Supporting people with Dementia in the General Hospital


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Colin MacDonald, Alzheimer Scotland Dementia Nurse Consultant

Presentation from Alzheimer Scotland conference 2011 - Creating Better Dementia Care.

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Supporting people with Dementia in the General Hospital

  1. 1. Colin MacDonald Alzheimer Scotland Nurse Consultant NHS Lothian [email_address]
  2. 2. Some scary stats... <ul><li>“ Dementia costs the UK £23 billion a year” </li></ul><ul><li>- more in terms of cost than cancer, stroke and heart disease put together! </li></ul><ul><li>“ On present trends the UK’s approach to managing </li></ul><ul><li>Dementia is unsustainable” </li></ul><ul><li>(Alzheimer Research Trust 2010) </li></ul>
  3. 3. Dementia in Scotland <ul><li>Currently 82,000 people with dementia in Scotland </li></ul><ul><li>- 60% in community </li></ul><ul><li>- 40% in institutional (long stay) care </li></ul><ul><li>Projected to double in the next 25 years </li></ul><ul><li>(Alzheimer’s Scotland 2011) </li></ul>
  4. 4. The disabling impact of Dementia..? <ul><li>Being in hospital: </li></ul><ul><li>“ Had a significant negative effect on general physical health” </li></ul><ul><li>“ Had a significant negative effect on symptoms of dementia – with increased confusion </li></ul><ul><li>and dependency” </li></ul><ul><li>“ Increased length of stay” </li></ul><ul><li>“ More likely to be prescribed anti-psychotic drugs” </li></ul><ul><li>“ Increased prevalence (34%) of being admitted to a Care Home” </li></ul><ul><li>(Counting the Cost - Alzheimer’s Society 2009) </li></ul><ul><li>But staff most staff do not come to their work to do a bad job! </li></ul>
  5. 5. Dementia in the general hospital <ul><li>Similar concerns raised: </li></ul><ul><li>Mental Welfare Commission (2010 + 2011) </li></ul><ul><li>Scottish Dementia strategy (2010) </li></ul><ul><li>Royal College of Psychiatrists (2011) </li></ul><ul><li>Alzheimer Scotland </li></ul><ul><li>“ 70% of admissions to care homes is via the acute hospital (general </li></ul><ul><li>and mental health)” (Lothian figures 2011) </li></ul>
  6. 6. Cost of getting it wrong..... Case Scenario Mr X is an 87 year old man with mild / moderate Dementia. He stays at home with his wife, who is his main carer. Mr X is fully mobile and continent, but needs some assistance to wash, dress, and with his meals. He goes to a local lunch club twice a week to give his wife a break. No other support services are required. On 1st April he develops severe chest pain and is taken to A&E. <ul><li>No diagnosis of Dementia obtained </li></ul><ul><li>Limited information requested /obtained from main carer </li></ul><ul><li>Admitted for “further tests” </li></ul><ul><li>Anxious and disorientated in new environment – moved to 3 different wards in 2 days </li></ul><ul><li>Staff understanding and tolerance of dementia poor </li></ul><ul><li>Increased agitation - identified risk of “wandering and aggression” </li></ul><ul><li>Commenced on psychotropic medication to calm him down. Sedative effects lead to: reduced mobility and risk of falls; increased incontinence; disturbed sleep pattern; less able to feed himself. Catheterised due to increased incontinence – this leads to a UTI </li></ul><ul><li>Develops delirium. Increased dependency and confusion. </li></ul><ul><li>Suffers a number of falls. No serious injury – but now covered in bruises. Weight loss also evident. </li></ul><ul><li>Now on one:one observation level to manage “risks” </li></ul><ul><li>Wife now unable to care for him at home and submits a complaint. </li></ul><ul><li>35 day stay then Mr X transferred to a Care home. </li></ul><ul><li>Extra costs of care: </li></ul><ul><li>Care Home @ approx £400 / week = £21,000 p.a. </li></ul><ul><li>Hospital costs (extra staff, bed days, </li></ul><ul><li>Medications, complaint etc) = £££’s extra!! </li></ul>Scenario 1 (Sub-optimum pathway) <ul><li>Dementia diagnosis obtained. </li></ul><ul><li>Information from main carer (wife) </li></ul><ul><li>Admitted to assessment ward for further tests </li></ul><ul><li>No further moves </li></ul><ul><li>Staff understanding and management of dementia good </li></ul><ul><ul><li>- wife allowed to stay to help him settle </li></ul></ul><ul><ul><li>- quiet area of ward </li></ul></ul><ul><ul><li>- reason for wandering identified (patient looking for toilet) </li></ul></ul><ul><ul><li>- sign on toilet door. Re-orientated by staff </li></ul></ul><ul><ul><li>- familiar staff. Calm approach. </li></ul></ul><ul><ul><li>- No psychotropic medications necessary </li></ul></ul><ul><li>Staff work in partnership with main carer to support Mr X to maintain his optimal abilities </li></ul><ul><li>Mr X has all investigations and necessary treatment </li></ul><ul><li>Discharged home after 3 days. </li></ul><ul><li>Extra costs of care: Nil !! </li></ul>Scenario 2 (Optimum pathway)
  7. 7. So what can we do? <ul><li>And what is happening in Lothian – </li></ul><ul><li>with the Alzheimer Scotland Nurse consultant? </li></ul>
  8. 8. Dementia audit project (One year cycle from Nov 2009 – Nov 2010) <ul><li>What did we do? </li></ul><ul><li>Baseline audit </li></ul><ul><li>– patient info system (TRAK) </li></ul><ul><li>- case note audit </li></ul><ul><li>Set up 5 “beacon” areas </li></ul><ul><li>Environmental and practice review </li></ul><ul><li>Education and support </li></ul><ul><li>Signed up to 10 “good practice statements” </li></ul>
  9. 9. Examples of actions and support (by Alzheimer Scotland Nurse Consultant) <ul><li>Education + support: </li></ul><ul><li>Routine visits </li></ul><ul><li>Educational materials and resources </li></ul><ul><li>Dementia awareness sessions </li></ul><ul><li>Hands on coaching / support (working with staff) </li></ul>
  10. 10. Examples of actions and support <ul><li>10 good practice statements based on: </li></ul><ul><li>Staff knowledge and awareness </li></ul><ul><li>Communicating the dementia diagnosis </li></ul><ul><li>Sharing and gathering info about the person </li></ul><ul><li>Screening and assessment (Delirium and depression) </li></ul><ul><li>Dementia friendly environment </li></ul><ul><li>Staff approaches and communication </li></ul><ul><li>Process and checklist for behaviour that challenges </li></ul><ul><li>Risk assessment tools </li></ul><ul><li>AWI / consent </li></ul><ul><li>Discharge arrangements </li></ul>
  11. 11. Examples of actions and support <ul><li>Good practice statement 3 : Sharing and gathering information about the </li></ul><ul><li>person. </li></ul><ul><li>“ All potential sources of important information are explored and utilised, including; the person with dementia, their main carers, care homes and other services or professionals”. </li></ul><ul><li>“ The person’s individual preferences, needs and abilities are documented”. </li></ul><ul><li>Introduced “This is me form” </li></ul><ul><li>(Produced by Alzheimer’s Society and supported by RCN) </li></ul>
  12. 14. Good practice statement 5: Dementia friendly environment: <ul><li>“ A sign on every toilet door” </li></ul><ul><li>“ A clock in every patient area” </li></ul>Examples of actions and support
  13. 15. Examples of actions and support <ul><li>Good practice statement 4: Screening and assessment </li></ul><ul><li>“ Any signs of confusion in older people will be screened for Dementia, Delirium </li></ul><ul><li>or Depression (evidenced in notes)” </li></ul><ul><li>Good practice statement 7: Behaviour that challenges </li></ul><ul><li>“ A systematic approach towards understanding the cause or origins of behaviour is </li></ul><ul><li>adopted. This will include pain, environmental stimuli, and staff approaches”. </li></ul><ul><li>Introduced: </li></ul><ul><li>Doloplus 2 - pain </li></ul><ul><li>4AT – Delirium </li></ul><ul><li>Cornell – Depression </li></ul><ul><li>Challenging behaviour process and checklist </li></ul>
  14. 16. Audit results - Phase 1 (TRAK info) <ul><li>Reduced length of stay and moves per patient </li></ul>Nov 2009 Nov 2010 Total number of patients with dementia 95 108 Average age 84 83 Average length of stay 30 days 17 Average ward moves per patient 2.7 1.9
  15. 17. Audit results - Phase 1 (discharge destination) <ul><li>Increase from 36% to 42% going directly home from hospital. </li></ul><ul><li>Decrease in total from 52% to 47% going to LTC from hospital. </li></ul>Nov 2009 Nov 2010 Home 36% 42% Care home 10% 20% Other NHS or LTC 42% 27% % discharged to (any) LTC 52% 47%
  16. 18. Audit results - Phase 2 (case notes) <ul><li>Only two patients (7%) Rx psychotropic meds during stay – in sharp </li></ul><ul><li>contrast to criticisms reported elsewhere (Alzheimer’s society 2009, MWC 2011) </li></ul><ul><li>Only one patient had a catheter inserted (3%) during their stay. Catheters </li></ul><ul><li>are regarded as a high risk factor in people with dementia due to potential </li></ul><ul><li>cause of infection, trauma and delirium. </li></ul>Nov 2009 Nov 2010 Psychotropic meds prescribed in hospital 24% 7% Catheter 30% 3%
  17. 19. Audit results - carer survey <ul><li>Carers who rated their involvement in care / treatment as good or very good increased from 36% to 64% </li></ul><ul><li>Carers views on staff awareness and knowledge of dementia rated as good or very good increased from 41% to 70% </li></ul><ul><li>Carers views on their involvement in discharge planning rated as good or very good increased from 30% to 47% </li></ul><ul><li>“ All the nurses did a good job. It was great to get him back to his old self again </li></ul><ul><li>and to get him back home” (Carer). </li></ul>
  18. 20. Audit results - staff survey <ul><li>The number of staff who have attended dementia training in the past 5 years increased from 12% to 45% </li></ul><ul><li>“ There is much more of a focus on dementia now. I have learned a lot in the last </li></ul><ul><li>year. I wondered what I did or how I managed before” (Staff nurse). </li></ul><ul><li>The number of staff who described their awareness and ability of meeting the needs of people with dementia as good or very good increased from 38% to 86%. </li></ul><ul><li>“ I always thought that medications were the best approach – but now know that it </li></ul><ul><li>is not the best. We can have a big influence on our patients care without meds” </li></ul><ul><li>(staff nurse). </li></ul>
  19. 21. Audit results - staff survey <ul><li>Reduction in all areas of impact on staff – especially stress, frustration </li></ul><ul><li>and fear: </li></ul><ul><li>- reduced feelings of frustration from 82% to 48% </li></ul><ul><li>- reduced feelings of stress from 46% to 34% </li></ul><ul><li>- reduced feelings of fear from 30% to 14% </li></ul><ul><li>“ I just try to understand them more now. I can always step back and try again </li></ul><ul><li>later...or someone else can try” (staff nurse). </li></ul>
  20. 22. Final point <ul><li>At a time when the General hospital is coming under </li></ul><ul><li>increased scrutiny and criticism in its care and treatment of </li></ul><ul><li>people with dementia this audit project has indicated the </li></ul><ul><li>positive trends that can be achieved. </li></ul><ul><li>The efforts and commitment of all staff involved in this </li></ul><ul><li>project should be acknowledged and congratulated. </li></ul>
  21. 23. <ul><li>Thank you </li></ul>