a decision is made not to operate. This is usually due to: Impacted hip fractures where the bones are in a good, stable position and should heal over time. If the hip fracture happened a few weeks ago and has already started to heal. Concerns that you may be too frail or unwell to cope with surgery. In this situation you may be given pain relief via a femoral catheter into your hip joint (a tube inserted into the cavity of your joint) and your Orthopaedic Consultant will decide how much weight you can put through your hip joint. Not everything in this booklet will be relevant to you if you are having conservative treatment. Please make sure you speak to your multi-discipline team to gain a better understanding of what specifically applies to you. 8

9 During Your Stay During your stay you will be cared for by a specialist team. An anaesthetist will see you to determine whether you are fit for surgery. We aim to operate as soon as possible and in most cases this will be within 36hrs of admission. Once you have initially recovered from your anaesthetic you will be transferred back to the ward. You may find a urinary catheter was inserted in theatre. We aim to remove this within a few days of surgery. You will be offered regular pain medication and can ask for more as required. Antibiotics are usually given on the first day after surgery. The Orthogeriatric Doctors will see you regularly during your stay. It s important that you start to walk as soon as possible as this aids healing and will help prevent further complications, for example, chest infections and pressure sores (bedsores). 9

10 During Your Stay Nutrition It s important to eat well during recovery time to aid healing. However, poor appetite is common after surgery so you may be prescribed nutritional supplements high calorie drinks which you will be encouraged to sip in-between meals. Gluten free and vegetarian meals are available. Please make sure you let staff know if you have any other dietary preferences. Anyone requiring assistance to eat will have their meals served on a red tray. This is so that staff can easily see who they need to spend time with at mealtimes. For these patients, family members are welcome to come and assist at mealtimes if they would like to. 10

11 Common Problems After a Hip Fracture Bleeding You may lose blood during your surgery. If this is the case you may require a blood transfusion or a course of iron tablets after your operation. Infection Antibiotics are routinely given to reduce the incidence of infection. The team will monitor your wound for any signs of infection, but it rarely requires further treatment. Your dressing will stay in place for at least five days. Confusion (Delirium) This is not unusual following surgery and can be distressing for you and your relatives. Previous short term memory problems or a history of dementia are associated with a high risk of post-operative confusion and disorientation. This can be made worse by: Medication: pain killers and anaesthetic drugs Infection Low oxygen levels Unfamiliar surroundings Confusion often gets worse in the evenings. Relatives are encouraged to speak to the nursing staff about how they can help with delirium by re-orientating and bringing in familiar items. 11

12 Common Problems After a Hip Fracture Constipation This is a common problem, exacerbated by reduced mobility, medication, dehydration and a change in diet. The nurses will monitor this daily. You ll be offered regular laxatives and will be encouraged to take them. Increasing your fluid intake will also help. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) DVT (a blood clot in the calf) may occur in patients after a hip fracture. Rarely, a clot can break off and travel to the lungs (PE). Immobility, dehydration and other underlying illnesses increase the risk of clots. To reduce the risk of developing a DVT, you will be given a deltaparin injection each evening. You will also have a pair of compression stockings (which will need to be worn continuously whilst on the ward) or occasionally calf pumps will be applied to your calves whilst in bed; these massage your calves to improve circulation. Leg Swelling This is common in the operated leg and can take several months to subside. It will improve as your mobility improves, but try to elevate the leg when you are sitting down. If your leg becomes hot, red or increasingly painful please let a member of staff know immediately. Pressure sores These can occur if you stay in one position for a period of time. Our nursing staff will monitor you for sores from the moment you arrive on the ward and will encourage you to change position throughout the day to help prevent them from developing. 12

13 Dislocation This is an occasional complication with a hemi-arthroplasty or total hip replacement. Those undergoing a total hip replacement will need to follow some guidelines or hip precautions to prevent dislocation (see p22). Brittle Bone (Osteoporosis) Treatment If you are elderly and have a broken hip, you may be suffering from a condition known as osteoporosis or brittle bones. This is very common in females. To confirm this you may be referred for a special scan known as a DEXA scan. If you are over the age of 75 years, you will be treated without the need of a scan. This is because its extremely common in this age group. There are a number of treatments for osteoporosis. Please go to the Osteoporosis Society website at nos.org.uk or call them on for more information. Once you have started treatment for osteoporosis it is likely you will need to continue it for at least 5 years. Unfortunately. At St Richard s we work hard to improve patient care but sadly 6.1% of patients with a hip fracture die within 30 days. Many though, are due to co-existing medical conditions. This compares with 7.5% nationally. Source: NHFD annual report

14 Common Problems After a Hip Fracture Patients with Dementia There are many different types of dementia and with some, patients find it difficult to retain and recall new information. Changes in routine, environment and unfamiliar people can all cause deterioration from normal functioning. It is possible this deteriorated state may become the new normal level. Our dementia nurse team is based in the hospital and can offer support, advice and practical tips for patients and carers during their hospital stay. On some of the wards we also have Knowing Me volunteers who support patients with dementia by providing activities and conversation. Nikki Perry, Dementia Care Support Nurse and Paul Morris, Demential Nurse As part of our care, we ll ask family members/carers to fill out a Knowing Me Passport which will help the staff understand the patient s likes and dislikes to help personalise care and heighten patient engagement. 14

15 As a relative of a patient with dementia, the visiting hours are relaxed and you can visit outside of the stated hours. You will need to obtain a Carer s Passport directly from the ward. Physiotherapy for patients with dementia focuses on: Clear, simple instructions and functional tasks e.g. getting in and out of bed or onto a commode. Only teaching exercises if appropriate. Aiming to discharge back to their rest home or nursing home within a week of being medically fit and with pain under control. (Patients with dementia do much better in their own, familiar environment). In a lot of cases, staff at rest homes and nursing homes are able to progress a patient s mobility over time at the point they are feeling ready. However, if we feel it is appropriate we will also refer for a community Physiotherapist to visit. If you have dementia and are still living in your own home you will require additional physiotherapy and occupational therapy to ensure you reach a safe level of function. You may also need additional help and support and ongoing community physiotherapy when you go home. 15

16 Mobility and Rehabilitation What does Physiotherapy involve? The Physiotherapy Team will aim to see you prior to your hip surgery (unless it is a weekend). We will put together a programme tailored to your needs. This will include: A discussion about your previous level of mobility and function. Your falls history. Ensuring you have had enough pain relief. Setting short-term and long-term goals. Teaching you some basic hip exercises. Aiming to sit you out of bed and into a chair using suitable equipment to help you step and move round e.g. zimmer frame. We aim to see you each day to: Progress your walking. Help build your confidence. Monitor and progress your hip exercises. Work on specific balance exercises if appropriate. These elements will be reinforced over the weekend by nursing staff if your Physiotherapist is not available. We also run: Chair based exercise groups twice a week (including a chance to talk to other patients on the ward). Teaching sessions for family/friends so that they can do hip exercises with you when they visit. We are available on the ward most afternoons between 3pm and 4pm and would be happy to demonstrate them during this time (see leaflet on the ward). 16

17 Time to Exercise... Remember: The more you can do in the early days to help you get back on your feet, the better the outcome. These exercises will improve your muscle strength, range of movement and prevent circulation problems. It is important that you practice them 3-4 times a day for at least 6 weeks to help your recovery. Lying on your back or sitting, bend and straighten your ankles briskly. If you keep your knees straight during the exercise you will stretch your calf muscles. Repeat 10 times. Lying on your back, squeeze your buttocks firmly together. Hold for approximately five seconds. Relax. Repeat 10 times. Lie on your back with legs straight. Bend your ankles and push your knees down firmly against the bed. Hold for five seconds. Relax. Repeat 10 times. We will also ask you to nominate a Hip Fracture Buddy. This is someone we can speak to, who will be able to come into the hospital to support you. 17

18 Exercises Place a rolled towel under your knee. Exercise your leg by pulling your foot and toes up, tightening your thigh muscle and straightening the knee (keep knee on the towel). Hold for approximately five seconds and slowly relax. Repeat 10 times. Lie on your back or propped up with pillows, with a sliding board under your leg. Bend and straighten your hip and knee by sliding your foot up and down the board. Repeat 10 times. Bring your leg to the side and then back to mid position. Repeat 10 times. Sitting. Bend your knee as much as possible, then straighten your knee to lift your leg off the ground. Repeat 10 times. 18

19 Progression Exercises Stand upright holding onto a secure surface such as a kitchen worktop. Lift your knee up towards your chest but do not lift beyond 90. Repeat 10 times. Stand upright holding onto a secure surface such as a kitchen worktop. Bring your leg backwards keeping your knee straight. Do not lean forwards. Repeat 10 times. Stand upright holding onto a support such as a kitchen worktop. Lift your leg sideways and bring it back keeping your upper body straight throughout the exercise. 19

20 Walking You ll be shown how to walk with a zimmer frame and then onto elbow crutches if/when we feel you re ready. We ll also give you tips and advice on how to walk as normally as possible along with information on how to progress your walking when you are at home. Walking sequence: Move your walking aid forward first. Follow with your operated leg. Finally step forward with your non-operated leg. Reminders for walking: Try not to limp. Bend your knee as you bring your operated leg forwards to take the next step. Take small steps when turning. Did you know. 76% of hip fractures occur in women. Source: British Orthopaedic Association. 20

21 Stairs and Steps Going up: One step at a time. Stand close to the stairs. Hold the handrail with one hand and crutches in the other hand. First step up with your non-operated leg. Then bring up your operated leg. Finally bring up your crutches. Going down: One step at a time. Stand close to the stairs. Hold handrail with one hand and crutches in the other hand. First place your crutch down onto the step. Step down with your operated leg. Then step down with your non-operated leg. If you are using two handrails you will be taken to our physiotherapy gym to practice. 21

22 Hip Precautions (for total hip replacements only) You will need to follow hip precautions for 6-8 weeks after surgery while the muscles and ligaments around the hip are healing. This is to reduce the risk of your new hip joint dislocating i.e. coming out of the socket. Do not bend your hip past 90 (right angle). Do not cross your legs while sitting or lying. Do not twist your hip. You will also need to think about what you have in place at home. Any mats or rugs should be taken up to avoid tripping up on them. Think about where you will be walking in your rooms and move anything that might be in the way. This is to make sure you have sufficient room to walk with your walking aid. Sitting When sitting on a bed, chair or toilet your hip joint should be higher than your knees. Your Occupational Therapist will measure your lower leg length to determine what the safe sitting height is for you: Your safe sitting height is: All the furniture that you sit on must be at least this height or higher. 22

23 Putting Hip Precautions into Practice Standing up To get out of the chair move to the front of the seat and place your operated leg slightly in front. Push up on the arms of the chair so that you don t bend forwards. Take hold of your walking aid once you are in standing. To get off the toilet, use the same method, pushing up on the equipment that has been provided for you. Sitting down Reach back for the arms of the chair. Put your operated leg out in front. Lower yourself down gently. Do not twist to retrieve items out of reach stand up & walk to get them or use the equipment your Occupational Therapist has given you Getting into bed It s important you get into bed with your unoperated leg first. This may mean that you will have to change sides, or if this is not possible, move the pillows to the foot of the bed so you sleep the other way around. This will make it easier to get into bed and protect your hip from dislocation. 23

24 Occupational Therapy (OT) It may take time for you to get used to everyday activities again. Your Occupational Therapist will provide advice about the equipment you might need and how you can adapt day to day activities to live as independently as possible. Some things for you to consider: Washing You will find it difficult to step into and get out of the bath for several weeks after your operation even to access an over the bath shower. If you have a walk-in shower or shower cubicle, you can use this as your wound dressing is shower proof. To wash your hair, stand and lean over the sink, stretching your operated leg out behind you. If possible, use the kitchen sink to wash your hair as this is usually higher. Your Occupational Therapist may provide you with a perching stool to support you to strip wash or a bath board to help you use an over the bath shower. If your only option is to strip-wash and you would rather shower, you might be able to use your local leisure club or sports centre for a small fee. These are usually walk-in showers. Alternatively, do your friends or family have a suitable shower you could use? Perching Stool Bath Board 24

25 Dressing After your operation, your hip is likely to be slightly stiff and uncomfortable, which may make it hard to bend and put on your underwear or trousers. If so, you may find it helpful to use small aids such as a helping hand or a long-handled shoe horn. Ask your Occupational Therapist about these during your stay in hospital. Helping Hand If you have had a hip replacement, you should continue using your aids for the first 6 weeks after your surgery. It is safest to dress and undress while sat on the side of the bed or on a chair. Always dress your operated side first. Remember to ask your family to bring in a set of clothes for you to wear during the day along with your preferred toiletries eg razors, toothbrush, antiperspirant. This will allow you to practice getting dressed and also help to get you back into your normal routine. If you feel unable to wash and dress yourself independently, please discuss this with your OT, who will advise on what options are available to you. Long Handled Shoe Horn 25

26 Occupational Therapy (OT) Cooking If you were able to prepare your own meals before your operation, you should be able to manage when you return home. You may become tired more quickly when standing, so it might help to have a stool or chair available. Think about how your kitchen cupboards are arranged - you ll need to make it easy to get to everything without having to bend or overstretch. If you don t fancy cooking, your OT can provide you with information on meal delivery services and other alternatives. Carrying Carrying food and drink may be difficult as you ll probably be using a walking frame or crutches. So think about ways around this that can work for you e.g. sitting at the kitchen worktop temporarily or using a bag, such as a rucksack to carry items. On some occasions, if suitable, a trolley may be provided. Your OT can discuss this with you. 26

27 Shopping Do you have a family member or friend to help with shopping? Or how about using the internet to order it? Most major supermarkets offer an online store which will deliver to your home for a charge. Don t forget to ask someone to buy a few essential groceries (milk, bread etc) for when you immediately return home so you can have a cuppa and something to eat. Furniture Heights It s important that your furniture at home is a suitable height to enable you to sit down and get up safely as well as being more comfortable after your hip operation. That s why your OT will ask about your furniture and how high it is. Please ask your family to help with this by returning the furniture height form as quickly as possible. This helps to prevent any delays in ordering equipment you might need. Housework It s recommended you avoid heavy tasks, such as vacuuming or carrying large amounts of laundry for up to six weeks. Consider asking friends or family to help you. Alternatively, your OT can provide you with information on community agencies who can offer assistance. 27

28 Occupational Therapy (OT) Driving and being a passenger You will be unable to drive initially after your operation. In fact, it s advisable not to start driving again until you feel comfortable and can carry out an emergency stop safely. This usually takes about 6 weeks. Please note that your insurance company may need a letter from your doctor to say that you can drive. When getting in and out of a car, it s best to use the front passenger seat. Ensure that the seat is pushed back as far as possible and angled so that it is partially declined. Wind down the window and use the door and doorframe to lower yourself into the seat. Lift one leg at a time and don t get into the car off the kerb. If you re going on a long journey (more than one hour), stop regularly and have a walk around. 28

29 Remember: To get into a car: Turn with your back to the seat Place your operated leg forwards Find a good place to hold on Lower your bottom onto the seat Lean back so you do not over bend your hip Slide your bottom as far back towards the handbrake as possible Lean back as you lift your legs up and into the car To get out of a car: Move your bottom over towards the handbrake Lean back as you turn and lift your legs out of the car Do not pull yourself forwards, place your hands behind you and push your bottom forwards Find good hand holds again Place operated leg forwards Stand yourself up 29

30 Occupational Therapy (OT) Sport and recreation Please discuss with your Physiotherapist any sports or hobbies that you want to return to. They will be able to advise you on how quickly you can return to your chosen sport or activity and you need to adapt your technique in the short term. Change of mood: Some people experience a change in mood during their stay, so please advise a member of the team if this worries you. You can be referred to our chaplaincy or volunteer ward services for emotional support. It can also help to have familiar things around you. Ask friends and family if they can bring in a few items from home, such as favourite music, photos and books. Unfortunately as there is limited space at your bedside, try and limit these to those items that would benefit you the most. 30

31 Sex Unless your doctor advises otherwise and you are able to keep to your hip precautions (if you have them), sexual activity may be resumed when the wound is soundly healed and the stitches removed. The stable position for your hip is on your back, with your partner on top. There is an information sheet available with more details from the ward Physiotherapist or Occupational Therapist. Pets When you return home your pets are likely to be very excited to see you. Consider sitting down when you re first reintroduced in case they jump up. Always be aware of where your pets are when you re walking to prevent tripping over them. You may need to ask family or friends to help you look after your animals whilst you are recovering. Models: Christine Barlow & Bramble 31

32 Going Home We aim to get you home as soon as possible after your hip surgery and planning for your discharge starts from the time you arrive on the ward. If you were very independent and active before your surgery you may feel ready to go home in the first week after your operation with support from the Community Physiotherapy team. If you were less mobile before you came into hospital, it may take you longer to get back on your feet. Your multi-disciplinary team may therefore offer you a period of rehabilitation at one of our community hospitals. These include The Bognor War Memorial Hospital, Midhurst Cottage Hospital, Arundel Hospital, Zachery Merton or Petersfield Hospital. It s important to have goals to work towards and to be motivated to achieve them while you are there. Please be aware that for some patients, rehabilitation takes many months and you may need extra support and equipment to help you manage safely at home in the future. Frail patients or those with pre-existing medical conditions may find it harder to get over a fractured hip. They may become dependent on others for help mobilising or for daily tasks and as a result may need to move permanently into long-term care. Unfortunately, it is also possible these patients may die during or shortly after surgery. 32

33 When can I go home? You are usually able to go home once you are: Medically fit. Walking safely with an appropriate walking aid eg elbow crutches. Able to do your hip exercises independently or under supervision from friends or relatives. Able to do any steps or stairs safely. Independent with all your activities of daily living or have the appropriate support in place. Have all the equipment you need. Do you look after someone who could not manage without your help? If you are looking after a partner, relative, child, neighbour or friend who has long term illness or is disabled or frail, then you are a carer and Carers Support is here to help you. Please call to speak to us. 33

34 On the day you go home The team will endeavour to have everything ready for you to leave the hospital on the morning of your discharge. The Goodwood Lounge is available for you to wait in if you cannot be collected until later in the day. We will arrange for you to be transferred there should you need to wait. Before you leave the ward you will be given: A telephone number for you to contact us if you have any questions or problems once you are home. Equipment on loan to you for use at home such as walking aids or toilet frames. Information on whether you have internal dissolvable stiches, steristrips, or clips. If you have clips you will be given a clip remover to take home. These should be removed at days. A letter for your practice nurse with advice on when to check your wound. District nurses will only be contacted if you are unable to attend your surgery for wound care. A copy of your GP letter informing them about your hospital stay. Spare dressings if required. Deltaparin injections and a yellow sharps box if required. This yellow box will be collected free of charge by your local council. Please telephone them directly to arrange collection. If you are on osteoporosis medication please remember you need to continue to take it for several years. Chichester District Council Arun Council

35 Preventing further falls Most patients admitted for a fractured hip have had a fall. Perhaps it was the first one you ve had or maybe you ve had a number of falls. The risk of falling increases with age but there are a number of practical steps you can take to help reduce your risk of falling again: Keep all rooms clear of clutter and check for hazards such as slippery floors or trailing wires. Clear away loose rugs. Wear supportive, low healed shoes at home, avoid walking in socks, stockings or floppy, backless slippers. Ensure your home is well lit, especially stairwells. Consider leaving a night light on if you have to get up frequently at night. Have regular eye tests. Eye tests are free if you are aged 60 or over. Have regular medication checks with your GP. Do regular exercise helps to strengthen your muscles and maintain your balance. There is lots of useful information in Age UK s Staying Steady leaflet which will be given to you on discharge. You may also be referred to the community Physiotherapy team, Falls Prevention team or Falls Clinic depending on whether your fall was the result of a slip/trip or due to blackouts/dizziness. 35

36 Things to remember Physiotherapy Follow-up (To be completed by Physiotherapist on day of discharge) You do not need any further physiotherapy input You will be referred for ongoing physiotherapy at.. Please contact the physiotherapist on the telephone numbers provided (p37) if you haven t heard anything in two weeks Occupational Therapy Equipment It is recommended you will need the following equipment:..... This equipment will be delivered to your home You need to take the equipment home with you Once you have finished with the equipment please ring to arrange collection. 36

37 Follow up As part of a national study we conduct follow up phone calls. These are done 30 days after admission to hospital with your broken hip. We ll ask you or your care home about your mobility and if you are still taking the bone protection medication you were prescribed whilst you were in hospital. Depending on what type of operation you had, you may get follow up from your consultant. Additional Resources: You may find the following helpful resources on discharge to help prevent further falls and admissions into hospital... Staying steady Age UK booklet My hip fracture care:12 questions to ask NHS choices 37

38 Glossary of Terms Deep Vein Thrombosis (DVT): Deltaparin: Extracapsular: Femoral catheter: Intracapsular: Occupational Therapist: Oesteoporosis: Orthogeriatric: Physiotherapist: Pulmonary Embolism (PE): A blood clot in the calf Anti clotting medication Outside of the hip joint A tube inserted into the hip joint cavity to deliver pain relief Inside the hip joint A health care professional that enables people to carry out everyday activities, promoting independence for discharge home. A condition that affects bones, causing them to become weak and fragile and more likely to break Bone and muscle care for older patients A health care professional who specialises in maximising movement, function and potential When a blood clot travels to the lungs 38

39 My Questions and Notes 39

40 We are committed to making our publications as accessible as possible. If you need this document in an alternative format, for example, large print, Braille or a language other than English, please contact the Communications Office by ing Communications@wsht.nhs.uk or speak to a member of the Orthopaedic department. Department: Fractured NOF Team Issue date: May 2016 Review date: April 2017 Trust Ref No: Author: Occupational and Physiotherapy Teams Version: 1 St Richards Hospital Spitalfield Lane Chichester PO19 6SE