Dawn Patience, Head of Nursing Medicine and Older People, Basildon and Thurrock University Hospitals NHS FT

Background

The trust strategy for dementia has been developed in the context of an increasing ageing population and an increase in the numbers of people attending and being admitted with a known or suspected diagnosis of dementia. The dementia strategy gives clear guidance for staff on treatment and care pathways. Environmental changes for the three older peoples wards aim to improve the patients' experiences whilst they are in hospital.

Working in collaboration with the local community a pilot has been commenced with the Dementia Intensive Support Team (DIST) being based in the Accident and Emergency Department to reduce hospital admissions and to support staff during the patient's stay by providing specialist mental health input for patients with challenging behaviour, referring patients with suspected dementia to the memory service, and providing support to carers following discharge.

Aim

• Monitoring of the numbers of patients admitted with dementia and to reduce admissions to hospital.
• Reducing the amount of moves whilst in hospital, with direct admissions from A&E if capacity allows.
• Environmental changes to improve patient experience e.g. clocks, calendars, red beakers
• Risk assessments to identify need for increased supervision.
• Pool of nursing staff for increased nursing supervision and diversion therapy.
• Referrals to the memory service and patients not being diagnosed in hospital.
• Identification of dementia patients on Patient Status at glance boards for specialist input.
• Treatment pathways identifying when anti-psychotic medication should be used - audit of antipsychotic drug use.
• Dementia nurse to facilitate mental health input when required.
• Staff education, e-learning packages and work with PCT and local university for other study days.
• Carers' champions completing carers assessments.

What did you do?

• Development of dementia strategy with key members of staff.
• Care pathway accessible on the Hospital Intranet which links to relevant other information e.g. Mental Capacity Act, safeguarding.
• PCT providing updated dementia patients list to be uploaded to the hospital system to allow patients to be flagged and identified from admission. 
• Dementia strategy group developed and monitored through PMO programme.
• Staff allocated to develop different strands of work: Consultant Geriatrician - developed treatment pathway with psychiatry; Dementia nurse- referrals to DIST team and memory service; Older Peoples service Manager; Complex Case Manager and Head of Nursing - development of the care pathway; care planning and in conjunction with the Senior Sisters for the three Older Peoples wards environmental changes required.
• Education and Training Department staff e-learning programme.
• Business case for pool of health care assistants (HCAs) to provide increased nursing supervision and diversion approved - staff appointed and training currently being undertaken.
• Dementia Nurse Specialist and Commissioners for health pilot of Dementia Support team covering community and  A&E to admission avoid, and supporting the patients and ward staff following admission.

What changed?

• Reduced length of stay for patients with dementia.
• Specialist advice from Dementia Service to medical and nursing staff.
• Reduction in patients diagnosed in hospital with dementia.
• Increased  referrals to memory service.
• Improved identification of patients with dementia.
• Improved staff awareness and education.
• Environmental changes, red beakers and tumblers.
• Feeding buddies to give encouragement and support at mealtimes.
• Identification and pathway management from A&E of patients.
• Increased nursing supervision assessment and HCA pool who have received enhanced training.

Capacity demands has reduced the ability for direct admissions, however the escalation patient checklist reduces the risks of dementia patients being moved to an escalation area when they are medically stable for discharge.

Advice for others

Staff buy in is essential for this work to be sustained and therefore teaching at the foundation programme and for all new staff is essential. There have been minimal costs for the environmental changes. Other changes have been made by updating current documentation and computer systems.

The pilot of DIST will be reviewed for its effectiveness and cost reductions of hospital admissions at the end of six months (February 2012).

For further information please contact Dawn Patience at dawn.patience@btuh.nhs.uk

See other examples at Dementia - best practice examples.