Clinical Pathway for patient with Multiple Sclerosis who requires intervention for fatigue management – Map of patient journey
Stage 1 - FOR ALL MS PATIENTS WHO CONTACT PRIMARY CARE REPORTING FATIGUE
Routine Patient
1a – Primary Care
1b – MS Team: receipt of referral /
pathway of care
1st Assessment
Patient reports fatigue / excessive tiredness to GP/
(Self) Referral into MS Team
Medical /
Practice
Nurse
/
community
nurse
/
AHP
/
Referral delegated to MSSN / OT Dept
Healthcare
neurologist / MS Nurse / Statutory or Voluntary
1st appointment offered
Consultations
staff
Referral to Primary care / GP for initial
Assessment
Investigations/
Observations
Medications
Nutritional /
elimination
Education /
information
Risk
management
Discharge
Planning
Goals
1c – First Review Assessment
Follow up consultation with MSSN / OT /
consultant (within locally agreed review
time).
Analysis of information supplied and
proposal of action plan
GP reviews patient
GP considers referral to 2° Care
History taken
Algorithm 1 & 2
Significant issue – ongoing or reactive
Instigate investigations
Sleep pattern / Over-activity
Blood markers
Infection screen
Exclude Relapse → Relapse pathway
Side effects of current medications
Drug interactions
Non-prescription drugs - impact
Dietary factors / Weight & BMI
Bladder &/or Bowel dysfunction
management – Table 1a
History – duration, pattern, type – physical &
cognitive symptoms & effects , impact on
lifestyle (work, relationships, libido, socialising)
TOOLS: Epworth Sleep Scale (ESS)
Fatigue Severity Scale (FSS) / pain scale
Hospital Anxiety & Depression Scale (HADS
Modified Fatigue Impact Scale (MFIS)
List all medications, supplements & CAMs
Side effects of current medications
Interactions / non-prescription drugs
Nutritional Diary
Continence Assessment
Analysis of:
Validated tool scores; lifestyle issues; and
sleep pattern
Review blood analysis if indication of
anaemia, hypothyroidism or Vit B12
deficiency
General information on lifestyle effects on fatigue
is given to patient – healthy living guidelines
Patient made aware of prevalence of fatigue in
MS, prim & 2° types, management strategies.
Provision of literature
Manageable as outpatient / admission required
Risk of falls
Skin integrity & nutritional status
Social exclusion / financial burden &
Employment issues
Environmental triggers / factors
Referral back to Primary care (GP)
Referral to Neurologist
Referral to psychologist
Refer into Fatigue Management Programme
Pacing, energy preservation techniques,
work issues & support, co-morbidity issues,
psychological issues, relapse management
Relapse management
Advise on methods for reducing risks
Involve OT / Physiotherapist / Dietician /
Psychologist / Benefits Adviser / Disability
Employment Adviser as required
Is situation manageable in primary care
Is referral to 2° Care required
Risk of falls
Skin integrity & nutritional status /
Social exclusion / financial burden & Employment
issues
Address Primary care issues and resolve problem
Referral to MS Team for full assessment &
ongoing management if not resolved
Primary fatigue established
Secondary factors identified
Patient managed within Primary care
Risks minimised
Scottish MS Specialist Nurses: - Pathways group April 2007 revised: 22/05/2007
Establish severity and extent of fatigue on
physical, cognitive, social and safety aspects of
ADLs
Rationalise medication
Referral to dietician / continence team
Advise on balanced diet +/- supplements
Referral to fatigue management group
Resolve issues & return to primary care (comorbidity, haematology factors, social
factors)
Agree appropriate review date
Control /Reduce fatigue
Resolve safety issues
Resolve/minimise: cognitive / social &
financial / physical (ADL) issues.
Clinical Pathway for patient with Multiple Sclerosis who requires intervention for fatigue management – Map of patient journey
Stage 2 – Managing Multiple Sclerosis related fatigue within the MS Team
Routine Patient
pathway of care
Secondary
factors
Sleep
2a – individual management
Manage contributory underlying conditions identified on
assessment (pain, spasticity, anaemia, etc) using local or
national guidelines
Rationalise contributory medications
Sleep hygiene – set goals for improving sleep pattern
Lifestyle
Agree individual interventions / goals:
Activity, rest & pacing at work & home
Planning & prioritising activities
Top Tips for fatigue management
Nutrition
Advise on balanced diet – healthy eating guidelines , eating
routines, fluid intake
Elimination
Cognitive
Advice on diet/fluids, voiding techniques, timing , medication
Counselling / relaxation / advise on or referral for management
of external stressors (relationship, financial, work, etc) /
mood, memory & concentration strategies / medication
Environmental
Advise or onward referral for:
Temperature management
Access issues, & ergonomics
Set realistic individual timescales for review
Measure by repeated use of validated tools
Onward referral where required
Set SMART goals for each factor identified above
Reduce fatigue on validated scoring
Establish if need for medication if no improvement in validated
scores (Suggest fatigue medications – e.g. Amantadine, Provigil,
Fluoxetine, etc)
Discharge
Planning
Goals
Scottish MS Specialist Nurses: - Pathways group April 2007 revised: 22/05/2007
2b – group management
Set aims and objectives for group – diaries
Overview of fatigue in MS
Deliver overview of contributory underlying
conditions & medication impacts
Discuss & review impact of sleep hygiene
Contrast / compare tiredness & fatigue
Advise / discuss :
Planning & prioritising activities
Pacing / energy conservation
Benefits of exercise / complimentary approaches
Top Tips for fatigue management
Dietician / team member gives advice on balanced
diet – healthy eating guidelines , eating routines,
fluid intake
Advice / discussion on good bladder & bowel habits
Discuss impact of anxiety on symptom experience
Recognising and managing low mood
Introduction to stress management & coping
strategies
Relaxation techniques & complimentary approaches
Memory & focussing strategies
Discuss management of environmental triggers &
issues:
Top Tips for fatigue management
Course evaluation & end of group
Refer onto individual management if required
Deliver overview of pharmaceutical interventions
Individual SMART goals set in relation to
programme
Involvement of relative / friend / carer to improve
understanding of impact of fatigue.
Who / where