Graham Dixon, Team Manager, Betsi Cadwaladr University Health Board

Background

Whilst the need to improve care for people with dementia in general hospitals has been acknowledged in national dementia strategies, recent reports indicate that much still needs to be done. However at Wrexham Maelor Hospital initiatives across the care of the elderly wards including the 1000 Lives+ programme have emerged, with implementation support being provided by the Older Person’s Liaison Psychiatry Team.

Aim

A patient’s journey through care environments especially for those with a dementia can be a daunting and often frightening experience. With essential care information driven by the dementia targets we can make a significant impact on care during the hospital stay. Specific measurements are recorded and monitored by review of run charts to establish compliance. Target compliance is aimed at 100 per cent but there is an expectation that 80-90 per cent should be routinely achieved. We are in the early implementation stages with appropriate data being collected monthly in the following target areas.        

• Identify on day of admission if patient already has a diagnosis of dementia.
• Where there is no previous history of dementia check history with family / other supporters.
• Assess for delirium and ensure appropriate treatment.
• Follow Dementia Pathway when identified.
• Seek advice from Liaison services for older adults with mental health problems, especially where additional needs identified from risk assessment in relation to challenging behaviour.
• Assess environmental needs – safety, stimulation, need for single room etc.
• Assess for assistance and maintaining skills with meals, toileting, and self care etc and ensure built into care plan and care provided accordingly.
• Review psychotropic medication on admission. Psychotropic medication to start with low dose, be time–limited and aimed at specific and quantified target symptoms and reviewed at least weekly.
• Improved care planning.
• Assess for capacity for major decisions and where person lacks capacity follow best interests process.
• Carers to be involved in care planning for the person in relation to discharge planning.
• If the patient has a diagnosis of dementia when being discharged - all carers offered carers assessment.

What did you do?

During 2009 the 1000 Lives+ Intelligent Targets for Dementia were in the pilot stages of development. For details of the 1000 Lives+ programme see 1000 Lives Plus: mental health - improving dementia care. 

Members of the liaison team played an integral part in the pilots and development within the general hospital setting followed by the production of a 'Dementia How To Guide' written by members of the older person’s liaison team and professor Bob Woods Bangor University, the 'How to Guide' supports healthcare teams to successfully implement interventions to improve safety and quality of care. Although there had been no specific study design the implementation of the target was planned to take a 1 – 3 – 5 approach to roll out.

Due to initial difficulties within the general hospital environment the roll out was marginally delayed. Dementia targets for Memory Clinic (Driver 1) and Older Person’s Mental Health In-Patients (Driver 3) have been rolled out effectively with meaningful data being collected monthly.  For General Hospital Wards (Driver 2) steady progress is being made during the early implementation stages specifically for the dementia target, with roll out planned within the coming months.

Sustainability models identified education and staff support as a key element in the roll out, ensuring staff remained interested. Training was initiated on the early implementation sites with all staff groups. Data collection commenced January 2011 and is disseminated at the 1000 Lives+ collaborative events every 3 months.  A  Health Board Dementia lead has now been identified and we remain involved with further care developments in line with the Wales national dementia plan.

We are currently at the early implementation phase of the All Wales roll out and remain a valuable source of support to the general hospital. We are involved in the planned assessment of ward environments and supporting the implementation of dementia targets with members of the senior management team.

What changed?

It is now recognised that initial cognitive presentation and history taking is a key element of the assessment process along with identifying specific care needs on an individualised basis.

Ward staff are able to identify when a patient requires further support from liaison psychiatry and follow the key aspects of the dementia driver diagrams. The overall process now allows for a smooth transition during the in-patient episode and assists towards a speedier discharge.

As with all processes there are areas that require improvement and on-going support. Our initial review of data identified variance in knowledge relating to assessment of capacity and best interests process. Members of the liaison team provided educational training and update sessions to all appropriate staffing groups to resolve the difficulty.

All carers being offered carers assessment identified variance in practice across the hospital environment and further work is being undertaken to review systems and processes which will allow easier implementation and compliance. 

Advice for others

The dementia targets are not the end of the process, but the beginning. The way they are used and the subsequent outcomes are the most important.

Adequate training, support and teamwork are important to introduce the use of intelligent targets and ensuring appropriate skill development and ownership of the work will ensure sustainability. The targets are simple to use and information is easily identified on a recording sheet held within the patients nursing notes. The data collection is kept simple allowing recording to take place easily and shared across the nursing team rather than any one individual.

There has been no formal cost analysis as the support for implementation has been met within current resource allocation. The development of the dementia targets has a real cost – in terms of time, training and effort. However providing the process is used effectively for improvement in care it becomes extremely cost effective and prevents harm.

A patient’s journey through care environments especially for those with a dementia can be a daunting and often frightening experience. With essential care information driven by the dementia targets we can and will make a significant impact on care during the hospital stay.
See also the 1000 Lives+ site.

For further information please contact Graham Dixon at graham.dixon@wales.nhs.uk

See other examples at Dementia - best practice examples.